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2014 Advanced Life Support ALS Field Treatment Manual San Joaquin County EMS Agency ALS Radio Report Format Initial MCI Report 1. 2. 3. 4. 5. 6. 7. 8. Confirm or cancel the MCI Alert Location of incident Name of incident, e.g. Blackjack Incident MCI position title, e.g. Blackjack Medical Group Supervisor Incident Type: a. Trauma b. Medical c. Hazmat Approximate number of patients Estimated time triage will be complete Second MCI Report Total number of patients and their triage categories: a. Immediate 1) Adult. 2) Pediatric. b. Delayed. c. Minor. Advisory Report to a Receiving Hospital Base Hospital Report/ALS Consultation Report 1. Unit ID. 2. Name and level (EMT or paramedic) of person making report. 3. Trauma, MCI, STEMI or Stroke Alert, if indicated. 4. Transport Code 2 or 3. 5. Patient age, gender, weight(s). 6. Chief complaint. 7. History of incident. 8. Trauma Triage Criteria met (if applicable). 9. Pertinent medical history. 10. Pertinent medications. 11. Vital signs to include: blood pressure, pulse, respirations, pulse oximetry. 12. Level of Consciousness 13. Treatment provided 14. Patient response to treatment. 15. Estimated time of arrival to receiving hospital 1. Unit ID. 2. Name and level (EMT or paramedic) of person seeking orders. 3. Request for consultation/orders needed (State reason for calling) 4. Trauma, MCI, STEMI or Stroke Alert, if indicated 5. Transport Code 2 or 3. 6. Patient age, gender, weight. 7. Chief Complaint. 8. History of incident. 9. Trauma Triage Criteria met (if applicable). 10. Patient Condition (e.g. stable, improving, worsening). 11. Vital Signs to include: blood pressure, pulse, respirations, pulse oximetry and Glasgow Coma Scale (best eye, motor, and verbal) 12. Interventions: a. BLS Treatment rendered and patient response. b. ALS Standing Orders implemented and patient response. 13. Primary survey (LOC, skin signs). 14. Secondary Physical Exam. 15. Past medical history/PMD. 16. Medications/allergies. 17. Estimated time of arrival to receiving hospital. Note: Patient transport should begin as soon as any immediate patient(s) are ready for transport and destinations are determined by Control Facility or standing orders. Don’t delay transport of immediate patients waiting for destinations for all patients May Receive Prehospital Report: MICN or Base Physician ONLY! May Receive Prehospital Report: Any Receiving Hospital Medical Personnel May Receive Prehospital Report: MICN or Base Physician ONLY! _________________________San Joaquin County EMS Agency San Joaquin County Emergency Medical Services ii _________________________San Joaquin County EMS Agency San Joaquin County Emergency Medical Services Agency ALS Field Manual Table of Contents ADULT ADVANCED LIFE SUPPORT TREATMENT POLICIES ...................................................... 1 5700 - ALS TREATMENT POLICIES – INTRODUCTION ................................................................................. 2 5701 - ROUTINE ALS CARE ........................................................................................................................ 4 5702 - ALS ADVANCED AIRWAY MANAGEMENT ....................................................................................... 5 5704 - ALS PATIENT ASSESSMENT – PRIMARY SURVEY ...........................................................................10 5705 - ALS PATIENT ASSESSMENT - SECONDARY SURVEY .......................................................................14 5707 - ALS ADULT PAIN MANAGEMENT...................................................................................................18 5710 - ALS MEDICAL CARDIAC ARREST...................................................................................................20 5710A - ALS MEDICAL CARDIAC ARREST - PIT CREW APPENDIX A ........................................................25 5711 - ALS VENTRICULAR FIBRILLATION/PULSELESS VTACH .................................................................29 5712 - ALS WIDE COMPLEX TACHYCARDIA WITH A PULSE ......................................................................31 5713 - ALS NARROW COMPLEX TACHYCARDIA; AFIB/AFLUTTER ...........................................................32 5714 - ALS NARROW COMPLEX TACHYCARDIA; SVT ..............................................................................33 5715 - ALS ASYSTOLE ..............................................................................................................................35 5716 - ALS PULSELESS ELECTRICAL ACTIVITY (PEA) .............................................................................36 5717 - ALS BRADYCARDIA .......................................................................................................................37 5719 - ALS CHEST PAIN ............................................................................................................................39 5720 - ALS CARDIOGENIC SHOCK.............................................................................................................41 5724 - ALS VENTRICULAR ECTOPY ..........................................................................................................42 5726 - ALS RETURN OF SPONTANEOUS CIRCULATION ..............................................................................43 5727 - ALS THERAPEUTIC HYPOTHERMIA ................................................................................................44 5731 - ALS ALLERGIC REACTION/ANAPHYLAXIS .....................................................................................46 5733 - ALS POISONING/OVERDOSE ...........................................................................................................48 5735 - ALS HEAT ILLNESS ........................................................................................................................51 5736 - ALS HYPOTHERMIA .......................................................................................................................52 5738 - ALS ENVENOMATION .....................................................................................................................53 5751 - ALS ALTERED LEVEL OF CONSCIOUSNESS (ALOC) ......................................................................54 5753 - ALS SEIZURES ................................................................................................................................56 5754 - ALS ACUTE STROKE ......................................................................................................................58 5761 - ALS GYNECOLOGICAL EMERGENCIES ............................................................................................59 5764 - ALS CHILDBIRTH ...........................................................................................................................62 5771 - ALS BRONCHOSPASM ....................................................................................................................65 5772 - ALS ACUTE PULMONARY EDEMA ..................................................................................................66 5774 - ALS AIRWAY OBSTRUCTION ..........................................................................................................67 5782 - ALS BURN CARE ............................................................................................................................68 5783 - ALS ADULT TRAUMA TREATMENT ................................................................................................69 5790 - ALS NERVE AGENT EXPOSURE ......................................................................................................72 PEDIATRIC ADVANCED LIFE SUPPORT TREATMENT POLICIES.............................................77 5800 - PEDIATRIC ROUTINE MEDICAL CARE .............................................................................................78 5810 - PEDIATRIC PULSELESS ARREST: ASYSTOLE/PEA ...........................................................................80 5811 - PEDIATRIC PULSELESS ARREST: VENTRICULAR FIBRILLATION/VENTRICULAR TACHYCARDIA ......81 5812 - PEDIATRIC BRADYCARDIA..............................................................................................................83 5813 - PEDIATRIC TACHYCARDIA WITH PULSES ........................................................................................84 5815 - PEDIATRIC APPARENT LIFE THREATENING EVENT .........................................................................86 San Joaquin County Emergency Medical Services iii _________________________San Joaquin County EMS Agency 5817 - PEDIATRIC AIRWAY OBSTRUCTION BY FOREIGN BODY ..................................................................87 5819 - PEDIATRIC RESPIRATORY DISTRESS: STRIDOR ...............................................................................88 5820 - PEDIATRIC RESPIRATORY DISTRESS: BRONCHOSPASM ...................................................................89 5824 - PEDIATRIC SHOCK ..........................................................................................................................91 5826 - PEDIATRIC ALLERGIC REACTION ....................................................................................................92 5828 - PEDIATRIC SEIZURE ........................................................................................................................94 5829 - PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS ...........................................................................95 5830 - PEDIATRIC POISONING/OVERDOSE .................................................................................................97 5837 - PEDIATRIC BURNS ........................................................................................................................100 5839 - PEDIATRIC PAIN MANAGEMENT ...................................................................................................101 5850 - NEONATAL RESUSCITATION .........................................................................................................104 ADVANCED LIFE SUPPORT SKILLS POLICIES AND INTERFACILITY TRANSFER MEDICATION POLICIES ......................................................................................................................107 2541- PARAMEDIC INFREQUENTLY USED SKILLS ....................................................................................108 2544 – INTRAOSSEOUS CANNULATION – EZ-IO ......................................................................................110 2545 – ENDOTRACHEAL INTUBATION – ADULT PERFORMANCE CRITERIA ..............................................114 2546 – INTRAOSSEOUS CANNULATION - MANUAL ..................................................................................118 2547 – TRANSCUTANEOUS PACING PERFORMANCE CRITERIA .................................................................120 2548 – NEEDLE THORACOSTOMY PERFORMANCE CRITERIA ...................................................................122 2549 – NEEDLE CRICOTHYROTOMY TRANSLARYNGEAL JET VENTILATOR..............................................124 2550 – NASO/OROGASTRIC INTUBATION PERFORMANCE CRITERIA ........................................................126 2551 – 12 LEAD ECG PERFORMANCE CRITERIA .....................................................................................129 2552 – KING AIRWAY PERFORMANCE CRITERIA .....................................................................................131 2553 – ENDOTRACHEAL INTUBATION – PEDIATRIC PERFORMANCE CRITERIA ........................................134 2554 – CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) PERFORMANCE CRITERIA ...........................137 2555 – NASOTRACHEAL INTUBATION – ADULT PERFORMANCE CRITERIA ..............................................139 2560 – PARAMEDIC SCOPE OF PRACTICE .................................................................................................145 5952 - MONITORING AN INFUSION WITH POTASSIUM CHLORIDE .............................................................149 5954 - MONITORING AN INFUSION OF HEPARIN .......................................................................................153 5955 - MONITORING AN INTRAVENOUS INFUSION OF NITROGLYCERIN ...................................................157 RELATED POLICIES ..............................................................................................................................163 5001 - AUTHORITY FOR MEDICAL EMERGENCY MANAGEMENT ..............................................................164 5103 - DETERMINATION OF DEATH IN THE FIELD ....................................................................................166 5105 - DO NOT RESUSCITATE ORDERS ....................................................................................................170 5106 - INTERACTION WITH PHYSICIAN OR OTHER HEALTH CARE PROVIDER ON SCENE .........................172 5106A - NOTE TO PHYSICIAN ON INVOLVEMENT WITH EMT-PS .............................................................175 5107 - USE OF RESTRAINTS .....................................................................................................................176 5108 - CARE OF MINORS IN THE FIELD ....................................................................................................180 5110 - ANATOMICAL DONOR CARDS .......................................................................................................183 5115 – CERVICAL SPINE IMMOBILIZATION ..............................................................................................185 5130 - ALS WITHOUT BASE HOSPITAL CONTACT ...................................................................................189 5130A - ALS WITHOUT BASE HOSPITAL CONTACT REPORT .....................................................191 5201 – MEDICAL PATIENT DESTINATION ................................................................................................193 5201A – MEDICAL PATIENT DESTINATION GROUND AMBULANCE ESTIMATE OF DRIVING TIME AND DISTANCE ................................................................................................................................................199 5210 – MAJOR TRAUMA TRIAGE CRITERIA .............................................................................................202 5215 – TRAUMA PATIENT DESTINATION .................................................................................................205 GROUND AMBULANCE TRANSPORT (TIMES/DISTANCE) ...........................................................................210 San Joaquin County Emergency Medical Services iv _________________________San Joaquin County EMS Agency SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES Adult Advanced Life Support Treatment Policies San Joaquin County Emergency Medical Services Page 1 of 216 ALS Treatment Policies – Introduction EMS Policy No. 5700 Approved: January 1, 2010 Supersedes: September 1, 2007 5700 - ALS Treatment Policies – Introduction INTRODUCTION I. The Advanced Life Support (ALS) treatment Policies for adults and pediatrics approved by the Medical Director of the San Joaquin County EMS Agency directs the delivery of advanced life support (ALS) by licensed Paramedics accredited to practice in San Joaquin County. The ALS treatment Policies are the accredited paramedic’s written orders authorizing the practice of ALS for specific patient conditions. All prehospital personnel are required to operate within their respective scope of practice. Accredited paramedics are expected to have a mastery of the ALS Treatment Policies, Basic Life Support (BLS) treatment Policies and all other San Joaquin County EMS Policies governing the delivery of emergency medical services in the field care setting. II. The ALS treatment Policies are to be used in concert with sound medical judgment. Unusual patient presentations make it impossible to develop a specific policy for every possible patient presentation. Paramedics should avail themselves of the opportunity to consult with a mobile intensive care nurse (MICN) or base hospital physician (BHP) when encountering unusual patient presentations or potential conflicts in treatment decisions. III. Base Hospital Physicians may order a deviation from any of the approved EMS Agency treatment Policies, as long as they remain within the paramedic scope of practice. These types or orders may not be relayed by the MICN. Each order from the BHP that deviates from Policy must be documented on a Base Hospital Report Form, the prehospital patient care report, and be submitted to the EMS Agency for review. IV. In those instances in which EMS Policy allows Paramedics to perform a procedure or provide medication only upon receipt of a San Joaquin County Emergency Medical Services Page 2 of 216 ALS Treatment Policies – Introduction EMS Policy No. 5700 Approved: January 1, 2010 Supersedes: September 1, 2007 Base Hospital Physician order, MICN’s are allowed to relay orders from the Base Hospital Physician. The paramedic shall document the Physician’s name on the patient care report. V. MICNs shall adhere to San Joaquin County EMS Agency Policies when offering advice, guidance, and direction to ALS and BLS field personnel. VI. In order to facilitate the best possible delivery of prehospital emergency medical care attending paramedics have the right to speak directly to a Base Hospital Physician during any call. VII. All prehospital EMS personnel are held to the following patient care standards: A. San Joaquin County EMS Agency Policies and Procedures. B. American Heart Association CPR, AED, and BLS airway obstruction and ventilation techniques. C. State of California EMT-P Course Curriculum. D. OES Region IV Multi-casualty Incident Plan, Field Operations Manual 1 and 2. E. S.T.A.R.T. Triage. F. OSHA and CAL-OSHA standards for infection control. San Joaquin County Emergency Medical Services Page 3 of 216 Routine ALS Care EMS Policy No. 5701 Effective: January 1, 2012 Supersedes: February 1, 2007 5701 - Routine ALS Care DEFINITIONS: A. Standard Precautions: Application of body substance isolation precautions including the use of appropriate personal protective equipment (PPE) shall apply to all patients receiving care, regardless of their diagnosis or presumed infectious status. Body substance isolation precautions apply to 1) blood; 2) all bodily fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; 3) non intact skin; and 4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the prehospital setting. POLICY: I. Routine ALS Medical Care shall consist of the following: A. Standard precautions B. Provision of appropriate BLS care in accordance with EMS Agency policy C. ECG monitoring D. IV access as indicated (may use saline lock when appropriate) E. Obtain blood glucose level, as indicated F. Transport G. Follow ALS treatment policies as indicated San Joaquin County Emergency Medical Services Page 4 of 216 ALS Advanced Airway Management EMS Policy No. 5702 Effective: October 16, 2013 Supersedes: October 1, 2012 5702 - ALS Advanced Airway Management DEFINITIONS: A. “Oral Tracheal Intubation (OTI) Attempt” means the introduction of an Endotracheal Tube Inducer (ETTI) or Endotracheal Tube past the patient’s teeth. B. “Difficult Airway” means an airway that has been predicted to be difficult based on assessment of the patient or upon an attempt to visualize the cords and the patient has a Cormack-Lehane grade of three (3) of four (4). C. “Successful OTI Attempt” means a verified placement and securing of the endotracheal tube into the patient’s trachea. D. “Successful OTI Attempt with Complications” means a verified placement and securing of the endotracheal tube into the patient’s trachea with any of the following: 1. Failure to perform and document meticulous BLS airway management skills prior to ALS intervention, as well as justification for ALS airway. 2. Failure to maintain continuous pulse oximetry and ECG monitoring, for at least one (1) minute before the attempt and continuously thereafter. 3. Deviations in vital signs associated with intubation suggestive of prolonged hypoxia, such as bradycardia or desaturation. 4. Subsequent dislodgement of the endotracheal tube recognized by the receiving hospital. 5. Subsequent diagnosis of mainstem intubation recognized by the receiving hospital. 6. Subsequent diagnosis of severe airway complications likely associated with the prehospital intubation, such as pharyngeal, esophageal perforation, laryngeal trauma, such as vocal cord paralysis, or aspiration pneumonia. POLICY: I. The approved airway management procedure for the unconscious San Joaquin County Emergency Medical Services Page 5 of 216 ALS Advanced Airway Management EMS Policy No. 5702 Effective: October 16, 2013 Supersedes: October 1, 2012 adult patient consists of the following: providing BLS airway management skills; correctly assessing the need for an advanced airway; and successfully inserting either an endotracheal tube via oral tracheal intubation, or a King Airway. II. Paramedics placing advanced airways shall follow the procedures specified in EMS Policies No. 2545, 2552, 2553, 2555, and 2556. III. Oral tracheal intubation in the pediatric patient should only be performed if unable to ventilate and oxygenate the patient using two-person Bag/Valve/Mask (BVM) ventilation. In cardiac arrest, oximetry will not be accurate, so intubation in this case should only occur if the patient cannot be ventilated by BVM. IV. Do not delay transport to establish an advanced airway in trauma patients except in the case of complete airway obstruction, as evidenced by a complete inability to ventilate the patient using an Oral Pharyngeal Airway (OPA) and BVM device. V. If unable to establish an airway due to complete airway obstruction not relieved using an OPA and BVM maneuvers, begin code three transport, and consider insertion of a King Airway, or needle cricothyrotomy (EMS Policy No. 2549) if the King Airway does not result in successful ventilation. VI. INDICATIONS FOR INTUBATION: A. Inability of the patient to protect their airway (coma, decreased level of consciousness with non-intact gag reflex). B. Inability to adequately ventilate or oxygenate the patient using an OPA and BVM device. C. Cardiac arrest. Adhere to sequence as specified in EMS Policy No. 5710 ALS Medical Cardiac Arrest. D. Failing respirations (irregular and shallow), respiratory arrest. VII. CONFIRMATION OF TUBE PLACEMENT: A. Paramedics shall ensure that all intubations are confirmed by San Joaquin County Emergency Medical Services Page 6 of 216 ALS Advanced Airway Management EMS Policy No. 5702 Effective: October 16, 2013 Supersedes: October 1, 2012 B. C. D. E. F. end tidal CO2 device (colorimetric or capnography) and/or esophageal detection device (EDD) (EDD not used for King Airway). Paramedics shall immediately confirm tube placement by auscultating bilateral lung fields for breath sounds, observe for chest rise and fall with ventilations, and listen for air flow into the epigastric area after placement of an endotracheal tube or King Airway. Paramedics shall continually monitor capnography readings on all patients who have an endotracheal tube or King Airway in place. Monitoring shall commence with transport and shall continue through to patient transfer at the emergency department. Paramedics shall attach a copy of the capnography strip and document the readings on the patient care record. Paramedics shall reconfirm ET Tube placement prior to transferring patient care. Paramedics shall visualize the pharynx and vocal cords with the laryngoscope, if there is any doubt as to proper placement of the endotracheal tube. VIII. INDICATIONS FOR KING AIRWAY A. Select King Airway directly upon assessing a CormackLehane grade of 3 or 4,or; B. Select a King Airway directly in response to other physical or physiological impediments to the successful insertion of an endotracheal tube, or; C. Select a King Airway after two unsuccessful attempts to insert an endotracheal tube. IX. APPROVED ADVANCED AIRWAY PROCEDURE: A. Prepare equipment and position patient with the intent to provide an airway via either an Endotracheal Tube or via a King Airway B. Upon a determination that the patient has a Cormack-Lehane grade of one (1) or two (2), attempt to insert an endotracheal San Joaquin County Emergency Medical Services Page 7 of 216 ALS Advanced Airway Management EMS Policy No. 5702 Effective: October 16, 2013 Supersedes: October 1, 2012 tube as described in EMS Policy No. 2545 – Endotracheal Intubation – Adult. 1. No more than two (2) attempts per patient with preoxygenation and continuous oximetry monitoring prior to each attempt. 2. After two (2) unsuccessful attempts at endotracheal intubation, insert a King Airway as described in EMS Policy No. 2552 King Airway. 3. An endotracheal tube inducer (ETTI) shall be used on all attempts. 4. Each attempt should last no longer than thirty (30) seconds. If during any attempt patient desaturates below 90%, immediately cease and reventilate to increase saturation. 5. Ventilate with 100% oxygen for one (1) minute prior to attempting to intubate, unless transitioning to an advanced airway per EMS Policy No 5710 ALS Medical Cardiac Arrest. 6. Monitor pulse oximetry continuously. C. Upon a determination the patient has a Cormack-Lehan grade of three (3) or four (4), continue providing BLS resuscitation, and provide a King Airway as described in EMS Policy No. 2552 – King Airway. 1. A patient with a Cormack-Lehane grade of three (3) or four (4) (epiglottis is not or is barely visible) will be considered to have a difficult airway. The King Airway shall be utilized on the first attempts for difficult airways in adult patients. Cormack and Lehan Classification (Grades) of Difficult Laryngoscopy Grade I Most of glottis is seen Grade II Only posterior portion of glottis can be seen Grade III Only epiglottis may be seen (none of glottis seen) Grade IV Neither epiglottis nor glottis can be seen San Joaquin County Emergency Medical Services Page 8 of 216 ALS Advanced Airway Management EMS Policy No. 5702 Effective: October 16, 2013 Supersedes: October 1, 2012 2. Only King Airway sizes three (3), four (4), and five (5) are authorized for use. 3. The King Airway is not authorized for use in adults < 4 feet tall. Authorized King Airway Sizes Size Height in Feet Color 3 4 – 5 Feet Yellow 4 5 – 6 Feet Red 5 > 6 Feet Purple 4. Use a laryngoscope to facilitate placement. 5. Do not exceed manufacture’s recommended pressures. 6. Remove and replace the King Airway if resistance is met upon initial insertion. 7. After two (2) unsuccessful attempts, place a BLS an airway and transport code 3 to the closest receiving hospital. D. Nasal Intubation: Nasal tracheal intubation may only be performed with a Base Hospital Physician order. The Base Hospital Physician’s name shall be documented on the PCR. San Joaquin County Emergency Medical Services Page 9 of 216 ALS Patient Assessment – Primary Survey Policy No. 5704 Effective: October 16, 2013 Supersedes: January 1, 2012 5704 - ALS Patient Assessment – Primary Survey PROCEDURE: The purpose of the primary survey is to identify and immediately correct life-threatening problems. I. Scene Size Up: A. Recognize hazards, ensure safety of scene and secure a safe area for treatment. B. Apply universal body/substance isolation precautions. C. Recognize hazards to patient and protect patient from further injury. D. Identify the number of patients and initiate ICS/MCI operations if warranted: 1. Ensure an ALS ambulance response and order additional resources. 2. Consider/confirm air ambulance response. 3. Initiate S.T.A.R.T. triage, if more than one patient. E. Observe position of patient(s). F. Determine mechanism of injury. G. Plan strategy to protect evidence at potential crime scene. II. General Impressions: A. Check for life threatening conditions. B. Introduce self to patient. C. Determine chief complaint or mechanism of injury. III. Airway: A. Ensure open airway B. Protect spine from unnecessary movement in patients at risk for spinal injury. C. Ensuring an adequate airway supersedes spinal immobilization. San Joaquin County Emergency Medical Services Page 10 of 216 ALS Patient Assessment – Primary Survey Policy No. 5704 Effective: October 16, 2013 Supersedes: January 1, 2012 D. Look and listen for evidence of upper airway problems and potential obstructions: 1. Vomit. 2. Bleeding. 3. Loose or missing teeth. 4. Dentures. 5. Facial Trauma. E.Utilize any appropriate adjuncts as indicated to maintain airway. IV. Breathing: A. Look, listen, and feel in order to assess ventilation and oxygenation. B. Expose chest, if necessary, and observe for chest wall movement. C. Determine approximate rate and depth and assess character and quality. D. Reassess mental status. E. Intervene for inadequate ventilation with: 1. Pocket mask or BVM device. 2. Supplemental oxygen. F. Assess for other life threatening respiratory problems and treat as needed. V. Circulation: A. Check for pulse and begin CPR. B. Defibrillation as necessary. C. Control life-threatening hemorrhage with direct pressure. D. Palpate radial pulse. 1. Determine absence or presence. 2. Assess general quality (strong/weak). 3. Identify rate (slow, normal, or fast). 4. Assess regularity (regular/irregular). E. Obtain baseline blood pressure. F. Assess skin for signs of hypo-perfusion/SHOCK or hypoxia (capillary refill, cyanosis, etc.). San Joaquin County Emergency Medical Services Page 11 of 216 ALS Patient Assessment – Primary Survey Policy No. 5704 Effective: October 16, 2013 Supersedes: January 1, 2012 G. Reassess mental status for signs of hypoperfusion/SHOCK. H. Treat hypoperfusion if appropriate. I. Obtain ECG and continually monitor cardiac rhythm as appropriate. VI. Level of consciousness: A. Determine need for spinal immobilization, EMS Policy No.5115 Cervical Spine Immobilization. 1. Determine Glasgow Coma Scale (GCS) Score (see page 3 for GCS chart). 2. Determine glucose level as needed, EMS Policy N. 5751, ALS Altered Level of Consciousness (ALOC). VII. Expose, Examine & Evaluate: A. In situations with suspected life-threatening mechanism of injury, complete a Rapid Trauma Assessment. B. Expose head, trunk and extremities. C. Head to Toe for DCAP-BTLS 1. Deformity. 2. Contusion/Crepitus. 3. Abrasion. 4. Puncture. 5. Bruising/Bleeding. 6. Tenderness. 7. Laceration. 8. Swelling. San Joaquin County Emergency Medical Services Page 12 of 216 ALS Patient Assessment – Primary Survey Policy No. 5704 Effective: October 16, 2013 Supersedes: January 1, 2012 Adult Glasgow Coma Scale: Eye Opening Verbal Response 4 = Spontaneous 5 = Oriented 3 = To verbal stimuli 2 = To painful stimuli 4 = Confused 3 = Inappropriate words 2 = Incomprehensible sounds 1 = No response 1 = No response Best Motor Response 6 = Obeys commands 5 = Localizes stimuli 4 = Withdrawal from pain 3 = Abnormal Flexion 2 = Abnormal Extension 1 = No response Note: Always document and report GCS as a breakdown of scores (i.e. GCS = Eye 3, Verbal 3, Motor 4 for a total score of 10). San Joaquin County Emergency Medical Services Page 13 of 216 ALS Patient Assessment – Secondary Survey EMS Policy No. 5705 Effective: September 1, 2007 Supersedes: 510.05 5705 - ALS Patient Assessment - Secondary Survey PROCEDURE: I. The secondary survey is the systematic assessment and complaint focused, relevant physical examination of the patient. The secondary survey may be done concurrently with the patient history and should be performed after the Primary Survey and the initiation of Routine Medical Care. The purpose of the secondary survey is to identify problems which, though not immediately life or limb threatening, could increase patient morbidity and mortality. Exposure of the patient for examination may be reduced or modified as indicated due to environmental factors. II. History: A. A patient’s history should optimally be obtained from the patient directly. If language, culture, age, disability barriers or patient condition interferes with obtaining the history, consult with family members, significant others or scene bystanders. Check for advanced directives such as a DNR order, Medic-Alert bracelet and prescription bottles as appropriate. Be aware of the patient’s environment and issues such as domestic violence, child or elder abuse or neglect and report concerns. The following information should be obtained during the history: 1. Allergies; 2. Medications; 3. Past medical history relevant to the chief complaint. 4. Have patient prioritize his or her chief complaint if complaining of multiple problems; 5. Ascertain recent medical history such as hospital admissions, surgeries, etc; 6. Mechanism of injury if appropriate; San Joaquin County Emergency Medical Services Page 14 of 216 ALS Patient Assessment – Secondary Survey EMS Policy No. 5705 Effective: September 1, 2007 Supersedes: 510.05 7. In addition obtain history relevant to specific patient complaints. III. Head and Face: A. Observe and palpate skull (anterior and posterior) and face for DCAP-BTLS; B. Check eyes for equality, responsiveness of pupils, movement and size of pupils, foreign bodies, discoloration, contact lenses or prosthetic eyes; C. Check nose and ears for foreign bodies, fluid or blood; D. Recheck mouth for potential airway obstructions (swelling, dentures, bleeding, loose or avulsed teeth, vomit, absent or present gag reflex) and odors, altered voice or speech patterns and evidence of dehydration. IV. Neck: A. Observe and palpate for DCAP-BTLS, jugular vein distension, use of neck muscles for breathing, tracheal tugging, tracheal shift, stoma and medical information medallions. V. Chest: A. Observe and palpate for DCAP-BTLS, scars, implanted devices such as pacemakers and indwelling IV/arterial catheters, medication patches, chest wall movement, asymmetry and accessory muscle use in breathing; B. Have patient take a deep breath if possible and observe and palpate for signs of discomfort, asymmetry and air leak from any wound. C. Assess lung sounds and heart tones as appropriate. VI. Abdomen: A. Observe and palpate for DCAP-BTLS, scars and distention; B. Palpation should occur in all four quadrants taking special note of tenderness, masses and rigidity. San Joaquin County Emergency Medical Services Page 15 of 216 ALS Patient Assessment – Secondary Survey EMS Policy No. 5705 Effective: September 1, 2007 Supersedes: 510.05 VII. Pelvis/Genital-Urinary: A. Generally, a patient’s genital area should not be exposed and examined unless the assessment of this body region is required due to the patient’s condition, such as trauma to the region, active labor or suspected/known bleeding. When possible have an EMT or paramedic of the same gender as the patient, perform evaluations of the pelvis/genital area. B. Observe and palpate for DCAP-BTLS, asymmetry, sacral edema and as indicated for other abnormalities; C. Palpate and gently compress lateral pelvic rims and symphysis pubis for tenderness, crepitus or instability; D. Palpate for bilateral femoral masses, if warranted. VIII. Shoulder and Upper Extremities: A. Observe and palpate for DCAP-BTLS, asymmetry, skin color, capillary refill, edema, medical information bracelet, and equality of distal pulses; B. Assess sensory and motor function as indicated. IX. Lower Extremities: A. Observe and palpate for DCAP-BTLS, asymmetry, skin color, capillary refill, edema and equality of distal pulses; B. Assess sensory and motor function as indicated. X. Back: A. Observe and palpate for DCAP-BTLS, asymmetry and sacral edema. XI. Precautions and Comments: A. Observation and palpation can be done while gathering a patient’s history. B. A systematic approach will enable the rescuer to be rapid and thorough and not miss subtle findings that may become life-threatening. C. Minimize scene times, especially with trauma patients and pediatrics, by packaging/preparing the patient for San Joaquin County Emergency Medical Services Page 16 of 216 ALS Patient Assessment – Secondary Survey EMS Policy No. 5705 Effective: September 1, 2007 Supersedes: 510.05 immediate transport upon ambulance or air ambulance arrival (spinal immobilization, miller board, pediatric immobilization device, ensuring rapid ingress/egress for BLS personnel and equipment.) D. The Secondary Survey should ONLY be interrupted if the patient experiences airway, breathing or circulation deterioration requiring immediate intervention. Complete the examination before treating the other identified nonlife threatening problems. E. Reassessment of vital signs and other observations are necessary, particularly in critical or rapidly changing patients. Vital signs should be taken approximately every 5 minutes. Changes and trends observed in the field are essential data to be documented and communicated to the transport personnel or receiving facility. F. As stated in the Primary Survey DCAP-BTLS is a mnemonic that stand for: 1. Deformity; 2. Contusion/Crepitus; 3. Abrasion; 4. Puncture; 5. Bruising/Bleeding; 6. Tenderness; 7. Laceration; 8. Swelling. San Joaquin County Emergency Medical Services Page 17 of 216 ALS Adult Pain Management EMS Policy No. 5707 Effective: February 1, 2007 Supersedes: NA 5707 - ALS Adult Pain Management DEFINITIONS: A. Pain: Pain is a significantly unpleasant sensation, occurring in varying degrees of severity, which results because of injury, disease, or emotional disorder. POLICY: I. The use of morphine to manage moderate to severe pain is an advanced life support procedure that is indicated for patients who are complaining of moderate to severe pain in the presence of adequate vital signs and level of consciousness. II. Morphine may be used to treat stable patients when extrication, movement, or transport is required and is anticipated to cause considerable pain to the patient when there are no known contraindications to administering analgesia. III. Morphine is a potent analgesic and should be used with caution. IV. Procedure: A. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. B. Monitor patient closely. C. Establish IV access (IV NS or NS lock as appropriate). D. Obtain full set of vital signs. E. Administer Morphine 2-4mg IV every five minutes as needed to relieve pain to a maximum dose of 20mg. If unable to secure IV access, administer Morphine 5-10mg IM, may repeat one dose in 30 minutes. Document pain scale before and after medication administration. San Joaquin County Emergency Medical Services Page 18 of 216 ALS Adult Pain Management EMS Policy No. 5707 Effective: February 1, 2007 Supersedes: NA F. Monitor patient and vital signs carefully; ensure patent airway. Do not administer morphine sulfate for pain if systolic blood pressure is < 90 or respirations are < 12 without base hospital physician order. V. Base Physician Order Requirements: A. Concomitant administration of midazolam requires a base hospital physician order. B. Contact the base hospital physician prior to administering any pain medication to the following types of patients: 1. Any patient with hypotension, respiratory rate < 12, or altered mental status 2. Women in labor VI. Contraindications: A. Absolute: Allergy or sensitivity to the medication being administered. B. Relative: 1. Nausea/Vomiting 2. Altered level of consciousness 3. Hypotension 4. Suspected drug and/or alcohol intoxication 5. Head injury 6. Pregnancy 7. Multiple systems trauma San Joaquin County Emergency Medical Services Page 19 of 216 ALS Medical Cardiac Arrest EMS Policy No. 5710 Effective: October 16, 2013 Supersedes: June 1, 2013 5710 - ALS Medical Cardiac Arrest PURPOSE: The purpose of this policy is to provide direction for BLS and ALS responders for resuscitation of patients who are > 8 years-old in cardiopulmonary arrest due to asystole, pulseless ventricular tachycardia, ventricular fibrillation, or pulseless electrical activity using minimally interrupted cardiac resuscitation (MICR). DEFINITIONS: A. B. C. D. E. F. “EMS Agency” means the San Joaquin County Emergency Medical Services (EMS) Agency. “MICR” means minimally interrupted cardiac resuscitation that focuses upon maintaining high quality chest compressions with both depth and rate. “MICR Algorithm” means a representation of correct treatment choices in response to a patient’s cardiac rhythm. “MICR Round” means the time required to complete 200 – 230 compressions (approx. two minutes), analyze the patient’s rhythm and provide a shock (if indicated). “Passive Oxygen Insufflation” (POI) is the method of providing oxygen to a patient during the first eight (8) minutes of resuscitation with an oral pharyngeal airway (OPA), high flow oxygen via non-rebreather mask, and no ventilations. “Pit Crew” means the configuration of EMS responders and their defined roles to resuscitate a patient in cardiopulmonary arrest. POLICY: I. The goal of cardiac resuscitation is to preserve cerebral and coronary function through meticulous attention to procedure and achieving return of spontaneous circulation (ROSC). San Joaquin County Emergency Medical Services Page 20 of 216 ALS Medical Cardiac Arrest EMS Policy No. 5710 Effective: October 16, 2013 Supersedes: June 1, 2013 A. Focus resuscitative efforts on accomplishing the following in rank order of importance: 1. Provide high quality chest compressions with minimal interruption. 2. Apply ECG or AED for analysis and defibrillation. 3. Initiate POI. 4. Provide epinephrine 1mg 1:10,000 via IV/IO each MICR Round. B. Use a team approach (“Pit Crew”). II. Maintain a chest compression rate of 100 compressions per minute and alternate chest compression duties between pit crew team members after each MICR Round. Each MICR Round consists of between 200 and 230 chest compressions and will vary based upon AED analysis and shock pattern limitations. III. Initiate an advanced airway after completion of four MICR Rounds and continue resuscitative efforts based on the patient’s current cardiac rhythm and applicable treatment protocols. IV. The starting point to measure the beginning of MICR Rounds is the time that the first EMS personnel on-scene initiates the MICR procedure (compressions), regardless of whether the first rounds include establishment of an I.V. or administration of epinephrine. V. Contraindications for use of MICR include: A. Traumatic arrest. B. Pediatric arrest. C. Respiratory arrest due to known respiratory problem (e.g. asthma). D. Drowning. E. Obstructed Airway (including partial obstruction due to vomitus). F. Patients with a Left Ventricular Assist Device San Joaquin County Emergency Medical Services Page 21 of 216 ALS Medical Cardiac Arrest EMS Policy No. 5710 Effective: October 16, 2013 Supersedes: June 1, 2013 PROCEDURE: I. Obtain patient history and document the following: A. Estimated down time. B. Circumstances surrounding arrest: 1. Onset (witnessed or un-witnessed). 2. Preceding symptoms. 3. Bystander CPR. 4. Duration of CPR. 5. Medications. 6. Environmental factors (hypothermia, inhalation, and asphyxiation). II. Treatment A. Follow the MICR Algorithm as described below: 1. First MICR Round: While providing a minimum of 200 chest compressions (two minutes), apply ECG. Use either AED or manual mode, depending upon which method minimizes interruption of compressions, and does not delay administration of an IV/IO and Epinephrine. Ensure that the airway is secure with an oral pharyngeal airway (OPA) and institute POI with high flow oxygen nonrebreather mask. If ALS is available start IV/IO and administer Epinephrine 1 mg (1:10,000) without interrupting chest compressions. 2. Subsequent MICR Rounds: Following the first MICR Round (200+ chest compressions and approximately two minutes), stop compressions to quickly check for a pulse and for ECG analysis. After analysis and while AED is charging, immediately perform thirty (30) chest compressions (less if required by AED limitations) then provide a single shock. a) Interruptions for defibrillation must be kept to a minimum. (1) Continue chest compressions immediately upon performing defibrillation. (2) Do not stop chest compressions to wait for an San Joaquin County Emergency Medical Services Page 22 of 216 ALS Medical Cardiac Arrest EMS Policy No. 5710 Effective: October 16, 2013 Supersedes: June 1, 2013 ECG analysis following defibrillation and do not interrupt chest compressions to perform BLS airway procedures, start IV/IOs, check pulses, or administer medications. b) Rotate chest compression duties between Pit Crew members every MICR Round. c) If ALS care is available, administer Epinephrine 1 mg (1:10,000) once every MICR Round. 3. For return of spontaneous circulation treat the patient in accordance with EMS Policy No.5726, Return of Spontaneous Circulation. B. MICR Algorithm MICR Algorithm Administer 1 mg IV/IO epinephrine without interrupting CCs. C. Approach to airway complications for BLS and ALS personnel 1. If BLS personnel determine that vomitus has compromised the patient’s airway, the BLS crews should suction the airway prior to applying an AED or POI. 2. If ALS personnel determine that vomitus has compromised the airway, the ALS crew should suction the airway and apply either an ETI or King Airway and transition to treatment described below in section III. III. Transition to the following treatment after four MICR Rounds (eight minutes): San Joaquin County Emergency Medical Services Page 23 of 216 ALS Medical Cardiac Arrest EMS Policy No. 5710 Effective: October 16, 2013 Supersedes: June 1, 2013 A. Place either a King Airway or an oral tracheal tube and secure it with a commercial tube restraint. While oral tracheal intubation will usually interfere with continuous chest compressions, endeavor to not interrupt compressions for longer than fifteen (15) seconds. B. Continue performing high quality, uninterrupted compressions (> 100/minute). C. Use waveform capnography from time of tube placement through the duration of the resuscitation attempt. Both numerical value (capnometry) and wave morphology MUST be obtained and documented every five (5) minutes. D. Once an advanced airway is in place, compressions are given continuously at a rate of 8-10 ventilations per minute. DO NOT HYPERVENTILATE. E. Based upon ECG rhythm analysis, follow the treatment path specific to Asystole, V-fib and Pulseless VTach, or PEA per SJCEMSA policies. IV. Base Hospital Direction and Patient Transport A. If patient fails to convert to a return of spontaneous circulation following four MICR Rounds and the appropriate treatment path specified in SJCEMSA policies has been followed for a combined total of fifteen (15) minutes, contact the Base Hospital to discuss discontinuation of resuscitative efforts or patient transport. If the patient remains in PEA or ventricular fibrillation prepare patient for transportation. Do not transport the patient unless ordered to do so by the Base Hospital or due to scene safety. San Joaquin County Emergency Medical Services Page 24 of 216 ALS Medical Cardiac Arrest-Pit Crew Appendix A EMS Policy No. 5710A Effective: June 1, 2013 Supersedes: None 5710A - ALS Medical Cardiac Arrest - Pit Crew Appendix A I. Pit Crew Concept A. The roles and responsibilities detailed below are guidelines. B. Regardless of the number of responders, Pit Crew members should focus upon the following critical tasks: 1. Uninterrupted compressions 2. Placement of AED or monitor for rhythm analysis and shocks as appropriate 3. Placement of an OPA airway and 100% oxygen by mask (non-rebreather preferred). C. Pit Crew members take positions according to the diagram below depending upon crew member availability in order of the following task priorities: 1. Compression Leader 2. Airway Leader 3. Compression Tech (May be Medication Leader if ALS EMR crew) 4. Medication Leader (When ALS available) 2 Airway Leader 1 Compression Leader 3 Compression Tech 4 Medication Leader San Joaquin County Emergency Medical Services Page 25 of 216 ALS Medical Cardiac Arrest-Pit Crew Appendix A EMS Policy No. 5710A Effective: June 1, 2013 Supersedes: None II. Pit Crew Procedures A. If necessary to ensure enough room to conduct cardiac resuscitation, move patient to an area with a minimum space of 5’ x 7’. B. Initiate properly executed chest compressions throughout duration of pulseless period utilizing a pacing metronome and assign a timekeeper to track duration of total time engaged in cardiac resuscitation effort. 1. Compression rate of 100 per minute. 2. Compression depth of 2 ½ inches. 3. Complete recoil. 4. Alternate compressors every MICR Round. C. Quickly return to chest compressions after appropriate rhythm checks and while monitor is charging. 1. After rhythm analysis (approximately 5-10 seconds) and shock is advised, immediately switch compression technicians and provide 30 compressions (less if required by AED limitations) prior to giving shock. . 2. Minimize interruptions. Immediately resume chest compressions after defibrillation attempts. 3. Do not pause to check pulse or analyze rhythm after defibrillation attempts. Quickly check pulse to determine return of spontaneous circulation the moment compressions are halted for AED analysis. III. Priorities for Pit Crew Members During MICR Rounds Priorities by MICR Rounds Round 1: Compression Leader: Initiate compressions @ rate of 100/min ONLY check for pulse if arrest witnessed by an ALS provider San Joaquin County Emergency Medical Services Page 26 of 216 ALS Medical Cardiac Arrest-Pit Crew Appendix A EMS Policy No. 5710A Effective: June 1, 2013 Supersedes: None 21/2” depth compression with full recoil Airway Leader: Place OPA and non-rebreather mask @ 15 lpm If ALS available, consider setting up IV Run AED Compression Tech: Place ECG/Defib pads Turn on monitor (if not AED, consider placing it in AED mode) Be available to take over compressions Medication Leader: Initiate IV/IO 1st dose of Epinephrine Check FSBS Round 2: Compression Leader: Operates AED Airway Leader: Performs compressions (alternating with compression leader if two person crew) Suction patient as needed Compression Tech: Performs compressions Assist as needed Medication Leader: 2nd dose of Epinephrine Consider Narcan Round 3: Compression Leader: Compressions Airway Leader: Maintain airway Run AED San Joaquin County Emergency Medical Services Page 27 of 216 ALS Medical Cardiac Arrest-Pit Crew Appendix A EMS Policy No. 5710A Effective: June 1, 2013 Supersedes: None Compression Tech: Assess quality of compressions Medication Leader: 3rd dose of Epinephrine Round 4: Compression Leader: Prep to transition to post MICR care Airway Leader: Support transition to post MICR care Prep equipment for patient movement Prep advanced airway adjuncts Compression Tech: Performs compressions Medication Leader: Consider reversible causes (Hs and Ts) Provide 4th dose of Epinephrine Post Round 4: Compression Leader: Perform Compressions Support post MICR care Airway Leader: Inserts advanced airway Uses confirmatory adjuncts (waveform capnography) Ventilates asynchronously at 8-10 per minute Compression Tech: Assist with compressions alternating with Compression Leader Medication Leader: Provide post MICR care Contact Base Hospital if no ROSC General: Prepare for patient transport if appropriate San Joaquin County Emergency Medical Services Page 28 of 216 ALS Ventricular Fibrillation/Pulseless Ventricular Tachycardia EMS Policy No. 5711 Effective: October 16, 2013 Supersedes: January 1, 2012 5711 - ALS Ventricular Fibrillation/Pulseless VTach POLICY: I. If ALS personnel witness a change in patient condition to ventricular fibrillation or pulseless VTach, immediately defibrillate the patient one time using manufacturer recommended dose of energy. II. After completing four rounds of MICR, confirm pulselessness and rhythm and proceed with treatment as described below in section III. III. Treatment: A. Continue administering continuous chest compressions and ventilate the patient 8-10 times per minute. DO NOT HYPERVENTILATE. B. Establish an advanced airway and administer 100% oxygen via BVM. C. Defibrillate patient one time using manufacturer recommended dose of energy (usually 120-200 joules in biphasic defibrillators). If not stated, use 200 joules (biphasic); or 360 joules (monophasic); then resume chest compressions immediately. D. Establish IV/IO of normal saline TKO. E. Administer Epinephrine 1 mg (1:10,000) via IV/IO. Repeat every 3-5 minutes followed by 200 compressions. F. Defibrillate 1 x @ 120 - 200 joules (biphasic); or 1 x @ 360 joules (monophasic); immediately resume compressions without waiting for a rhythm check. G. Administer Lidocaine 1mg/kg IVP/IO (may repeat once in 3-5 minutes). H. For return of spontaneous circulation, see EMS Policy No.5726, Return of Spontaneous Circulation. I. If the patient remains pulseless and apneic following four rounds of MICR and seven (7) minutes of ALS resuscitative San Joaquin County Emergency Medical Services Page 29 of 216 ALS Ventricular Fibrillation/Pulseless Ventricular Tachycardia EMS Policy No. 5711 Effective: October 16, 2013 Supersedes: January 1, 2012 measures, ALS personnel shall contact the Base Hospital Physician to determine whether to continue or discontinue resuscitative measures. IV. Special Considerations: A. Suspected hyperkalemia in renal dialysis patients – Consider IVP/IO administration of 500 mg of 10% Calcium Chloride and1 mEq/kg of Sodium Bicarbonate, and consult Base Hospital Physician to discuss further management. San Joaquin County Emergency Medical Services Page 30 of 216 ALS Wide Complex Tachycardia with a Pulse EMS Policy No. 5712 Effective: October 16, 2013 Supersedes: January 1, 2012 5712 - ALS Wide Complex Tachycardia with a Pulse PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Unconscious: A. Establish an IV of normal saline TKO. B. Consult with Base Hospital Physician. 1. Synchronized cardioversion at 100 joules (monophasic energy dose or equivalent biphasic energy dose). 2. If no response: repeat synchronized cardioversion at 200 joules (or biphasic equivalent). 3. If no response: repeat synchronized cardioversion at 300 joules (or biphasic equivalent). 4. If no response: repeat synchronized cardioversion at 360 joules (or biphasic equivalent). 5. If rhythm does not convert with cardioversion administer Lidocaine 1 mg/kg IVP (may repeat x 1 in 3-5 minutes). C. Consult with Base Hospital Physician for further interventions. III. Conscious (stable or unstable) (chest Pain, BP less than 90 mmHg systolic, decreased LOC, shortness of breath, signs of shock): A. Place on 12 Lead ECG if chest pain is present. B. Establish an IV of normal saline TKO. C. In the presence of continuous chest pain, administer Lidocaine 1mg/kg IVP. May repeat every 5-10 minutes at ½ initial dose up to a total of 3 mg/kg. D. Lidocaine Drip: 1gm in 250 ml Normal Saline. Utilizing a dial-a-flow and extension tubing, administer 2-4 mg/min to decrease or eliminate ventricular ectopy. San Joaquin County Emergency Medical Services Page 31 of 216 ALS Narrow Complex Tachycardia; AFIB/AFlutter EMS Policy No. 5713 Effective: January 1, 2012 Supersedes: February 1, 2007 5713 - ALS Narrow Complex Tachycardia; AFib/AFlutter PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Unconscious: A. Consult Base Hospital Physician. 1. Synchronized cardioversion at 100 joules (monophasic energy dose or equivalent biphasic energy dose). 2. If no response: repeat synchronized cardioversion at 200 joules (or biphasic equivalent). 3. If no response: repeat synchronized cardioversion at 300 joules (or biphasic equivalent). 4. If no response: repeat synchronized cardioversion at 360 joules (or biphasic equivalent). III. Conscious (stable or unstable) (chest Pain, BP less than 90 mmHg systolic, decreased LOC, shortness of breath, signs of shock): A. Place on 12 Lead ECG only if chest pain is present. B. Establish an IV of normal saline TKO. C. Monitor and transport patient. D. Consider reversible causes of tachycardia. E. Consult with Base Hospital Physician for medication orders if transport time > 10 minutes or change in patient condition. San Joaquin County Emergency Medical Services Page 32 of 216 ALS Narrow Complex Tachycardia; SVT EMS Policy No. 5714 Effective: January 1, 2012 Supersedes: February 1, 2007 5714 - ALS Narrow Complex Tachycardia; SVT PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Unconscious A. B. C. Consider reversible causes of tachycardia such as hypoxia and hypovolemia. Establish an IV of normal saline TKO. Consult Base Hospital Physician. 1. Synchronized cardioversion at 100 joules monophasic energy dose (or equivalent biphasic energy dose). 2. If no response: repeat synchronized cardioversion at 200 joules (or biphasic equivalent). 3. If no response: repeat synchronized cardioversion at 300 joules (or biphasic equivalent). 4. If no response: repeat synchronized cardioversion at 360 joules (or biphasic equivalent). III. Conscious (stable or unstable) (chest Pain, BP less than 90 mmHg systolic, decreased LOC, shortness of breath, signs of shock): A. B. C. D. E. Consider reversible causes of tachycardia including hypoxia and hypovolemia and treat accordingly. Perform Valsalva’s maneuver. Establish an IV of normal saline TKO. Administer Adenosine 6mg rapid IVP immediately followed by 20 ml of normal saline. If no response after 2 minutes: Administer Adenosine 12mg rapid IVP immediately followed by 20 ml of normal saline. San Joaquin County Emergency Medical Services Page 33 of 216 ALS Narrow Complex Tachycardia; SVT EMS Policy No. 5714 Effective: January 1, 2012 Supersedes: February 1, 2007 F. G. H. If no response after 2 minutes: Administer Adenosine 12mg rapid IVP immediately followed by 20 ml of normal saline. Consider 12 Lead ECG if chest pain is present. Consult with Base Hospital Physician. San Joaquin County Emergency Medical Services Page 34 of 216 ALS Asystole EMS Policy No. 5715 Effective: October 16, 2013 Supersedes: January 1, 2012 5715 - ALS Asystole PROCEDURE: I. After completing four rounds of MICR, confirm pulselessness and rhythm. II. Treatment: A. Continue administering continuous chest compressions and ventilate the patient 8-10 times per minute. DO NOT HYPERVENTILATE. B. Establish an advanced airway and administer 100% oxygen via BVM. C. Establish IV/IO of normal saline TKO. D. Consider reversible causes and treat as indicated: 1. Hypovolemia – Start 2 large bore IV/IO lines and administer rapid 2 liter volume infusion of NS, then 250 ml boluses until systolic B/P is >90 mmHg . 2. Hypoxia – Administer 100% oxygen 3. Tension pneumothorax. – Perform thoracentesis. 4. IDDM and Dialysis (Acidosis) – Administer 1 mEq/kg of Sodium Bicarbonate IVP/IO 5. Cardiac tamponade – Continue CPR 6. Drug overdoses – Administer reversal agents as indicated. Contact Base Hospital Physician for orders if necessary. 7. Hypothermia – Initiate rewarming activities. 8. Renal Failure/Dialysis (Hyperkalemia) - Administer 500 mg of 10% Calcium Chloride and1 mEq/kg of Sodium Bicarbonate IVP/IO. E. Administer Epinephrine 1 mg (1:10,000) IVP/IO every 3 – 5 minutes twice. F. If the patient remains pulseless and apneic following four rounds of MICR and seven (7) minutes of ALS resuscitative measures, ALS personnel shall contact the Base Hospital Physician to determine whether to continue or discontinue resuscitative measures. San Joaquin County Emergency Medical Services Page 35 of 216 ALS Pulseless Electrical Activity EMS Policy No. 5716 Effective: October 16, 2013 Supersedes: February 15, 2010 5716 - ALS Pulseless Electrical Activity (PEA) PROCEDURE: I. After completing four rounds of MICR, confirm pulselessness and rhythm. A. Establish an advanced airway. B. Administer rapid infusion until systolic BP is greater than 90 mmHg or 2 liters has been infused; then reduce infusion rate TKO. II. Consider reversible causes and treat as indicated: A. Hypovolemia – Start 2 large bore IV/IO lines and administer rapid 2 liter volume infusion of normal saline. Continue infusions of normal saline in 250 ml bolus increments until systolic BP is greater than 90 mmHg . B. Hypoxia – Continue to administer 100% oxygen and manage ventilations as needed. C. Tension pneumothorax. D. IDDM and Dialysis (Acidosis) – Administer 1 mEq/kg of Sodium Bicarbonate IVP/IO. E. Cardiac tamponade – Continue CPR. F. Drug overdoses – Administer reversal agents as indicated. Contact Base Hospital Physician for orders if necessary. G. Hypothermia – Initiate rewarming interventions. H. Renal Failure/Dialysis (Hyperkalemia) - Administer 500 mg of 10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate IVP/IO. III. Following four round of MICR administer Epinephrine 1 mg (1:10,000) IVP/IO every 3 - 5 minutes two times before contacting the Base Hospital. IV. If the patient remains pulseless and apneic following four rounds of MICR and seven (7) minutes of ALS resuscitative measures, ALS personnel shall contact the Base Hospital Physician to determine if the patient should be transported or to discontinue resuscitative measures. San Joaquin County Emergency Medical Services Page 36 of 216 ALS Bradycardia EMS Policy No. 5717 Effective: January 1, 2012 Supersedes: February 15, 2010 5717 - ALS Bradycardia PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Unstable Patients (systolic BP < 90mmHg, signs of shock, decreased level of consciousness, chest pain, and shortness of breath): A. Establish IV of normal saline TKO. B. Administer Atropine in increments of 0.5mg IVP every 5 minutes to 1.5 mg. 1. If patient remains unstable, consult with Base Hospital Physician as described in II. C. 2. Atropine may be administered every five (5) minutes to a maximum of 3mg as needed. C. Consult Base Hospital Physician. 1. Initiate transcutaneous pacing. 2. Provide sedation with Midazolam 1-2 mg and/or Morphine Sulfate 1-2 mg slow IVP, and titrate to effect. 3. If capture is maintained but patient remains symptomatic, consider fluid challenges of 250 ml NS. Recheck vital signs after every 250 ml or more frequently as needed. 4. If inadequate response to Atropine and pacing, consider administering Dopamine 400 mg/250 cc premix. Using a dial-a-flow start at 10 mcg/kg/min and titrate to systolic BP of 90mmHg. (See page 2 for Dopamine dosage chart). D. For Renal Failure/Dialysis (suspected Hyperkalemia) – Consult with Base Hospital Physician to obtain order for administration of 500 mg of 10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate IVP. III. Stable Patients: A. Monitor patient and transport. B. Consult Base Hospital Physician as needed. San Joaquin County Emergency Medical Services Page 37 of 216 ALS Bradycardia EMS Policy No. 5717 Effective: January 1, 2012 Supersedes: February 15, 2010 DOPAMINE DOPAMINE 400 mg in 250 cc NS or D5W 60 drops/min = 60 ml/hr Weight (kg) gtts/min to = 10 mcg/kg/min Weight (kg) gtts/min to = 10 mcg/kg/min 35-45 15 gtts/min 85-90 35 gtts/min 45-55 20 gtts/min 95-105 40 gtts/min 60-70 25 gtts/min 110 & up 45 gtts/min 75-80 30 gtts/min San Joaquin County Emergency Medical Services Page 38 of 216 ALS Chest Pain EMS Policy No. 5719 Effective: October 16, 2013 Supersedes: October 1, 2011 5719 - ALS Chest Pain POLICY: I. Perform routine ALS/BLS medical care. II. Treatment: A. Oxygen 12 - 15 lpm via non-rebreather mask. B. IV of normal saline TKO. C. Administer nitroglycerin 0.4 mg SL - if systolic blood pressure is above 90 mmHg. May repeat every 5 minutes if signs/symptoms persist and systolic BP remains above 90 mmHg. D. If patient is able to swallow, give Aspirin 325 po. E. Perform 12 Lead ECG – Initiate STEMI Alert* if indicated. F. Transport. III. STEMI ALERT Process: A. Contact SRC ASAP to announce the STEMI alert, provide an ETA, and state that transmission of the 12 lead ECG will be sent when en route (if equipped to do so). B. Initiate rapid transport to a STEMI receiving center per EMS Policy No. 5201, Medical Patient Destination. C. Transmit ECG to SRC when en route to the SRC (if equipped to do so). D. Administer morphine sulfate 2 mg slow IVP if patient is still symptomatic after three (3) Nitroglycerin doses, or if Nitroglycerin is contraindicated. 1. May repeat morphine sulfate 2-4 mg slow IVP every 3-5 minutes to a maximum of 15 mg total. Monitor BP and respirations between dosages. Do not repeat doses if systolic BP less than 90 mmHg. NOTE: *All STEMI alerts shall be based on the cardiac monitor/defibrillator manufacture’s operating instructions San Joaquin County Emergency Medical Services Page 39 of 216 ALS Chest Pain EMS Policy No. 5719 Effective: October 16, 2013 Supersedes: October 1, 2011 regarding STEMI alerting messages. LP12 (*** ACUTE MI SUSPECTED ***); LP15 (*** MEETS ST ELEVATION MI CRITERIA ***); Zoll E Series (** ** ** ** * ACUTE MI * ** ** ** **) IV. Special Considerations for all patients: A. If systolic blood pressure less than 90 mmHg, administer a 250 cc fluid bolus. B. Nitroglycerin is contraindicated and should NOT be administered to patients of either gender who have taken Viagra, (sildenafil citrate) or Levitra (vardenafil HCL) within 24 hours or Cialis (tadalafil) within 36 hours. C. Aspirin should NOT be administered to patients with an aspirin allergy or active GI bleeding. San Joaquin County Emergency Medical Services Page 40 of 216 ALS Cardiogenic Shock EMS Policy No. 5720 Effective: January 1, 2012 Supersedes: February 15, 2010 5720 - ALS Cardiogenic Shock PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. B. C. D. E. Apply Oxygen at 10 to 15 LPM via a non-rebreather mask. Obtain 12 Lead ECG and transport to an SRC if indicated. Treat significant arrhythmias. Establish IV of normal saline TKO. Administer a NS fluid challenge of up to 1 liter while rechecking vital signs and lung sounds after every 250 mls. If patient’s lungs are not clear, discontinue the fluid challenge and consult the base hospital physician. F. If systolic blood pressure remains less than 90 mmHg following fluid challenges, or if the patient’s lungs are not clear, consult Base Hospital Physician. Anticipate an order for an infusion of Dopamine, titrated at 10mcg/kg/min to a systolic blood pressure of 90 mmHg using a dial-a-flow with extension tubing. G. Transport immediately. DOPAMINE 400 mg in 250 cc NS or D5W - 60 drops/min = 60 ml/hr Weight gtts/min to = 10 Weight gtts/min to = 10 (kg) mcg/kg/min (kg) mcg/kg/min 35-45 15 gtts/min 85-90 35 gtts/min 45-55 20 gtts/min 95-105 40 gtts/min 60-70 25 gtts/min 110 & up 45 gtts/min 75-80 30 gtts/min San Joaquin County Emergency Medical Services Page 41 of 216 ALS Ventricular Ectopy EMS Policy No. 5724 Effective: January 1, 2012 Supersedes: February 1, 2007 5724 - ALS Ventricular Ectopy DEFINITIONS: A. Ventricular ectopy: Couplets or multifocal PVCS > 6 BPM, or non-sustained runs of ventricular tachycardia. PROCEDURE: I. II. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. Treatment: A. Obtain 12 lead ECG and transport to a STEMI Receiving Center if indicated. B. Establish IV of normal saline. C. In the presence of continuous chest pain, administer Lidocaine 1mg/kg IVP. May repeat every 5-10 minutes at ½ initial dose up to a total of 3 mg/kg. D. Lidocaine Drip: 1gm in 250 ml Normal Saline. Utilizing a dial-a-flow with extension tubing, administer 2-4 mg/min to decrease or eliminate ventricular ectopy. San Joaquin County Emergency Medical Services Page 42 of 216 ALS Return of Spontaneous Circulation EMS Policy No. 5726 Effective: January 1, 2012 Supersedes: February 15, 2010 5726 - ALS Return of Spontaneous Circulation POLICY: I. Perform routine ALS/BLS medical care while confirming palpable carotid pulse and blood pressure. II. Monitor for reoccurrence or cardiac instability. III. Treatment: A. For adult patients begin therapeutic hypothermia as indicated in accordance with EMS Policy No 5727, ALS Therapeutic Hypothermia. B. Establish IV of normal saline TKO. C. B/P greater than 90 systolic: 1. Monitor cardiac rhythm and vital signs. 2. If patient was resuscitated from VF/VT or ventricular ectopy is present, administer Lidocaine 1mg/kg IVP. May repeat every 5-10 minutes at ½ initial dose up to a total of 3 mg/kg. 3. Lidocaine Drip: Utilizing a dial-a-flow and extension tubing administer 1gm in 250 ml normal saline or D5W. Administer 2-4 mg/min to decrease or eliminate ventricular ectopy. D. B/P less than 90 systolic 1. Administer fluid challenge of 500ml IV. 2. If heart rate is less than 60 BPM: a. Administer Atropine 0.5mg IVP. Repeat every 5 minutes as needed to a maximum dose of 3 mg. b. Initiate transcutaneous pacing if HR and B/P do not improve following administration of Atropine. 3. Consider Dopamine infusion. Using a dial-a-flow and extension tubing start at 10mcg/kg/min and titrate to a systolic blood pressure of 90 mmHg. San Joaquin County Emergency Medical Services Page 43 of 216 ALS Therapeutic Hypothermia EMS Policy No. 5727 Effective: January 1, 2012 Supersedes: NA 5727 - ALS Therapeutic Hypothermia POLICY: Implementation of therapeutic hypothermia for comatose cardiac arrest patients with Return of Spontaneous Circulation (ROSC) is a procedure endorsed by the American Heart Association and outlined in the 2003 Advisory Statement by the ALS Task Force of the International Liaison Committee on Resuscitation (ILCOR). Mild hypothermia is thought to reduce cerebral oxygen demand post arrest, and reduce the damage caused by inflammatory responses that occur once cerebral perfusion is restored. Inducing mild hypothermia in comatose patients post out-of-hospital cardiac arrest has been shown to improve neurological function and decrease mortality I. INDICATIONS: A. Patients 18 years of age and over: 1. The sustained return of spontaneous circulation for a minimum of 5 minutes following cardiac arrest. 2. Persistent coma following cardiac arrest (VF, pulseless VT, PEA, and Asystole): unresponsive, not following verbal commands, not presenting with any purposeful movements, GCS < 8. Brainstem reflexes and posturing movements may be present. 3. Blood pressure ≥ 90 mmHg systolic. 4. SpO2 > 85%. 5. Blood glucose > 50 mg/dL. II. CONTRAINDICATIONS: A. Traumatic cardiac arrest. B. GCS ≥ 8, and/or rapidly improving GCS. C. Pregnancy. D. DNR. San Joaquin County Emergency Medical Services Page 44 of 216 ALS Therapeutic Hypothermia EMS Policy No. 5727 Effective: January 1, 2012 Supersedes: NA III. Treatment: A. In conjunction with EMS Policy No. 5726, ALS Return of Spontaneous Circulation, the paramedic should begin cooling measures as follows: 1. Expose patient and apply eight (8) cold packs: a. 2 on head b. 2 on the neck over the carotid arteries c. 1 in each axilla d. 1 on each femoral artery at groin 2. Institute other cooling measures (e.g. removal of the patient’s clothes, turn on ambulance AC in the patient compartment and direct air flow over the patient). 3. Obtain a 12-lead ECG. 4. If patient begins to shiver contact the base hospital contact for administration of Midazolam or if patient becomes responsive, discontinue therapeutic hypothermia. 5. Advise the emergency department personnel upon arrival that you have initiated the cooling process. B. Patient Transportation Considerations: 1. If the 12 lead ECG indicates a ST Elevated Myocardial Infarction (STEMI), the patient shall be transported to a STEMI receiving center. 2. If the 12 lead ECG does not indicate a STEMI, the patient shall be transported to a receiving hospital with therapeutic hypothermia capabilities. San Joaquin County Emergency Medical Services Page 45 of 216 ALS Allergic Reaction/Anaphylaxis EMS Policy No. 5731 Effective: January 1, 2012 Supersedes: February 1, 2007 5731 - ALS Allergic Reaction/Anaphylaxis PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. B. C. D. Remove allergen if possible. Mild reaction (urticaria only): 1. Consider diphenhydramine 50mg IM. Moderate to severe reaction (Urticaria with one or more of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps). 1. Consider epinephrine 1:1000, 0.01mg/kg SQ. Maximum dose 0.5mg. (Use with caution in patients over the age of 35 years and in patients with known coronary artery disease or HTN.) 2. If wheezing, initiate hand held nebulizer dose of Albuterol 5mg in 6 ml NS. May repeat as needed. 3. Consider IV NS TKO or saline lock. 4. Administer diphenhydramine 1mg/kg to maximum dose of 50mg IM or IVP. Anaphylaxis (Urticaria and signs of shock with any or all of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps). 1. Administer epinephrine 1:1000, 0.01mg/kg SQ. Maximum dose 0.5mg. (Use with caution in patients over the age of 35 years and in patients with known coronary artery disease or HTN.) 2. Establish large bore IV of NS and administer 250ml fluid boluses as indicated. 3. If wheezing, initiate hand held nebulizer dose of Albuterol 5mg in 6 ml NS. May repeat as needed. San Joaquin County Emergency Medical Services Page 46 of 216 ALS Allergic Reaction/Anaphylaxis EMS Policy No. 5731 Effective: January 1, 2012 Supersedes: February 1, 2007 4. 5. 6. 7. Administer diphenhydramine 1mg/kg to maximum dose of 50mg IM or IVP. Consider intubation. If patient is unresponsive with no palpable pulses, administer epinephrine (1:10,000) 0.01mg/kg to max dose of 0.5mg IV. Consult base hospital physician for further orders. San Joaquin County Emergency Medical Services Page 47 of 216 ALS Poisoning/Overdose EMS Policy No. 5733 Effective: January 1, 2012 Supersedes: January 1, 2007 5733 - ALS Poisoning/Overdose DEFINITIONS: A. Poisoning/Overdose: Ingestion and/or exposures to one or more toxic substances, including alcohol. PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Identify substance. Bring any containers, labels or a sample (if safe) into the hospital with the patient. Determine type, amount, and time of the exposure. III. Treatment: A. Establish IV of normal saline TKO or saline lock if indicated. B. Initiate early transport and receiving hospital notification. IV. Substance Specific Treatment: A. Opiates: 1. Manage airway and adequate ventilation. 2. Administer Naloxone titrated to maintain adequate ventilation and airway control. Initial dose is 0.4mg - 2 mg IVP (maximum dose of 4mg). May administer Intranasally (IN), IM, or SL if unable to start IV. B. Cocaine/Amphetamines: 1. Consider activated charcoal 1gm/kg PO, not to exceed 50gms given orally if within the first 60 minutes of ingestion. 2. Monitor for seizures and/or dysrhythmias and treat accordingly. 3. For immediate control of psychomotor agitation, consult Base Hospital Physician for sedative order. San Joaquin County Emergency Medical Services Page 48 of 216 ALS Poisoning/Overdose EMS Policy No. 5733 Effective: January 1, 2012 Supersedes: January 1, 2007 C. Insecticides (organophosphates, carbonates): 1. Skin exposure: decontaminate patient as soon as possible (remove clothes, wash skin). 2. Avoid contamination of prehospital personnel. 3. Assess for SLUDGE (salivation, lacrimation, urination, diaphoresis/diarrhea, gastric hypermotility, and emesis/eye [small pupils and/or blurry vision]). 4. If indicated, administer Atropine 2.0 mg IVP slowly. If no tachycardia or pupil dilation, give second dose of 2.0mg IVP. Note: Atropine does not reverse muscle weakness that leads to respiratory failure. 5. Atropine can be toxic and orders for repeated doses above 4 mg should be given by the Base Hospital Physician Only. D. Cyclic Antidepressants: 1. Anticipate rapid deterioration of condition. 2. In the presence of life-threatening dysrhythmias: a. Hyperventilate if assisting ventilation. b. Administer Sodium Bicarbonate 1mEq/kg IVP. 3. For seizures, see EMS Policy, No. 5753, Seizures. 4. For signs of shock see EMS Policy No. 5720, Cardiogenic Shock. E. Beta Blockers: 1. Consider activated charcoal 1gm/kg PO, not to exceed 50gms given orally if within the first 60 minutes of ingestion. 2. Obtain blood glucose level. F. Calcium Channel Blockers: 1. Consider activated charcoal 1gm/kg PO, not to exceed 50gms given orally if within the first 60 minutes of ingestion). 2. If bradycardic and/or hypotensive, consult Base Hospital Physician for order to administer Calcium Chloride 500mg slow IVP over five (5) minutes. May repeat x 1 in ten (10) minutes. San Joaquin County Emergency Medical Services Page 49 of 216 ALS Poisoning/Overdose EMS Policy No. 5733 Effective: January 1, 2012 Supersedes: January 1, 2007 G. Phenothiazine Reactions: 1. Administer Diphenhydramine 1 mg/kg IVP/IO to a maximum of 50 mg. If unable to establish IV access, administer IM. H. Other Non-Caustic Drugs: 1. If patient is awake and alert consider activated charcoal orally—1gm/kg PO, not to exceed 50gms if within the first 60 minutes of ingestion. 2. Consider contacting Poison Control Center. I. Hydrocarbons (kerosene, gasoline, lighter fluid, turpentine, furniture polish, etc): 1. Do not induce vomiting-transport immediately. J. Caustic Substances (acids/alkalis): 1. Do not induce vomiting. San Joaquin County Emergency Medical Services Page 50 of 216 ALS Heat Illness EMS Policy No. 5735 Effective: January 1, 2010 Supersedes: February 1, 2007 5735 - ALS Heat Illness DEFINITIONS: A. Heat Cramps: Cramping of the most worked muscles following replacement of exertion induced fluid losses (sweating) with water; exhaustion, fatigue, flu-like symptoms, normal/slightly elevated body temperature, normal mental status with clear lung sounds. B. Heat Stroke: Triad of exposure to heat stress, altered mental status and elevated body temperature; often associated with absence of sweating, tachycardia and hypotension. PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Specific Heat Cramps/Heat Exhaustion Treatment: A. Move patient to cool environment and initiate passive cooling measures. B. If lungs clear, give fluid challenge of 250mls of NS. May repeat x 4. C. Recheck vital signs and lungs after every 250 mls. III. Specific Heat Stroke Treatment: A. Move to cool environment and begin cooling measures: 1. Remove clothing and splash/sponge with water. 2. Place cool packs on neck, axilla, and inguinal areas. 3. Promote cooling by fanning. 4. IV NS 10 cc/kg (maximum of 2 liters) while repeating vital signs and listening to lung sounds after every 250 mls. San Joaquin County Emergency Medical Services Page 51 of 216 ALS Hypothermia EMS Policy No. 5736 Effective: January 1, 2012 Supersedes: February 1, 2007 5736 - ALS Hypothermia PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. Early receiving hospital notification. B. Ensure patent airway. C. Move to sheltered area minimizing patient’s physical exertion or movement. Remove patient’s wet clothing and cover with warm, dry sheet or blankets. D. Establish IV of normal saline. If lungs clear, consider fluid challenge of 10 ml/kg warm normal saline. Recheck vitals following each infusion of 250 mls of normal saline. E. Severe hypothermia (stuporous or comatose, dilated pupils, hypotensive or pulseless, slowed to absent respirations): 1. Prepare to support ventilations using appropriate airway adjuncts. If spontaneous respirations are present, intubate only if necessary to prevent aspiration or if ventilations are inadequate (4-6/min may be adequate). 2. Ventilate using warm, humidified oxygen if available. Avoid hyperventilating the patient. 3. Observe for organized rhythm and pulses for one minute. If organized rhythm present, move quickly but gently to warm environment (ambulance) and provide appropriate treatment for cardiac rhythm per EMS Agency policy. San Joaquin County Emergency Medical Services Page 52 of 216 ALS Envenomation EMS Policy No. 5738 Effective: February 1, 2007 Supersedes: SJ-A61 5738 - ALS Envenomation PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. Refer to EMS Policy No. 5535, Basic Life Support Envenomation. B. Insect bite: 1. Scrape away stinger (if appropriate). 2. Observe for Allergic Reaction/Anaphylaxis and treat accordingly (EMS Policy No. 5731). 3. Apply cold packs for pain management. C. Snake bite: 1. Immobilize extremity at or below heart level. 2. Circle swelling and note time. 3. Apply a light constricting band about 2" above and below the bite. The purpose of constricting bands is to restrict lymphatic flow, not blood, so they should not be too tight. Check pulses below the bands and readjust the bands as necessary when they tighten due to swelling. 4. Consider pain management. 5. Initiate early receiving hospital notification. 6. Expedite transport. For snakebite, do NOT: 1. Apply ice to site. 2. Make incisions over bite. 3. Apply a tourniquet. 4. Delay transport to initiate IV. San Joaquin County Emergency Medical Services Page 53 of 216 ALS ALOC EMS Policy No. 5751 Effective: October 16, 2013 Supersedes: January 1, 2012 5751 - ALS Altered Level of Consciousness (ALOC) PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Obtain a complete patient history including current medications. III. Identify and document neurological deficits. IV. Consider indications for spinal immobilization precautions, per EMS Agency Policy No. 5115 Cervical Spine Immobilization. V. Consider potential causes (hypoglycemia, stroke, neurological injury, syncope, overdose, and sepsis). VI. Treatment: A. B. C. D. Establish IV/IO of normal saline and administer a 10ml/kg bolus if signs of shock are present (maximum infusion of 2 liters). Check blood glucose. 1. Glucose paste may be administered if the patient is a known diabetic, can hold head upright, can self administer medication, and has an intact gag reflex. 2. If blood sugar is less than 60 mg/dl, administer either Dextrose 50% 25 Gms IVP; or Dextrose 10% 50 ml IV/IO bolus, repeated every minute until GCS is 15. Maximum dose of Dextrose 10% is 10 ml/kg. If narcotic overdose is suspected, administer Naloxone 0.4mg-2mg IV titrated to achieve effective respirations (maximum dose 4 mg). If unable to obtain IV access, may administer Naloxone 2 mg IM or Intranasally (1mg in each nares using approved San Joaquin County Emergency Medical Services Page 54 of 216 ALS ALOC EMS Policy No. 5751 Effective: October 16, 2013 Supersedes: January 1, 2012 E. F. atomizer attached to syringe). Treat rhythm disturbances as appropriate. Transport immediately if progressive neurologic deficit is evident or unable to maintain effective airway. San Joaquin County Emergency Medical Services Page 55 of 216 ALS Seizures EMS Policy No. 5753 Effective: October 16, 2013 Supersedes: January 1, 2012 5753 - ALS Seizures PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Protect from injury. III. Initiate cooling measures, if febrile patient. IV. Treatment: A. B. C. D. If witnessed by prehospital personnel to be seizing for > 2 minutes or patient has two or more seizures without regaining consciousness; Establish IV of normal saline TKO. 1. Administer Midazolam 2 mg slow IVP or 4 mg intranasally (2 mg in each nares using a mucosal atomizer device). a. May be administered IM if unable to obtain vascular access, or IN device unavailable. b. May be repeated if necessary every 5 minutes to a maximum dose of 10 mg. Obtain blood glucose level. 1. If glucose less than 60 mg/dl, administer Dextrose 50% 25Gms IV/IO or administer Dextrose 10% 50ml IV/IO bolus, repeated every minute until GCS is 15. Maximum dose is 10 ml/kg. If narcotic overdose suspected: 1. Administer Naloxone IVP in 0.4 mg increments titrated to achieve effective respirations (maximum dose 4 mg) or administer IN 1 mg in each nares. 2. If unable to establish an IV and narcotic overdose suspected, may administer Naloxone 2mg IM, SQ, or SL. San Joaquin County Emergency Medical Services Page 56 of 216 ALS Seizures EMS Policy No. 5753 Effective: October 16, 2013 Supersedes: January 1, 2012 E. V. For pregnant patients, treat as indicated for seizures per this policy and refer to EMS Policy No. 5761, ALS Gynecological Emergencies. Continued Seizure Activity: A. B. Be prepared to assist ventilations. Make base contact if seizures continue after maximum dose of Midazolam. San Joaquin County Emergency Medical Services Page 57 of 216 ALS Acute Stroke EMS Policy No. 5754 Effective: February 1, 2012 Supersedes: February 1, 2007 5754 - ALS Acute Stroke PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Assess patient using the Cincinnati Prehospital Stroke Scale (CPSS) and document findings. The patient is considered a possible stroke if any of the tested signs/symptoms is abnormal. III. Initiate early notification and transport to the receiving hospital. IV. Treat patient according to EMS Policy No. 5751, ALS Altered Level of Consciousness (ALOC), including blood glucose level determination. V. Transport without delay if progressive neurologic deficit is evident or unable to maintain effective airway. San Joaquin County Emergency Medical Services Page 58 of 216 ALS Gynecological Emergencies EMS Policy No. 5761 Effective: January 1, 2012 Supersedes: February 1, 2007 5761 - ALS Gynecological Emergencies DEFINITIONS: A. “Severe Pre-Eclampsia” means a third trimester pregnancy with hypertension (BP systolic greater than 160 mmHg, diastolic greater than 110 mmHg), mental status changes, visual disturbances and/or peripheral edema. B. “Eclampsia” means third trimester pregnancy with hypertension (BP systolic greater than 160 mmHg, diastolic greater than 110 mmHg), mental status changes, visual disturbances, peripheral edema, seizures and/or coma. C. “High Risk Obstetrical” means a pregnancy is one in which some condition puts the mother, the developing fetus, or both at higher-than-normal risk for complications during or after the pregnancy and birth. INFORMATION NEEDED: A. Last menstrual period and possibility of pregnancy. B. Duration and amount of any bleeding. C. If pregnant – month of pregnancy, any anticipated problems e.g. pre-eclampsia, lack of prenatal care, expected multiple births). D. Presence of contractions, cramps, or discomfort. E. Pertinent past medical history. OBJECTIVE FINDINGS: A. Estimated blood loss. B. Low blood pressure or high blood pressure. C. Spontaneous abortion – passage of products of conception, fetus less than 20 weeks gestation. D. Headaches, blurred vision. E. Severe abdominal cramps or sharp abdominal pain. San Joaquin County Emergency Medical Services Page 59 of 216 ALS Gynecological Emergencies EMS Policy No. 5761 Effective: January 1, 2012 Supersedes: February 1, 2007 PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Obtain appropriate gynecological medical history. III. Without Shock: A. Treatment: 1. Non-pregnant patient: a. Establish IV of normal saline TKO. b. If post-partum and placenta has delivered, perform fundal massage and put infant to breast (as appropriate). 2. Pregnant patient: a. Place patient in left lateral position. b. If any bleeding in third trimester, establish two (2) large bore IVs of normal saline TKO. c. Consult base hospital. IV. With Shock: A. Treatment: 1. Non-pregnant patient: a. Establish a large bore IV of normal saline. Administer a fluid challenge of 10 ml/kg. Recheck vital signs after each infusion of 250 mls normal saline. b. Consider second large bore IV of normal saline. c. If post-partum and placenta delivered, perform fundal massage and put infant to breast (as appropriate). 2. Pregnant Patient: a. Position in left lateral position if concern for spinal injury is not present. If concern is present, keep in spinal precaution and manually attempt movement of uterus towards left side with gentle traction. San Joaquin County Emergency Medical Services Page 60 of 216 ALS Gynecological Emergencies EMS Policy No. 5761 Effective: January 1, 2012 Supersedes: February 1, 2007 b. Establish a large bore IV of normal saline. Administer a fluid challenge of10 ml/kg. Recheck vital signs after each infusion of 250 mls normal saline. c. Consider second IV of normal saline. V. Pre-Eclampsia/Eclampsia: A. Treatment: 1. Position patient on left side. 2. Transport quickly in a quiet environment (no siren). 3. Establish IV of normal saline TKO, while enroute to hospital. 4. Treat seizures according to EMS Policy No. 5753, Seizures. 5. Consult Base Hospital Physician to obtain order for Magnesium Sulfate 2 gms slow IVP over 3 – 5 minutes. VI. High Risk Obstetrical: A. High Risk Obstetrical patients are patients that are pregnant who have signs and symptoms of active labor or vaginal bleeding with one or both of the following conditions: 1. No history of prenatal care. 2. Estimated gestational age from 20 to 33 weeks. San Joaquin County Emergency Medical Services Page 61 of 216 ALS Childbirth EMS Policy No. 5764 Effective: January 1, 2012 Supersedes: January 1, 2010 5764 - ALS Childbirth DEFINITIONS: A. B. C. Imminent Delivery: Regular contractions, bloody show, low back pain, feels like bearing down, crowning. Breech Presentation: Presentation of buttocks or both feet. Limb Presentation: Presentation of single extremity. INFORMATION NEEDED: A. Estimated due date, month of pregnancy, any anticipated problems (e.g. pre-eclampsia, lack of prenatal care, expected multiple births). B. Onset of regular contractions, current frequency of contractions, rupture of membranes. C. Urge to bear down, number of previous pregnancies and live births. OBJECTIVE FINDINGS: A. Observe perineal area for fluid, bleeding, crowning (during contraction), abnormal presentation (breech, extremity, cord). PROCEDURE: I. II. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. Treatment: A. Normal Delivery: 1. Establish IV of normal saline TKO. 2. Assist mother with delivery, using clean, preferably sterile technique. 3. Check for cord around the neonate’s neck, and gently slide San Joaquin County Emergency Medical Services Page 62 of 216 ALS Childbirth EMS Policy No. 5764 Effective: January 1, 2012 Supersedes: January 1, 2010 4. 5. 6. 7. 8. overhead if possible. If the cord is tight, clamp and cut the cord to unwind the cord and deliver neonate as quickly as possible. Suction the neonate’s mouth and nose with bulb syringe. Perform neonatal resuscitation if needed. Dry and wrap the neonate (especially the head). Keep the neonate warm and place with mother (if possible). Deliver placenta and place in a bio-hazard bag and transport to hospital. Perform fundal message to help stop postpartum bleeding. B. Complicated Delivery: 1. Apply high flow oxygen. 2. Establish IV of normal saline TKO. 3. Begin rapid transport to a Neonate/High Risk Pregnancy receiving hospital and make early base hospital contact. 4. Prepare for neonatal resuscitation. 5. Breech Delivery: a. Assist with and continue delivery if possible. b. Provide airway for neonate with gloved hand if unable to continue delivery. c. If unable to deliver, place mother in shock position. 6. Prolapsed Cord: a. Place mother in shock position, elevate hips with pillows, if possible place mother in knee chest position. b. If cord is present, assess cord for palpable pulse. c. If strong regular pulse is absent, gently insert gloved hand into vagina to relieve pressure on cord. d. Cover exposed cord with saline soaked dressing. 7. High Risk Delivery: Any newborn who meets one or more of the following conditions shall be transported to a designated Neonatal Intensive Care Center in accordance with EMS Policy No. 5201, Medical Patient Destination: a. Significant anoxia either prior to or during transport. b. Estimated gestational age less than 33 weeks. 8. Neonatal patients who are in cardiac/respiratory arrest should be treated in accordance with EMS Policy No. 5201, San Joaquin County Emergency Medical Services Page 63 of 216 ALS Childbirth EMS Policy No. 5764 Effective: January 1, 2012 Supersedes: January 1, 2010 Medical Patient Destination and be transported to the closest receiving hospital. Notes: First priority in childbirth is assisting mother with delivery of child. The primary enemy of the newborn is hypothermia which can occur in minutes. Ensure the newborn has a clear airway. Suction with bulb syringe as needed. Keep baby at or below the level of the mother’s heart until cord is clamped. Do not pull on the umbilical cord. San Joaquin County Emergency Medical Services Page 64 of 216 ALS Bronchospasm EMS Policy No. 5771 Effective: January 1, 2010 Supersedes: June 1, 2008 5771 - ALS Bronchospasm DEFINITIONS: A. Bronchospasm: Acute onset of respiratory difficulty, including toxic inhalation, asthma, COPD and other etiologies that may induce bronchospasm. PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. Mild to moderate bronchospasm: 1. Initiate nebulizer dose of Albuterol 2.5mg in 3 ml NS and Atrovent 0.5mg in 2.5 ml NS. 2. Repeat Albuterol prn. B. Severe bronchospasm: 1. Assist ventilations with 100% oxygen and initiate an inline nebulizer treatment of Albuterol 2.5 mg in 3 ml NS and Atrovent 0.5mg in 2.5 ml NS 2. Continue Albuterol 2.5 mg nebulizer/bag-valve-mask. 3. Epinephrine 1:1000, 0.01 mg/kg SQ. Maximum dose 0.5 mg. (Use with caution in patients over 35 years of age and in patients with coronary artery disease). 4. Consider CPAP (see EMS Policy No. 2554, Continuous Positive Airway Pressure). 5. Ensure early receiving hospital notification. Note: Breath actuated nebulizer should only be utilized with patients who have adequate spontaneous respirations. Patients that require ventilatory support should have nebulized medications administered via standard nebulizer equipment. San Joaquin County Emergency Medical Services Page 65 of 216 ALS Acute Pulmonary Edema EMS Policy No. 5772 Effective: October 16, 2013 Supersedes: February 2, 2010 5772 - ALS Acute Pulmonary Edema DEFINITIONS: A. Acute Pulmonary Edema: Acute onset of respiratory difficulty with systolic blood pressure over 120. May have history of cardiac disease, rales, or occasional wheezes. PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. B. C. D. E. Oxygen 12 - 15 lpm via non-rebreather mask. Initiate IV access. Nitroglycerin 0.4 mg spray or tablets, repeat every 5 minutes if systolic blood pressure remains greater than 100mmHg. If patient is in severe respiratory distress, consider CPAP (Policy No. 2554, Continuous Positive Airway Pressure). If using CPAP and patient cannot tolerate further sublingual nitroglycerin, apply one (1) inch of nitroglycerine paste to the patient’s chest wall. Remove the paste if systolic blood pressure falls below 90mmHg. San Joaquin County Emergency Medical Services Page 66 of 216 ALS Airway Obstruction EMS Policy No. 5774 Effective: January 1, 2010 Supersedes: February 1, 2007 5774 - ALS Airway Obstruction DEFINITION: A. Severe obstruction: Signs of severe obstruction include poor air exchange, increased breathing difficulty, silent cough, cyanosis, and/or inability to speak or breathe. PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Follow EMS Policy No. 5573, BLS Obstructed Airway – Adult. III. If no signs of severe obstruction present, maintain airway and apply oxygen. IV. If patient has signs of severe obstruction and/or is unconscious: A. Continue abdominal and chest thrusts. B. Assist ventilation with BVM. C. Use direct laryngoscopy and Magill forceps to remove foreign body. D. If unsuccessful, attempt endotracheal intubation. E. If unsuccessful and unable to ventilate adequately with BVM, consider Needle Cricothyrotomy (Policy No. 2549). San Joaquin County Emergency Medical Services Page 67 of 216 ALS Burn Care EMS Policy No. 5782 Effective: February 24, 2012 Supersedes: February 1, 2007 5782 - ALS Burn Care PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Treatment: A. Stop the burning process. B. Follow EMS Policy No. 5586, Basic Life Support Burns. C. Consider early advanced airway intervention if airway and/or facial burn is involved. D. Superficial burns: 1. Consider initiating IV of NS at TKO rate. 2. For pain management, in absence of hypotension and no narcotic allergies, administer Morphine Sulfate per Adult Pain protocol. E. Major burns (>20% total body surface area [BSA]): 1. Initiate large bore IV access. Initiate fluid replacement using the Parkland Formula. 2. For pain management, in absence of hypotension and no narcotic allergies, administer Morphine Sulfate per EMS Policy No. 5707, Adult Pain Management. III. Initiate early notification of receiving hospital and consult with base hospital as appropriate. Parkland Formula: Amount of IV fluid infused during the first 24 hours = weight in kg X 4 ml X % BSA burned. Administer one-half of the calculated fluid during the first 8 hours. Note: The starting time is considered the time at which the burn occurred and not the time at which medical care is initiated. To obtain an initial hourly infusion rate, use the following formula: (4ml x kg x % BSA) / 8 Example: 120kg male with 20% BSA burn = (4 x 120 x 20) / 8 = 1200 ml/hr infusion rate San Joaquin County Emergency Medical Services Page 68 of 216 ALS Adult Trauma Treatment EMS Policy No. 5783 Effective: October 16, 2013 Supersedes: January 1, 2012 5783 - ALS Adult Trauma Treatment PROCEDURE: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. II. Do not delay transport. III. Treatment: A. Patient with Unstable Airway: 1. Secure airway using the simplest, effective method, while maintaining spinal immobilization, if indicated. B. Hypovolemic Patient 1. Establish 1-2 large bore IV(s) of normal saline. a. If patient is hypotensive, administer normal saline wide open until systolic blood pressure greater than 90 mmHg or 2 liters has been infused, and then reduce infusion TKO. b. Continue to monitor blood pressure and if the systolic blood pressure remains less than 90 mmHg after initial bolus, give 250 ml boluses until BP greater than 90. c. Reassess the patient after each bolus. C. Pain Management: In absence of hypotension and no narcotic allergies, administer Morphine Sulfate per EMS Policy No. 5707, Adult Pain Management. D. Head, Neck, and Facial Trauma Considerations: 1. If brain injury is suspected, elevate the head of the patient, (as long as no signs of shock are present). 2. Maintain patent airway. If intubation is indicated and time allows, premedicate brain injury patients with Lidocaine 1.5mg/kg IVP prior to intubation. E. Chest Trauma Considerations: 1. Impaled object – Immobilize and leave in place. San Joaquin County Emergency Medical Services Page 69 of 216 ALS Adult Trauma Treatment EMS Policy No. 5783 Effective: October 16, 2013 Supersedes: January 1, 2012 2. Flail chest – Stabilize chest, observe for tension pneumothorax. 3. Open chest wound – Cover wound with loose dressing (do not seal). Continuously monitor patient for tension pneumothorax. 4. Tension pneumothorax – Perform needle thoracostomy (or remove any occlusive dressing covering an open chest wound). 5. Cardiac Tamponade – If systolic BP is less than 90 mmHg, treat as traumatic shock. 6. Cardiac Contusion – Monitor for dysrhythmias and treat accordingly. F. Abdominal Trauma Considerations: 1. Impaled object – Immobilize and leave in place. 2. Evisceration of organs – Cover eviscerated organs with saline soaked gauze. Do not attempt to replace organs into the abdominal cavity. 3. Genital injuries – Cover genitalia with saline soaked gauze. If necessary, apply direct pressure to control bleeding. Treat amputation as extremity amputation. G. Extremity Trauma Considerations: EMS Policy No. 5585, BLS Extremity Trauma. H. Amputation – Cover amputated part with dry sterile dressing and place in sealed plastic bag (or wrapped with plastic) on top of ice or cold pack. I. Traumatic Arrest: 1. Patient transport considerations: a. If the estimated transport time (from time of traumatic arrest to arrival at the Trauma Center) is < ten minutes, continue BLS resuscitation and immediately transport the patient to the Trauma Center. Consider providing an advanced airway enroute. b. If the estimated transport time (from time of traumatic arrest to arrival at the Trauma Center) is > ten minutes begin BLS resuscitation and attach the ECG for rhythm check. 2. Treatment: San Joaquin County Emergency Medical Services Page 70 of 216 ALS Adult Trauma Treatment EMS Policy No. 5783 Effective: October 16, 2013 Supersedes: January 1, 2012 a. For patients in asystole provide BLS resuscitation and contact the Base Hospital Physician to request orders to cease resuscitative efforts. b. For patients in ventricular fibrillation or pulseless VTach, provide BLS resuscitation and defibrillate the patient once. i. If no ROSC contact the Base Hospital Physician to request orders to cease resuscitative efforts. ii. If ROSC transport the patient to the trauma center. While enroute start two large bore IVs and administer Lidocaine 1mg/kg IVP/IO. Consider providing an advanced airway enroute. c. For patients in PEA provide BLS resuscitation and consider treating for tension pneumothorax and hypovolemia: i. If no ROSC contact the Base Hospital Physician to request orders to cease resuscitative efforts. ii. If ROSC transport the patient to the trauma center. Consider providing an advanced airway enroute. San Joaquin County Emergency Medical Services Page 71 of 216 ALS Nerve Agent EMS Policy No. 5790 Effective: July 1, 2010 Supersedes: NA 5790 - ALS Nerve Agent Exposure DEFINITIONS: A. “CHEMPACK” means a voluntary component of the Federal Strategic National Stockpile Program (SNS) operated by the Centers for Disease Control and Prevention (CDC) for the benefit of the U.S. civilian population. The CHEMPACK program’s mission is to provide state and local governments a sustainable nerve agent antidote cache that increases their capability to respond quickly to a nerve agent event such as a terrorist attack. B. “Nerve Agents” mean an extremely toxic organophosphate-type chemicals, including GA (tabun), GB (sarin), GD (soman), GF (cyclosarin), and VX, which attack the nervous system and interfere with chemicals that control nerves, muscles, and glands. They are odorless and invisible and can be inhaled, absorbed through the skin, or swallowed. C. “Nerve agent antidotes” means to counteract the effects of nerve agent by 1) decreasing symptoms and 2) regenerating an enzyme that is wiped out by nerve agents. Nerve agent antidotes are among the five (5) actions taken after exposure to nerve agent, as follows: 1. Terminate the exposure (stop breathing and move quickly to good air; decontaminate victims and emergency medical staff within minutes of exposure; don personal protective equipment; ventilate pre-hospital and hospital treatment areas). 2. Support ventilation. 3. Provide atropine therapy. 4. Provide oxime therapy. 5. Provide antiseizure therapy. 6. Document treatment on the triage tag. San Joaquin County Emergency Medical Services Page 72 of 216 ALS Nerve Agent EMS Policy No. 5790 Effective: July 1, 2010 Supersedes: NA PROCEDURE I. As soon as the scene is identified as hazardous materials incident, secure, isolate, and deny entry, ensure appropriate resources are responding, and notify the base hospital. II. Decontamination should precede any treatment by EMS personnel. III. All Providers will ensure personal safety by assuring adequate decontamination of victims is conducted and all response personnel will utilize appropriate personal protective (PPE). Medical procedures within the Exclusion Zone (Hot Zone/contaminated area) will only be performed by personnel who have specific training to allow them to function in that area. Under no circumstances should responding personnel at any level of expertise use Personal Protective Equipment or assist in patient decontamination without completing the required training. IV. EMTs and paramedics that have been trained and equipped may utilize the nerve agent protocol to self-administer EMS CHEMPACK auto-injectors when they have been exposed to nerve agents and are symptomatic. V. Once the EMS CHEMPACK is deployed to an active incident, the Medical Group Supervisor may contact the Base Hospital and request that all paramedics on that incident operate under standing orders. VI. TREATMENT: A. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine ALS Care. B. Position the patient on side (recovery position). San Joaquin County Emergency Medical Services Page 73 of 216 ALS Nerve Agent EMS Policy No. 5790 Effective: July 1, 2010 Supersedes: NA C. Monitor Respiratory status closely. Use airway adjuncts, administer high flow O2, suction, ventilate, and advanced airways as indicated. D. Establish IV, NS. Titrate to maintain Systolic BP of greater than 90 mm Hg. E. Nerve agent medications should never be given prophylactically. F. The auto-injectors included in EMS CHEMPACK Nerve Agent Antidote Kits will be used only by those paramedics that have been trained in their use. Paramedics may administer atropine IM/IV in situations where EMS CHEMPACK Nerve Agents Antidote Kits are not available. G. Administer antidotes as outlined below. H. Seizure: After Atropine administration: Valium: Adults - titrate 2.5 - 10 mg slow IV push to effect. If unable to obtain and IV administer IM 10 mg given deep IM (slowly). If recurrent or persistent seizure, repeat X 1 IV/IM to a maximum of 20 mg. Pediatric (less than 40kg, or 9 years old) 0.05-0.3 mg IV over 2-3 min q 15-30 min, titrated to effect; not to exceed 10 mg LEVELS OF EXPOSURE MILD MODERATE Rhinorrhea Salivation Chest tightness Lacrimation Dyspnea Urination Bronchospasm Defecation GI symptoms Emesis Miosis San Joaquin County Emergency Medical Services SEVERE Jerking Twitching Staggering Headache Drowsiness Coma Seizures Apnea Page 74 of 216 ALS Nerve Agent EMS Policy No. 5790 Effective: July 1, 2010 Supersedes: NA Exposure: Onset "Exposed," but Asymptomatic: N/A MILD (Vapor): Seconds MILD (Liquid): Minutes to Hours MODERATE: Seconds to Hours TREATMENT ATROPINE (2 Mg Auto-injector) 2-PAM (600 Mg Auto-injector) NONE Monitor every 15 minutes Adult: One (1) Auto-injector, (2 mg) IM. Peds: 0.02 mg/kg, min. dose 0.1 mg. Seconds to Hours Monitor every 15 minutes Adult: One (1) Auto-injector, (600 mg) IM, one time only, prn. If S & SX continue 5 min. after administering Atropine, administer 2-Pam Cl. MR q 3-5 min. prn. Adult: Two (2) Auto-injectors, (4mg) IM. Peds: 0.02 mg/kg, min. dose 0.1 mg. MR q 3-5 min. prn. Three (3) Auto-injectors (6 mg) IM. SEVERE: NONE Peds: If Bp unobtainable, consider administering MARK I Kit(s). San Joaquin County Emergency Medical Services Peds: N/A, DO NOT Administer. Adult: One (1) Auto-injector, (600 mg) IM. MR X1 in 5-10 min. prn. Peds: N/A, DO NOT Administer. Adult: Three (3) Auto-injectors, (1.8 Gms) IM, MAX dose. Do NOT repeat. Peds: N/A, DO NOT Administer. Page 75 of 216 San Joaquin County EMS Agency San Joaquin County Emergency Medical Services Page 76 of 216 San Joaquin County EMS Agency SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES Pediatric Advanced Life Support Treatment Policies San Joaquin County Emergency Medical Services Page 77 of 216 Pediatric Routine Medical Care EMS Policy No. 5800 Effective: January 1, 2012 Supersedes: June 1, 2007 5800 - Pediatric Routine Medical Care POLICY: I. Pediatrics – Patients that are fourteen (14) years of age or younger, and fall within the limits of the Broselow Pediatric Emergency Tape shall be treated per the San Joaquin County ALS Pediatric Protocols. The Broselow Pediatric Emergency Tape is considered an accurate source of medical information and is in line with San Joaquin County ALS Pediatric Policies. If in doubt concerning whether to treat patient as an adult or pediatric (i.e., obese child or smaller adult) contact the base hospital. A. B. C. Neonate/newborn: Birth to one month of age. Infant: One month to one year of age. Child: One year to twelve years of age. II. If at any time during the primary survey further intervention is required, refer to the appropriate treatment policies. III. A pediatric length-based resuscitation tape will be used to determine drug doses, fluid volumes, defibrillation settings, and equipment sizes. The tape is designed to estimate a child’s weight based on length (head to heel). The tape also includes information about abnormal vital signs. A. All patients will have a complete physical assessment completed including: B. Complete a primary survey. 1. Airway: Assessment of airway patency and protective reflexes. 2. Breathing: Assessment of ventilatory status including signs and symptoms of respiratory distress/failure. This assessment shall include a respiratory rate and pulse oximetry. San Joaquin County Emergency Medical Services Page 78 of 216 Pediatric Routine Medical Care EMS Policy No. 5800 Effective: January 1, 2012 Supersedes: June 1, 2007 3. Circulation: Assessment of perfusion and circulatory status to include: heart rate, mental status, skin signs, quality of pulse, capillary refill, and blood pressure. 4. Disability: Evaluation of level of consciousness using the AVPU pneumonic (alert, verbal, pain, unresponsive). C. Perform a secondary survey. 1. Perform a head to toe assessment: A complete physical assessment shall be completed with supporting documentation. 2. Obtain patient history. 3. Assess environment and provide psychosocial support to patient and family. San Joaquin County Emergency Medical Services Page 79 of 216 Pediatric Pulseless Arrest: Asystole/PEA EMS Policy No. 5810 Effective: July 24, 2014 Supersedes: January 1, 2012 5810 - Pediatric Pulseless Arrest: Asystole/PEA POLICY: I. Perform routine ALS/BLS medical care while confirming pulselessness and appropriate (non shockable) rhythm on the cardiac monitor. II. Treatment: A. B. C. D. E. F. G. H. Perform immediate, effective CPR. Continue CPR, maintain patent airway with 100% oxygen via BVM. Provide appropriate airway management with simplest most effective airway adjunct. Establish IV/IO of normal saline TKO. Do not delay transport. If unable to obtain vascular access, begin transport and continue efforts while en route. Consider reversible causes and treat as indicated. Administer Epinephrine 0.01 mg/kg (1:10,000) IVP/IO, max of 1 mg. Repeat every 3-5 minutes. Continue CPR for 5 cycles/2 minutes and recheck pulse/rhythm. Initiate transport to receiving hospital if not already en route. Note: In cases where transport is not available or practical an order to terminate resuscitation efforts may be given by the Base Hospital Physician for patients in Asystole or PEA < 30 that are unresponsive to treatment (See EMS Policy No. 5103, Determination of Death). Note: CPR should be administered for complete sequences of 5 cycles/2 minutes. During 5 cycles/2 minutes, establish IV/IO and administer medications during CPR to minimize interruptions in chest compressions. San Joaquin County Emergency Medical Services Page 80 of 216 Pediatric Pulseless Arrest: VFIB/VTACH EMS Policy No. 5811 Effective: January 1, 2012 Supersedes: June 1, 2007 5811 - Pediatric Pulseless Arrest: Ventricular Fibrillation/Ventricular Tachycardia POLICY: I. Perform routine ALS/BLS medical care while confirming pulselessness and appropriate (shockable) rhythm on the cardiac monitor. II. Treatment: A. If unwitnessed arrest, perform and complete initial CPR sequence (5 cycles/2 minutes) while preparing equipment. B. Defibrillate patient one (1) time at 2J/kg and then resume CPR immediately for 5 cycles/2 minutes (do not check rhythm or pulse after shock). C. Continue CPR and maintain patent airway with 100% oxygen via BVM. D. Provide appropriate airway management. E. Check rhythm/pulse. If shockable rhythm, defibrillate 1 x @ 4J/kg and resume CPR immediately after the shock. F. Continue CPR for 5 cycles/2 minutes while performing appropriate airway management. G. Establish IV/IO of normal saline TKO. H. After 2 minutes of CPR, check pulse and rhythm. If no pulse, resume CPR and administer Epinephrine 0.01 mg/kg IVP/IO. Repeat every 3-5 minutes. I. After 2 minutes of CPR, check rhythm and if appropriate defibrillate at 4J/kg. J. Resume and continue CPR for 5 cycles/2 minutes. K. Administer Lidocaine 1mg/kg IVP/IO (may repeat x 1 in 3-5 minutes). L. After 2 minutes of CPR, check rhythm and if appropriate defibrillate at 4J/kg. If non shockable rhythm present, treat according to appropriate policy. San Joaquin County Emergency Medical Services Page 81 of 216 Pediatric Pulseless Arrest: VFIB/VTACH EMS Policy No. 5811 Effective: January 1, 2012 Supersedes: June 1, 2007 Note: CPR should be administered for complete sequences of 5 cycles/2 minutes, between each shock. During 5 cycles/2 minutes, establish IV/IO and administer medications during CPR (before or after shock) to minimize interruptions in chest compressions. San Joaquin County Emergency Medical Services Page 82 of 216 Pediatric Bradycardia EMS Policy No. 5812 Effective: January 1, 2012 Supersedes: February 15, 2010 5812 - Pediatric Bradycardia POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care, and EMS Policy No. 5800, Pediatric Routine Medical Care. II. Treatment: A. Assure adequate oxygenation and ventilation. Most bradycardia in children is due to hypoxia. B. Check blood glucose. C. Check temperature and begin warming if hypothermic. D. Normal Perfusion: 1. Establish IV of normal saline TKO. E. Decreased Perfusion and/or Respiratory Distress: 1. Establish IV of normal saline and administer a fluid bolus of 20ml/kg. 2. Recheck vital signs. 3. If patient remains bradycardic despite adequate oxygenation and ventilation, administer Epinephrine 0.01mg/kg IVP/IO to a maximum dose of 1mg. May repeat epinephrine dose every 3-5 minutes as indicated. 4. If increased vagal tone or AV block present, administer Atropine 0.02mg/kg IVP/IO, minimum dose 0.1mg and maximum dose 1mg. May repeat once. 5. If bradycardia remains, consult with Base Hospital Physician. San Joaquin County Emergency Medical Services Page 83 of 216 Pediatric Tachycardia with Pulses EMS Policy No. 5813 Effective: June 15, 2007 Supersedes: SJ-P05 5813 - Pediatric Tachycardia with Pulses DEFINITIONS: A. “Sinus Tachycardia” indicates a rapid heart rate with a narrow QRS (less than or equal to 0.08 sec.) that is less than 220/min. in an infant or less than 180/min. in a child. B. “Supraventricular Tachycardia” indicates a rapid heart rate with a narrow QRS (less than or equal to 0.08 sec.) that is greater than 220/min. in an infant or greater than 180/min. in a child. C. “Ventricular Tachycardia” indicates a rapid heart rate with a wide QRS (greater than 0.08 sec.). POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. Treatment: A. Consider pediatric normal values for heart rate. Infants may have heart rates as high as 220/minute and children may have heart rates as high as 180/minute in the presence of fever, anxiety, and/or pain. B. Manage airway and ventilations as indicated. C. Establish IV of normal saline TKO. D. Treat according to rhythm: 1. Sinus Tachycardia: a. Consider and treat underlying cause (fever, pain, trauma, hypovolemia). b. Consider fluid bolus of normal saline 20 ml/kg IVP/IO. May repeat as indicated. c. Recheck vital signs after each bolus. d. If suspected trauma, refer to EMS Policy No. 5833, Pediatric Trauma. 2. Supraventricular Tachycardia: San Joaquin County Emergency Medical Services Page 84 of 216 Pediatric Tachycardia with Pulses EMS Policy No. 5813 Effective: June 15, 2007 Supersedes: SJ-P05 a. Conscious: 1. Attempt vagal maneuver. 2. If unsuccessful, administer Adenosine 0.1mg/kg rapid IVP/IO push to a maximum dose of 6 mg followed by rapid 20ml flush of normal saline. 3. If unsuccessful, administer Adenosine 0.2mg/kg rapid IVP/IO push (to a maximum dose of 12 m) followed by rapid 20ml flush of normal saline. b. Unconscious: 1. Transport without delay. 2. Administer Adenosine 0.1mg/kg rapid IVP/IO push, to a maximum dose of 6mg followed by rapid 20ml flush of normal saline while setting up to perform cardioversion. 3. Consult Base Hospital Physician for orders: a) Perform synchronized cardioversion at 1 J/kg. b) If no response at 1 J/kg, perform synchronized cardioversion at 2 J/kg. 3. Ventricular Tachycardia: a. If no pulse refer to EMS Policy No. 5811, Pulseless Arrest: VFIB/VTACH. b. Conscious : 1. Administer Lidocaine 1mg/kg IVP/IO. May repeat once in 3-5 minutes. c. Unconscious: 1. Transport without delay. 2. Administer Lidocaine 1 mg/kg IV/IO while setting up to perform cardioversion. 3. Consult Base Hospital Physician for orders: a) Perform synchronized cardioversion at 1 J/kg. b) If no response at 1 J/kg, perform synchronized cardioversion at 2 J/kg. c) If no response, perform synchronized cardioversion at 4 J/kg. d. If cardioversion is successful, consult with Base Hospital Physician for post cardioversion medication orders. San Joaquin County Emergency Medical Services Page 85 of 216 Pediatric Apparent Life Threatening Event EMS Policy No. 5815 Effective: June 1, 2007 Supersedes: NA 5815 - Pediatric Apparent Life Threatening Event DEFINITIONS: “Apparent Life Threatening Event (ALTE)” indicates an episode that is frightening to the observer (may think the infant has died) and involves some combination of: Apnea (central or obstructive) Color change (cyanosis, pallor, erythema, plethora) Marked change in muscle tone (limpness) Choking or gagging POLICY: A. I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. These events usually occur in infants < 12 months old, however, any child less than 2 years old who exhibits the symptoms listed above may be considered an ALTE. III. Treatment: A. Assume the history given is accurate. B. Determine the severity, nature and duration of the episode. C. Obtain a medical history. D. Perform a complete physical exam that includes the general appearance of the child, skin color, extent of interaction with environment, and evidence of trauma. E. If hypoglycemia suspected or ALOC, obtain glucose level. F. Consider and treat any identifiable causes. G. Transport patient to the hospital. Note: Most patients will have a normal physical exam when assessed by responding field personnel. Contact the base physician for consultation if the parent/guardian is refusing medical care and/or transport, prior to completing a Refusal of Care form. San Joaquin County Emergency Medical Services Page 86 of 216 Pediatric Airway Obstruction EMS Policy No. 5817 Effective: January 1, 2012 Supersedes: June 1, 2007 5817 - Pediatric Airway Obstruction by Foreign Body POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. Treatment: A. B. C. D. E. Attempt to clear the airway using BLS maneuvers. 1. For infants administer back blows and chest thrusts. 2. For children > 1 year of age, administer abdominal thrusts. If unable to clear foreign body, visualize the larynx and remove the foreign body with Magill forceps. Assist ventilation with BVM and 100% oxygen. If unsuccessful, attempt endotracheal intubation. If patient has a complete airway obstruction and you are unable to clear foreign body using BLS maneuvers and direct visualization, consider Cricothyrotomy. San Joaquin County Emergency Medical Services Page 87 of 216 Pediatric Respiratory Distress: Stridor EMS Policy No. 5819 Effective: January 1, 2012 Supersedes: June 1, 2007 5819 - Pediatric Respiratory Distress: Stridor POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. For suspected airway obstruction refer to EMS Policy No. 5817, Pediatric Airway Obstruction. III. For suspected allergic reaction refer to EMS Policy No. 5826, Pediatric Allergic Reaction. IV. Treatment: A. B. C. D. E. Place patient in position of comfort. If suspected croup, consider saline nebulizer treatment. If suspected epiglottis, do not attempt to visual airway. Administer oxygen, allow parent to administer if appropriate. If patient deteriorates, or becomes completely obstructed, attempt to ventilate via BVM. Perform endotracheal intubation only if BVM ventilation is unsuccessful or impossible. San Joaquin County Emergency Medical Services Page 88 of 216 Pediatric Respiratory Distress: Bronchospasm EMS Policy No. 5820 Effective: March 10, 2010 Supersedes: June 1, 2008 5820 - Pediatric Respiratory Distress: Bronchospasm DEFINITIONS: A. “Mild Respiratory Distress” indicates mild wheezing, shortness of breath and/or cough. Able to speak full sentences. B. “Moderate Respiratory Distress” indicates spontaneous breathing and adequate tidal volume with significant wheezing/SOB accompanied by any of the following signs: accessory muscle use, nasal flaring, grunting, and/or inability to speak full sentences. C. “Severe Respiratory Distress” indicates ineffective ventilations and/or inadequate tidal volume which may be accompanied by any of the following signs: accessory muscle use, cyanosis, inability to speak, gasping respirations, and/or decreased level of consciousness. POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care, and EMS Policy No. 5800, Pediatric Routine Medical Care. II. Treatment: A. Place patient in position of comfort. B. Administer oxygen, allow parent to administer if appropriate. C. Treat according to severity: 1. Mild Distress: a. Monitor heart rate, respiratory rate, and pulse oximetry. b. Administer Albuterol 2.5mg in 3 ml NS via nebulizer. May repeat as indicated. 2. Moderate Distress: a. Monitor heart rate, respiratory rate, and pulse oximetry. San Joaquin County Emergency Medical Services Page 89 of 216 Pediatric Respiratory Distress: Bronchospasm EMS Policy No. 5820 Effective: March 10, 2010 Supersedes: June 1, 2008 b. Administer Albuterol 2.5mg in 3 ml NS by nebulizer with Atrovent 0.5mg in 2.5 ml NS c. May repeat Albuterol as indicated. d. Consider epinephrine 0.01 mg/kg Sub-Q (Maximum dose is 0.3 mg). 3. Severe Distress: a. Assist ventilations with BVM and 100% oxygen. b. If unable to adequately oxygenate and ventilate patient, perform endotracheal intubation. c. Administer Albuterol 2.5mg in 3 ml NS and Atrovent 0.5mg in 2.5 ml NS by nebulizer/BVM/ETT. May repeat Albuterol as indicated (not to exceed 20mg per hour). d. Consider epinephrine 0.01 mg/kg Sub-Q (Maximum dose is 0.5mg). San Joaquin County Emergency Medical Services Page 90 of 216 Pediatric Shock EMS Policy No. 5824 Effective: January 1, 2012 Supersedes: June 1, 2007 5824 - Pediatric Shock POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. For suspected or known trauma refer to EMS Policy No. 5833, Pediatric Trauma. III. For suspected allergic reaction refer to EMS Policy No. 5826, Pediatric Allergic Reaction. IV. Treatment: A. Assure adequate oxygenation and ventilation. B. Establish IV/IO of normal saline TKO. C. Administer rapid fluid bolus of normal saline 20 ml/kg. May repeat as indicated. D. If suspected Cardiogenic Shock, consult with Base Hospital Physician for Dopamine orders. San Joaquin County Emergency Medical Services Page 91 of 216 Pediatric Allergic Reaction EMS Policy No. 5826 Effective: January 1, 2012 Supersedes: June 1, 2007 5826 - Pediatric Allergic Reaction POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. Treatment: A. Remove allergen if possible. B. Mild reaction (urticaria only): 1. Consider diphenhydramine 1 mg/kg IM (maximum of 50 mg). C. Moderate to severe reaction (Urticaria with one or more of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps). 1. Epinephrine 1:1000, 0.01mg/kg SQ (maximum dose 0.3mg). 2. Administer diphenhydramine 1 mg/kg IM (maximum of 50 mg). 3. If wheezing, initiate hand-held nebulizer dose of Albuterol 2.5mg in 3 ml NS. May repeat as needed. 4. Consider IV normal saline TKO or saline lock. D. Anaphylaxis (Urticaria and signs of shock with any or all of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps). 1. Epinephrine 1:1000, 0.01mg/kg SQ (maximum dose 0.3mg). 2. Establish IV/IO access and administer normal saline fluid bolus of 20 ml/kg. May repeat as indicated. 3. If wheezing, administer Albuterol 2.5mg in 3 ml normal saline. May repeat as needed. 4. If patient is unresponsive with no palpable pulses, administer epinephrine (1:10,000) 0.01mg/kg to max dose San Joaquin County Emergency Medical Services Page 92 of 216 Pediatric Allergic Reaction EMS Policy No. 5826 Effective: January 1, 2012 Supersedes: June 1, 2007 of 0.5mg IVP/IO and diphenhydramine 1mg/kg to maximum dose of 50mg IM or IVP/IO. 5. Consider intubation. 6. Consult Base Hospital Physician for further orders. San Joaquin County Emergency Medical Services Page 93 of 216 Pediatric Seizure EMS Policy No. 5828 Effective: October 1, 2012 Supersedes: January 1, 2012 5828 - Pediatric Seizure POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. Midazolam should not be given unless the patient is actively seizing (two (2) or more seizures without regaining consciousness or a seizure that is witnessed by the paramedic to last for longer than two (2) minutes). III. Treatment: A. Protect from injury, do not restrain. B. Initiate cooling measures if febrile. C. If two (2) or more generalized seizures occur without regaining consciousness or the paramedic observes seizure activity that lasts for two (2) or more minutes: 1. Establish IV/IO normal saline TKO. a) Evaluate blood glucose level. If blood glucose level is less than 60 mg/dl refer to EMS Policy No. 5829, Pediatric Altered Level of Consciousness. 2. If continued seizure activity, administer Midazolam: a) 0.2 mg/kg IN (half dose in each nostril) to a maximum dose of 5 mg or b) 0.1mg/kg IVP/IO/IM to a maximum dose of 5 mg). 3. For continued seizure activity not controlled by the initial dose of Midazolam, consult Base Hospital Physician for consideration of further Midazolam orders. San Joaquin County Emergency Medical Services Page 94 of 216 Pediatric ALOC EMS Policy No. 5829 Effective: October 16, 2013 Supersedes: October 1, 2012 5829 - Pediatric Altered Level of Consciousness POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care, and EMS Policy No. 5800, Pediatric Routine Medical Care. II. Treatment: A. Initiate appropriate airway management. B. Establish IV/IO of normal saline. C. Evaluate blood glucose level. If blood glucose level is less than 60 mg/dl, administer dextrose: 1. Child older than two years of age – Dextrose 50% 1 ml/kg IV/IO or Dextrose 10% 10 ml/kg IV/IO. 2. Child less than two years of age – Dextrose 50% 0.5 ml/kg IV/IO or Dextrose 10% 10 ml/kg IV/IO. 3. Neonate – Dextrose 10% 3 ml/kg IV/IO (Base Hospital Physician order). D. If mental status and respiratory effort are depressed, administer Naloxone: 1. 0.1 mg/kg IN (half dose in each nostril) to a maximum initial dose of 2 mg, or; 2. 0.4 mg - 2 mg IV/IO. Titrate in small increments to maintain adequate ventilation and airway control to a total initial dose of 2 mg. E. If positive response to initial dose of Naloxone and strong suspicion of opiate overdose, may repeat Naloxone dose one (1) time only in five minutes. San Joaquin County Emergency Medical Services Page 95 of 216 Pediatric ALOC EMS Policy No. 5829 Effective: October 16, 2013 Supersedes: October 1, 2012 Pediatric Glasgow Coma Scale: Pediatric Glasgow Coma Scale <1 year 1 – 4 years >4 years EYE Opening 4 Open Open Open 3 To voice To voice To voice 2 To pain To pain To pain 1 No response No response No response Verbal response 5 Coos & babbles Oriented, speaks, Alert & oriented interacts socially 4 Irritable cry Confused speech, Disoriented disoriented, consolable 3 Cries to pain Inappropriate words, Inappropriate words inconsolable 2 Moans to pain Incomprehensible Incomprehensible sounds agitated 1 No response No response No response Best Motor Response 6 Normal, Obeys commands Obeys commands spontaneous movement 5 Withdraws to Localizes stimuli Localizes stimuli touch 4 Withdraws from Withdraws from pain Withdraws from pain pain 3 Abnormal flexion Abnormal flexion Abnormal flexion 2 Abnormal Abnormal Extension Abnormal extension Extension 1 No response No response No response Note: Always document and report GCS as a breakdown of scores (i.e. GCS = Eye 3, Verbal 3, Motor 4 for a total score of 10). San Joaquin County Emergency Medical Services Page 96 of 216 Pediatric Poisoning/Overdose EMS Policy No. 5830 Effective: October 1, 2012 Supersedes: January 1, 2012 5830 - Pediatric Poisoning/Overdose POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. Identify substance. Bring any containers, labels or a sample (if safe) into the hospital with the patient. Determine type, amount and time of the exposure. III. Treatment: A. Establish IV normal saline TKO or saline lock if indicated. B. Initiate early transport and receiving hospital notification. IV. Substance Specific Treatment: A. Opiates: 1. Manage airway and ensure adequate oxygenation and ventilation. 2. If mental status and respiratory effort are depressed administer Narcan: a. 0.1 mg/kg IN, (half dose in each nostril) or; b. 0.4 mg - 2 mg IVP/IO. Titrate in small increments to maintain adequate ventilation and airway control to a total initial dose of 2 mg. May administer IM, SL or SQ if unable to start IV. B. Insecticides (organophosphates, carbonates): 1. Decontaminate patient as soon as possible (remove clothes, wash skin). 2. Avoid contamination of prehospital personnel. 3. Assess for SLUDGE (salivation, lacrimation, urination, diaphoresis/diarrhea, gastric hypermotility, and emesis/eye [small pupils and/or blurry vision]). 4. If indicated, administer Atropine 0.05 mg/kg IVP/IO slowly. San Joaquin County Emergency Medical Services Page 97 of 216 Pediatric Poisoning/Overdose EMS Policy No. 5830 Effective: October 1, 2012 Supersedes: January 1, 2012 C. D. E. F. G. H. May give second dose of Atropine 0.05 mg/kg in 5 minutes if indicated to a maximum dose of 4 mg. 5. If further doses of Atropine are required, consult the base hospital physician. Cyclic Antidepressants: 1. Anticipate rapid deterioration of condition. 2. Consider activated charcoal 1gm/kg PO, not to exceed 50 gms given orally if within the first 60 minutes of ingestion. 3. In the presence of life-threatening dysrhythmias or rapid deterioration: a. Hyperventilate if assisting ventilation or if intubated. b. Administer Sodium Bicarbonate 1 mEq/kg IVP. 4. For seizures, see EMS Policy, No. 5828, Pediatric Seizures. Beta Blockers: 1. Consider activated charcoal 1 gm/kg PO, not to exceed 50 gms given orally if within the first 60 minutes of ingestion. 2. Obtain blood glucose level. Calcium Channel Blockers: 1. Consider activated charcoal 1gm/kg PO, not to exceed 50gms given orally (if within the first 60 minutes of ingestion). 2. Calcium Chloride 10% 20 – 30 mg/kg IVP over 3 – 5 minutes. 3. If bradycardic and/or hypotensive, consult base hospital physician. Phenothiazine Reactions: 1. Administer Diphenhydramine 1 mg/kg slow IVP to a maximum of 50 mg. If unable to establish IV access, administer IM. Other Non-Caustic Drugs: 1. If patient is awake and alert consider activated charcoal orally—1 gm/kg PO, not to exceed 50gms if within the first 60 minutes of ingestion. 2. Consider contacting Poison Control Center. Hydrocarbons (kerosene, gasoline, lighter fluid, turpentine, etc): San Joaquin County Emergency Medical Services Page 98 of 216 Pediatric Poisoning/Overdose EMS Policy No. 5830 Effective: October 1, 2012 Supersedes: January 1, 2012 1. Do not induce vomiting. 2. Transport without delay. I. Caustic Substances (acids/alkalis): 1. Do not induce vomiting. 2. Consider diluting by having the patient drink 1-2 glasses of milk or water. San Joaquin County Emergency Medical Services Page 99 of 216 Pediatric Burns EMS Policy No. 5837 Effective: October 16, 2013 Supersedes: June 1, 2007 5837 - Pediatric Burns POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. II. For major burns, consider direct air ambulance transport to an approved pediatric trauma center. Refer to EMS Policy No. 5215 Trauma Patient Destination. III. Use caution in children to prevent hypothermia. A. Stop the burning process. 1. For burns that are less than 10% of the patient’s total body surface area (TBSA) consider initial cooling of burn with moist dressings. 2. For burns that cover more than 10% of the patient’s TBSA, cover affected body surface with dry, sterile dressing or sheet. Do not use wet or cool dressings. IV. Treatment: A. B. C. D. E. F. Assure adequate oxygenation and ventilation. Administer high flow oxygen if inhalation injury is suspected. Establish vascular access if indicated. Monitor for dysrhythmias and treat as appropriate. For major burns (greater than 10% TBSA), administer fluid bolus of NS 20 ml/kg. May repeat as necessary. For severe pain, refer to EMS Policy No. 5839, Pediatric Pain Management. San Joaquin County Emergency Medical Services Page 100 of 216 Pediatric Pain Management EMS Policy No. 5839 Effective: June 1, 2007 Supersedes: SJ-P81 5839 - Pediatric Pain Management DEFINITIONS: A. “Pain” indicates a significantly unpleasant sensation, occurring in varying degrees of severity, which results because of injury, disease, or emotional disorder. POLICY: I. The use of morphine to manage moderate to severe pain is an advanced life support procedure that is indicated for patients who are complaining of moderate to severe pain in the presence of adequate vital signs and level of consciousness. II. Morphine may be used to treat stable pediatric patients when extrication, movement, or transport is required and is anticipated to cause considerable pain to the patient when there are no known contraindications to administering analgesia. III. Morphine is a potent analgesic and should be used with caution. IV. Document pain scale before and after medication administration. A. For children under the age of 3, use the behavioral or the FACES scale. B. For children over the age of 3, use the FACES or the visual analog scale. V. Treatment: A. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5502, Routine BLS Care, EMS Policy No. 5701, San Joaquin County Emergency Medical Services Page 101 of 216 Pediatric Pain Management EMS Policy No. 5839 Effective: June 1, 2007 Supersedes: SJ-P81 Routine ALS Care and EMS Policy No. 5800, Pediatric Routine Medical Care. B. Monitor patient closely. C. Establish IV access (IV NS or NS lock as appropriate). D. Obtain full set of vital signs. E. Administer Morphine 0.05mg/kg slow IV. May repeat once in five minutes. F. If unable to secure IV access, administer Morphine 0.1mg/kg IM, may repeat one dose in 30 minutes. G. Monitor patient and vital signs carefully; ensure patent airway. Do not administer morphine sulfate for pain if the patient has any absolute or relative contraindications without base hospital physician order. VI. Base Physician Order Requirements: A. Do not administer morphine sulfate for pain if the patient has any contraindications without base hospital physician order. B. Contraindications: 1. Allergy or sensitivity to the medication being administered. 2. Nausea/Vomiting 3. Altered level of consciousness 4. Hypotension 5. Suspected drug and/or alcohol intoxication 6. Head injury 7. Respiratory distress/failure 8. Pregnancy 9. Multiple systems trauma VII. Pain Scales A. Behavioral Pain Scale Select the most appropriate description for each row and total the numbers. San Joaquin County Emergency Medical Services Page 102 of 216 Pediatric Pain Management EMS Policy No. 5839 Effective: June 1, 2007 Supersedes: SJ-P81 Face 0 No expression or smile Legs 0 Normal or relaxed position 0 Lying quietly, normal position, moves easily Activity Cry 0 No cry (awake or asleep) Consolability 0 Content, relaxed 1 Occasional grimace, withdrawn, frown 1 Uneasy, restless, tense 1 Squirming, tense, shifting back and forth 1 Moans or whimpers, occasional complaint 1 Reassured by voice, hugging. Distractible. 2 Frequent frown, clenched jaw, quivering chin 2 Kicking or legs drawn up 2 Arched, rigid, or jerking 2 Cries steadily, screams, sobs, frequent complaints 2 Difficult to console or comfort B. Wong-Baker FACES Scale C. Visual Analog Scale 0 1 No Pain 2 San Joaquin County Emergency Medical Services 3 4 5 6 7 8 9 10 Worst Pain Ever Page 103 of 216 Neonatal Resuscitation EMS Policy No. 5850 Effective: June 1, 2007 Supersedes: SJ-P81 5850 - Neonatal Resuscitation POLICY: I. Perform routine ALS/BLS medical care as directed in EMS Policy No. 5800, Pediatric Routine Medical Care. II. Resuscitation should be initiated on all premature infants who weigh 1 pound and are reported to be over 20 weeks gestation. III. Obtain pertinent history before delivery if possible (e.g. multiple births, preterm, medical treatment, drug use, and presence of meconium). IV. Treatment: A. Position Airway. B. Suction mouth and nasopharynx with bulb syringe. C. Dry and keep warm with dry towel or blanket. D. Stimulate by drying vigorously including head and back. E. Clamp and cut cord. F. Evaluate respirations: 1. Mild distress - Administer blow by oxygen. 2. Respiratory depression, failure, or gasping respirations – Assist ventilations with 100% oxygen at a rate of 40-60 breaths/min. G. Check heart rate at cord: 1. HR less than 60/minute a. Continue assisted ventilations. b. Begin chest compressions at a rate of 120/min. c. If no improvement in 1 minute, establish vascular access and administer epinephrine 0.01 mg/kg (1:10,000) IV/IO. d. If no improvement in 30 seconds, perform endotracheal intubation. San Joaquin County Emergency Medical Services Page 104 of 216 Neonatal Resuscitation EMS Policy No. 5850 Effective: June 1, 2007 Supersedes: SJ-P81 e. Reassess heart rate and respiratory rate while en route to the hospital. If heart rate is above 80/minute, stop chest compressions and continue assisting ventilations. 2. HR 60-80/minute a. Continue to assist ventilations with 100% oxygen. b. If no improvement after 30 seconds of assisted ventilations, begin chest compressions. c. Reassess heart rate and respiratory rate while en route to the hospital. If heart rate is above 80/minute, stop chest compressions and continue assisting ventilations. 3. HR 80-100/minute and rising a. Continue oxygen via mask or blow by. b. Stimulate and reassess heart rate and respirations after 15-30 seconds. c. If heart rate is less than 100/minute, begin assisted ventilations with 100% oxygen. 4. HR above 100/minute a. Check skin color. If peripheral cyanosis is noted, administer blow by oxygen. b. Reassess heart rate and respiratory rate while en route to the hospital. H. If narcotic induced respiratory depression is suspected administer Naloxone 0.1mg/kg via IV/IO/ETT. San Joaquin County Emergency Medical Services Page 105 of 216 San Joaquin County EMS Agency San Joaquin County Emergency Medical Services Page 106 of 216 San Joaquin County EMS Agency SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES Advanced Life Support Skills Policies and Interfacility Transfer Medication Policies San Joaquin County Emergency Medical Services Page 107 of 216 Paramedic Infrequently Used Skills EMS Policy No. 2541 Effective: October 16, 2013 Supersedes: July 1, 2010 2541- Paramedic Infrequently Used Skills PURPOSE: The purpose of this policy is to specify the requirements ALS providers shall adhere to in demonstrating competency for infrequently used skills by ALS personnel. DEFINITIONS: A. “Infrequently Used Skills “means ALS procedures that have been identified through the CQI process as an area performed on an infrequent basis within the San Joaquin EMS system which requires on-going training to maintain competency. POLICY: I. Provider Responsibilities: A. Demonstration of competency in infrequently utilized skills is to be performed in a training environment using mannequins. B. Providers are required to develop a process that affords all ALS personnel the opportunity to demonstrate competency at the required intervals. C. Providers and ALS personnel shall follow the process specified in EMS Agency Policy when verifying an infrequently used skill. D. Providers shall track individual employees training records using a spreadsheet or other EMS Agency approved format. The spreadsheet or other approved format may be used to track infrequently used skills training in lieu of the EMS Agency’s performance criteria check sheets. Regardless of the record keeping format providers are required to utilize San Joaquin County Emergency Medical Services Page 108 of 216 Paramedic Infrequently Used Skills EMS Policy No. 2541 Effective: October 16, 2013 Supersedes: July 1, 2010 the EMS Agency’s performance criteria when verifying skills. E. Providers shall ensure sufficient training equipment and supplies are available to implement this Policy. F. Providers shall make records available to the EMS Agency, upon request, to demonstrate compliance with this Policy. G. The infrequently used skills and minimum intervals at which competency shall be demonstrated by ALS personnel are as follows: 1. Adult Endotracheal Intubation – Quarterly 2. Pediatric Endotracheal Intubation – Quarterly 3. Nasotracheal Intubation – Quarterly 4. Nasogastric Suctioning - Quarterly 5. King Airway – Quarterly 6. MICR: Two Rounds and Transition to Advanced Airway - Quarterly 7. Transcutaneous Cardiac Pacing – Annually 8. Intraosseous Infusions – Annually 9. Needle Thoracostomy – Annually 10. Needle Cricothyrotomy – Annually H. Upon recommendation of the majority of the members of the CQI Council, the Medical Director may increase the frequency of the training intervals to bi-monthly. However, the Medical Director reserves the right to increase or decrease the frequency of infrequently used skills’ training based on his/her professional medical judgment regardless of the recommendations from the CQI Council. San Joaquin County Emergency Medical Services Page 109 of 216 Intraosseous Cannulation Performance Criteria – EZ-IO EMS Policy No. 2544 Effective: January 1, 2012 Supersedes: NA 2544 – Intraosseous Cannulation – EZ-IO Intraosseous cannulation provides a safe and reliable method for rapidly achieving a route for administration of medications, fluids, and blood products in a non-collapsible vascular space. A. .Assessment/Treatment Indicators: 1. Resuscitation. 2. Altered mental status (GCS 8 or less). 3. Status epilepticus with prolonged seizure activity greater than 10 minutes, and refractory to IM anticonvulsants. B. Contraindications 1. Fractures of the involved bone. 2. Fourth Degree burn, infection or area of cellulitis overlying the site of insertion. 3. Congenital deformity or history of osteogenesis imperfecta or osteoporosis. 4. Previous IO attempt at chosen site. 5. Patient < 3kg. C. Potential Complications and Interventions: 1. Tubing becomes obstructed with bone or bone marrow: replace the tubing extension set. 2. Local infiltration of fluids, medications, or local bleeding: stop infusion, remove needle, and apply pressure with sterile gauze. D. Approved Sites (listed in order of use): 1. Primary site is the proximal tibia. Palpate the landmarks at the proximal tibia (patella and tibial tuberosity). Insertion site should be approximately one finger width to the medial side of the tibial tuberosity. This is the only approved site for pediatric patients. 2. Secondary site is the distal tibia. Palpate the landmarks at the distal tibia. Insertion site should be two finger widths proximal to the medial malleolus along the midline of the tibia. San Joaquin County Emergency Medical Services Page 110 of 216 Intraosseous Cannulation Performance Criteria – EZ-IO EMS Policy No. 2544 Effective: January 1, 2012 Supersedes: NA 3. Proximal Humerus shall only be used if both tibias are unavailable. Insertion site is located directly on the most prominent aspect of the greater tubercle. Slide thumb up the anterior shaft of the humerus until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm (depending on patient anatomy) above the surgical neck is the insertion site. Ensure that the patient’s hand is resting on the abdomen and that the elbow is adducted (close to the body). E. Equipment: 1. Laryngoscope with appropriate size handle 2. Endotracheal tube 3. Water soluble lubricating jelly 4. 10 ml syringe 5. Endotracheal tube inducer (ETTI) 6. Oxygen 1. 2. 3. 4. 5. 6. Uses universal precautions. States: Indications and contraindications. Demonstrates the ability to correctly select the primary, secondary, and tertiary sites for IO cannulation. Selects the correct size needle A. 15mm (Pink) for patients 3 – 39 kg B. 25mm (Blue) for patients > 40 kg. C. 45mm (Yellow) for patients > 40 kg with excessive tissue over the insertion site. Assembles equipment, attaches extension (EZ-Connect) tubing to IV tubing, and correctly assembles the EZ-IO driver and needle set. Cleans insertion site using aseptic technique. San Joaquin County Emergency Medical Services Page 111 of 216 Intraosseous Cannulation Performance Criteria – EZ-IO EMS Policy No. 2544 Effective: January 1, 2012 Supersedes: NA 7. 8. 9. 10. 11. 12. 13. 14. 15. Needle Insertion: Stabilize the selected site and begin insertion from a 90-degree angle to the plane of the site. Inserts the needle until the needle is touching the bone. Ensures that the 5mm mark is visible before powering the driver. If 5 mm mark is not visible uses a larger needle. Powers the driver, using limited pressure and advances the needle until you feel a change in resistance. Flushes the needle with Lidocaine (See # 11 Pain Management below) if patient semi-conscious or with saline if patient is unconscious. Stabilizes the needle set and removes the drill and then the stylet. Confirms placement by aspiration, ability to infuse a 10ml saline flush without signs of infiltration, leakage or local edema. Understands that a flash of blood in the catheter may (but does not always) occur to confirm placement. Pain Management: A. For conscious or semi-conscious patients administer 0.5 mg/kg 2% Lidocaine (not to exceed 50 mg) slowly (over 30-45 seconds) through the IO site. Wait approximately 30–60 seconds before “power” flushing with normal saline. B. In the event a patient regains consciousness and complains of severe pain secondary to the IO insertion, temporarily stop infusing the fluids, and administer Lidocaine as listed above. Attaches IV tubing to EZ connect tubing. It is unlikely that fluid will run freely on a gravity drip. Applies pressure to IV bag and adjust flow as required. Secure the EZ-IO needle and tubing in place. If the EZ IO is placed in the humerus, or in a pediatric patient, the EZ stabilizer shall be used. States: Potential complications and interventions. Place EZ-IO identification band on patient, document time, date, and person completing the procedure. San Joaquin County Emergency Medical Services Page 112 of 216 Intraosseous Cannulation Performance Criteria – EZ-IO EMS Policy No. 2544 Effective: January 1, 2012 Supersedes: NA 16. 17. 18. Restrain patient prn to prevent inadvertent dislodging of the needle. States: Document IO placement on PCR. Removal Process: States: Attach syringe to needle, then twists the needle in a clockwise direction and pulls straight out. Once needle has been removed applies direct pressure to control any bleeding, then covers area with a sterile dressing. San Joaquin County Emergency Medical Services Page 113 of 216 Endotracheal Intubation – Adult Performance Criteria EMS Policy No. 2545 Effective: October 16, 2013 Supersedes: October 1, 2012 2545 – Endotracheal Intubation – Adult Performance Criteria In the absence of a protected airway, BVM ventilation may result in the generation of pharyngeal pressure high enough to cause gastric distention. In addition, gastric distension promotes regurgitation and increases the potential for aspiration of gastric contents. A. Assessment/Treatment Indicators: 1. Inability of patient to protect the airway (coma, decreased level of consciousness without gag reflex). 2. Inability to ventilate or oxygenate the patient using BLS airways and BVM. 3. Cardiac arrest. Adhere to sequence as specified in EMS Policy No. 5710 ALS Medical Cardiac Arrest. 4. Agonal or failing respirations, respiratory arrest. 5. Base Hospital Physician Order. B. Relative Contraindications: 1. Intubation may be contraindicated on patients that are known diabetics or narcotics overdoses, prior to the administration of Dextrose or Narcan. C. Potential Complications: 1. Esophageal Intubation 2. Mainstem Intubation 3. Perforation or laceration of upper esophagus, vocal cords, larynx 4. Laryngospasm or bronchospasm 5. Dental and soft-tissue trauma 6. Aspiration of oral or gastric contents 7. Dysrhythmias 8. Hypertension/Hypotension D. Equipment: 1. Laryngoscope with appropriate size blade 2. Endotracheal tube & King Airway 3. Water soluble lubricating jelly 4. 10 ml syringe San Joaquin County Emergency Medical Services Page 114 of 216 Endotracheal Intubation – Adult Performance Criteria EMS Policy No. 2545 Effective: October 16, 2013 Supersedes: October 1, 2012 5. Endotracheal tube inducer (ETTI) 6. Oxygen 7. Magill forceps 8. Battery powered suction unit 9. Yankauer Tonsil Tip suction catheter 10. Appropriate size suction catheter 11. ET tube holder 12. End tidal CO2 13. Disposable bag valve device – BVM Performance Criteria 1. Use universal precautions. 2. States this is a two (2) person procedure 3. Assures an adequate BLS airway. 4. States: Will ventilate with 100% oxygen for a minimum of (15) fifteen seconds prior to intubation attempt (unless transitioning to an advanced airway per EMS Agency Policy No. 5710 ALS Medical Cardiac Arrest). 5. States: Indications and contraindications. 6. States: Each attempt should last no longer than thirty (30) seconds. If during any attempt patient desaturates below 90%, immediately cease and reventilate to increase saturation. 7. Ensures that all required equipment is present & quickly accessible s listed above. 8. Ensures suction is available and working. 9. Checks light source, ensures a bright, tight, white light. 10. Select appropriate size ET tube and King Airway. 11. Checks tube cuffs for leaks by injecting air into cuff with syringe and deflates cuff. 12. Position patient in the “ear to sternal notch position.” 13. Places right hand on patient larynx to prepare for bimanual laryngoscopy (external laryngeal manipulation [ELM]) 14. Prepares to insert tube. San Joaquin County Emergency Medical Services Page 115 of 216 Endotracheal Intubation – Adult Performance Criteria EMS Policy No. 2545 Effective: October 16, 2013 Supersedes: October 1, 2012 15. 16. 17. 18. 19. 20. 21. 22. 23. Gently inserts laryngoscope blade into mouth and applies upward traction with left hand to visualize the vocal cords. Does not use teeth as a fulcrum. Asks for assistance to use the ETTI. If patient has a Cormack-Lehane grade of three (3) or four (4) (epiglottis is not or is barely visible), does not attempt the insertion of an endotracheal tube; reinserts a BLS airway and provides respirations via BVM. Provides the patient with a King Airway as described in Agency policy No. 2552 King Airway. The paramedic introduces the ETTI into the patient's mouth, and gently advances it through the glottic opening. HINT: The Coude tip is felt bouncing off the tracheal rings in 6590% of cases, and it stops advancing at 24-40 cm because of the narrowing airways. Occasionally, the tip will impinge on a tracheal ring and stop; slight clockwise rotation rotates the tip off of the trachea ring permitting insertion. The ETTI should rest midline in the trachea and should not be advanced past 35 cm or the black line on the ETTI should not pass the lips. Does not preload ET on ETTI. Assistant places ET over ETTI and gently rotates down toward mouth. Paramedic takes over tube and rotates it in a counter clockwise motion, until the tube is placed in the trachea. If resistance is felt, the tube is rotated 90˚ clockwise and advanced. The paramedic continues to visualize the cords until the tube is placed. HINT: the average tube placement for females is 21 cm and for males 24 cm. Once the tube is in place, the assistant removes the ETTI while stabilizing tube manually. Inflates cuff with 10 ml of air and detaches syringe. San Joaquin County Emergency Medical Services Page 116 of 216 Endotracheal Intubation – Adult Performance Criteria EMS Policy No. 2545 Effective: October 16, 2013 Supersedes: October 1, 2012 24. 25. 26. 27. 28. 29. 30. Simultaneously maintains tube position, ventilates patient and confirms tube placement and: a. Notes capnography readings. PPV at the appropriate CO2 level as well as respiratory rate. b. Observes bilateral rise and fall of chest wall. c. Auscultates bilateral breath sounds with absence of sounds over abdomen. d. Confirms placement with end tidal CO2 device. If initial attempt at intubation fails, reattempts after ventilating the patient for a period of 30 seconds by BVM. If air was heard on the right side only, what would you do? (States: would deflate the cuff, pull tube back slightly -1 cm, re-inflate the cuff, and auscultate for bilateral air entry). Secures tube using commercially approved tube holder Notes tube markers at front teeth, secures tube, and places oral airway. Provides ventilations at 10 – 12 per minute. Successfully intubates in no more than two (2) attempts per patient with ventilations between attempts. If unsuccessful after two (2) attempts, verbalizes the other airways that can be used. San Joaquin County Emergency Medical Services Page 117 of 216 Intraosseous Cannulation - Manual EMS Policy No. 2546 Effective: January 1, 2012 Supersedes: February 15, 2010 2546 – Intraosseous Cannulation - Manual Intraosseous cannulation provides a safe and reliable method for rapidly achieving a route for administration of medications, fluids, and blood products in a non-collapsible vascular space. A. Assessment/Treatment Indicators: 1. Resuscitation. 2. Altered mental status (GCS 8 or less). 3. Status epilepticus with prolonged seizure activity greater than 10 minutes, and refractory to IM anticonvulsants. B. Contraindications: 1. Fractures of the involved bone. 2. Fourth Degree burn, infection or area of cellulitis overlying the site of insertion. 3. Congenital deformity or history of osteogenesis imperfecta or osteoporosis. 4. Previous IO attempt at chosen site. 5. Patient < 3kg. C. Potential complications and interventions: 1. Tubing becomes obstructed with bone or bone marrow: replace the tubing extension set. 2. Local infiltration of fluids, medications, or local bleeding: stop infusion, remove needle, and apply pressure with sterile gauze. D. Insertion site: 1. Previous IO attempt at chosen site. Proximal tibia is the only approved site for manual insertion of the IO needle. Palpate the landmarks at the proximal tibia (patella and tibial tuberosity). Insertion site should be approximately one finger width to the medial side of the tibial tuberosity. E. Equipment: 1. Intraosseous needles: 15ga or 18ga 2. Betadine solution or swabs 3. Sterile gauze and gloves San Joaquin County Emergency Medical Services Page 118 of 216 Intraosseous Cannulation - Manual EMS Policy No. 2546 Effective: January 1, 2012 Supersedes: February 15, 2010 4. 5. 6. 7. Extension tubing Syringes (2) 10 ml Broselow Pediatric Resuscitation Tape (Pediatric patients only). Adhesive tape Performance Criteria 1. 2. Uses universal precautions. States: Indications, contraindications, and selects insertion site for IO cannulation 3. Assembles equipment, attaches extension tubing to IV tubing, and checks the needle to ensure bevels of the outer needle and internal stylet are properly aligned. 4. Cleans insertion site using aseptic technique. 5. After skin prep, places patient in supine position and holds leg firmly. 6. Directs and inserts needle perpendicular to bone using a boring or screwing motion until needle “pops” into the bone marrow space (marked by sudden lack of resistance). Needle should stand-alone. 7. Attempts aspiration of bone marrow to assist in placement confirmation. 8. Disconnects first syringe and connects second syringe, flushing with at least 3 ml of normal saline, observing for fluid extravasation. 9. Attaches extension tubing to needle and adjusts flow as required. If fluid does not run freely apply a pressure infuser and adjust flow as required. 10. Secures needle with sterile gauze and tape. 11. Restrains patient prn to prevent inadvertent dislodging of the needle. 12. States: Document IO placement on PCR. San Joaquin County Emergency Medical Services Page 119 of 216 Transcutaneous Pacing Performance Criteria EMS Policy No. 2547 Effective: February 15, 2010 Supersedes: January 1, 2010 2547 – Transcutaneous Pacing Performance Criteria Transcutaneous pacing is used for short intervals as a bridge until transvenous pacing can be initiated or until the underlying cause of the bradyarrhythmia (e.g., hyperkalemia, drug overdose) can be reversed. A. Assessment/Treatment Indicators: 1. Indicated for adult patients with hemodynamically unstable bradycardia. 2. Is authorized as a standing order for paramedics in treating adult patients with unstable bradycardia. Hemodynamically unstable bradycardia means a patient with a BP < 90, related to a bradycardic rhythm (HR <60) with serious signs and symptoms related to heart rate, (i.e.: chest pain, SOB, ALOC, shock, pulmonary congestion, CHF). 3. TCP should not be delayed for hemodynamically unstable bradycardia patients while waiting for IV access or for atropine to take effect. 4. Base Hospital Physician order is required to perform TCP. B. Contraindications: TCP is not authorized for use on patients less than 15 years of age. Not authorized for hypothermic patients because the bradycardia is usually a physiologic response to the body temperature. C. Equipment: 1. Transcutaneous cardiac pacemaker 2. Cardiac monitor with defibrillator 3. Versed 4. 10 ml syringe 5. ECG electrodes 6. Pulse oximetry device San Joaquin County Emergency Medical Services Page 120 of 216 Transcutaneous Pacing Performance Criteria EMS Policy No. 2547 Effective: February 15, 2010 Supersedes: January 1, 2010 Performance Criteria 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Uses universal precautions. Explain procedure to the patient. States indications and contraindications for pacing. Apply pre-gelled adhesive pacing pads to chest wall according to manufacturer’s recommendations. Apply ECG electrodes Confirm rhythm. Activate pacing device per manufacturer’s instructions. Set heart rate Increases output until capture occurs (and increase output 10% above threshold) Confirms capture by correlating QRS spike with pulses. Reassesses BP and LOC. Increases rate prn (not to exceed 100) if patient remains hypotensive and symptomatic from inadequate perfusion. Determines what the lowest threshold response and maintains output control at this level. NOTE: Any movement of patient may increase the capture threshold response; subsequently, the output may have to be adjusted to compensate for this. Provides patient with sedation/pain relief prn. Continue monitoring. Contact base hospital for further orders if patient symptoms are not resolving (consideration for dopamine, further alteration of pacer settings or if further sedation/pain control orders required). San Joaquin County Emergency Medical Services Page 121 of 216 Needle Thoracostomy Performance Criteria EMS Policy No. 2548 Effective: January 1, 2010 Supersedes: January 1, 2009 2548 – Needle Thoracostomy Performance Criteria Tension pneumothorax is defined as air under pressure in the pleural space. Needle thoracostomy should be performed to aid in a rapidly deteriorating adult or pediatric patient with severe respiratory distress. A. Assessment/Treatment Indicators: 1. Restlessness, anxiety, or decreased LOC. 2. Diminished or absent breath sounds on the affected side. 3. Possible tracheal deviation away from the affected side (late sign). 4. Shock syndrome (weak rapid pulse, hypertensive initially, with hypotension a late find). 5. Distended neck veins (JVD). 6. Progressively worsening dyspnea/cyanosis. B. Potential complications: 1. Conversion from a closed pneumothorax to an open one 2. If there is not a pneumothorax, insertion of a needle will produce a pneumothorax. 3. Laceration of the lung or laceration of the intercostal vessels. C. Equipment: 1. 14 or 16 gauge 2 to 2 ½ inch needle and cannula or patients > 50kg or 14 or 16 gauge 2 to 2 ½ inch needle and cannula, 18g, 1 to 1 1/4 inch needle and cannula for patients less than 50kg 2. Betadine swab 3. 10 ml syringe 4. Tape 5. Disposable bag valve device – BVM 6. One-way flutter valve Performance Criteria 1. 2. 3. Uses universal precautions. States indications and possible complications of the procedure. Assembles equipment and selects appropriate size needle and cannula. San Joaquin County Emergency Medical Services Page 122 of 216 Needle Thoracostomy Performance Criteria EMS Policy No. 2548 Effective: January 1, 2010 Supersedes: January 1, 2009 4. 5. 6. 7. 8. 9. 10. Locates insertion site at the second intercostal space, midclavicular line or the fourth intercostal space at the midaxillary line. Prepare area with Betadine swap. Firmly inserts the needle (attached to syringe) perpendicular to the chest wall, over the top of the rib until pleura is penetrated as indicated by one or more of the following: a. A “popping sound” is heard, or giving away sensation is felt. b. A “hissing” noise follows evidence of a tension pneumothorax. c. Ability to aspirate free air or blood into the syringe. Advances the catheter and removes needle and syringe. Adds flutter or Heimlich Valve to prevent re-accumulation of air in the pleural space. Secures needle hub in place with tape over Benzoin tincture or with other approved device. Reassesses patient lung sounds, respiratory status immediately, and every five (5) minutes thereafter. Considers the following: a. The procedure may have to be repeated if the tension is not relieved. b. Air transport: The needle thoracostomy should be done prior to takeoff to allow for escape of air that may accumulate in the pleural space with atmospheric pressure changes. San Joaquin County Emergency Medical Services Page 123 of 216 Needle Cricothyrotomy TLJV EMS Policy No. 2549 Effective: January 1, 2012 Supersedes: January 1, 2010 2549 – Needle Cricothyrotomy Translaryngeal Jet Ventilator Transtracheal catheter ventilation is a temporary emergency procedure to provide oxygenation when airway obstruction cannot be relieved by other methods. A. Assessment/Treatment Indicators for the unconscious patient : 1. Patient is unconscious and unresponsive. 2. Total airway obstruction following unsuccessful attempts of BLS and ALS obstructed airway procedures. 3. Massive facial trauma in a patient who cannot be intubated by either oral or nasotracheal means. 4. Injury to the trachea/larynx in a patient who cannot adequately ventilated or intubated by either oral or nasotracheal means. 5. Airway obstruction due to infection. B. Contraindications: NONE. C. Potential Complications: 1. With the high pressure used during ventilation and the possibility of air entrapment, may produce a pneumothorax. 2. Hemorrhage may occur at the site of the needle insertion, especially if the thyroid is perforated. 3. Perforation of the esophagus. 4. Subcutaneous or meditational emphysema. 5. Usually does not allow enough ventilation to adequately eliminate carbon dioxide. D. Equipment: 1. Translaryngeal jet ventilator with push-button and high-pressure tubing with locking device (Adult) or disposable Bag-Valve device (Pediatric) 2. Endotracheal tubes: 3.0 or 3.5 ET 3. Providone iodine 4. Oxygen supply @ 50 PSI 5. 10 - 12 gauge needle for adult, 12 – 14 gauge needle for pediatrics 6. Battery powered suction device San Joaquin County Emergency Medical Services Page 124 of 216 Needle Cricothyrotomy TLJV EMS Policy No. 2549 Effective: January 1, 2012 Supersedes: January 1, 2010 7. Yankauer Tonsil Tip Suction Catheter Non-rigid 8. 10 ml syringe 9. End-tidal CO2 device Performance Criteria 1. Uses universal precautions. 2. States: Indications and contraindications. 3. 8. Locates and prepares insertion site at the cricothyroid membrane between the thyroid and cricoid cartilage of larnyx. Performance Criteria Place 5 ml of normal saline in the syringe. Attaches the IV catheter to the syringe and inserts the needle midline at a 45 angle with a quick smooth downward motion following the direction of the trachea. Applies negative pressure to the syringe during insertion. Bubbles in the syringe indicate that the needle is in the trachea. Advances the catheter over the needle, and withdraws the needle and syringe. If using cricothyrotomy cannula, removes obturator. Attaches oxygen delivery device. Assesses for hemorrhage or subcutaneous emphysema, which may indicate improper placement. Ventilates using TLJV - one (1) second on and three (3) seconds off. 9. States if TLJV fails can attach 3.5 ET hub and ventilates with BVM. 4. 5. 6. 7. 10. Auscultates lungs while manually holding needle. 11. Secures needle hub in place with tape over Benzoin or with other approved device. 12. Transport immediately to closest hospital for airway management. 13. Contact Base Hospital if unable to adequately ventilate patient. 14. States: Document needle cricothyrotomy placement on PCR. San Joaquin County Emergency Medical Services Page 125 of 216 Naso/Orogastric Intubation Performance Criteria EMS Policy No. 2550 Effective: January 1, 2010 Supersedes: January 1, 2009 2550 – Naso/Orogastric Intubation Performance Criteria A. Assessment/treatment indicators: 1. Gastric distention which impedes ABC’s: a. Full arrest b. Near drowning 2. Gastrointestinal bleeding. 3. Possible drug overdose. 4. Insertion considerations: a. Nasal route for children and adults (if nasal flaring occurs in children, take out and use oral route). b. Oral route for infants under six (6) months. c. Oral route for patients with mid-facial trauma. B. Contraindications: 1. Known esophageal strictures, varices and/or other esophageal disease. 2. Ingested caustics. 3. Significant facial or head trauma. 4. Patients with bleeding disorders. C. Potential complications and interventions: 1. Insertion of N/G or O/G tube into trachea/lung. If patient experiences respiratory distress at any time during the procedure remove the tube immediately. D. Equipment: 1. Adults: 1 6 - 18 Fr tube; Peds: 10 Fr tube 2. Yankauer Tonsil Tip Suction Catheter 3. Appropriate size Suction Catheter 4. Battery powered suction equipment, should be immediately available. 5. 60 ml cath-tipped syringe. 6. Water-soluble lubricating jelly. 7. Adhesive tape 8. Stethoscope 9. 2% Lidocaine Jelly San Joaquin County Emergency Medical Services Page 126 of 216 Naso/Orogastric Intubation Performance Criteria EMS Policy No. 2550 Effective: January 1, 2010 Supersedes: January 1, 2009 Performance Criteria 1. 2. 3. 4. 5. 6. 7. Uses universal precautions. States indications and contraindications. Places patient in High Fowlers, unless otherwise contraindicated. Assembles equipment and checks suction equipment. NASOGASTRIC OROGASTRIC INSERTION INSERTION Measures combined distance Measures the combined between the tip of the nose distance between the corner of to the ear lobe to the xiphoid the mouth to the ear lobe to process. the xiphoid process. Examines nares to determine Examines oropharyngeal nare with best airflow. cavity for obstructions/secretions. Lubricates distal 2-3” of N/G Lubricates distal 2-3” of O/G tube with water-soluble tube with water-soluble lubricant. 2% Lidocaine Jelly lubricant. not to exceed 5 ml, may also be applied to distal end of N/G tube. San Joaquin County Emergency Medical Services Page 127 of 216 Naso/Orogastric Intubation Performance Criteria EMS Policy No. 2550 Effective: January 1, 2010 Supersedes: January 1, 2009 8. 9. 10. 11. 12. 13. Inserts nasogastric tube: Inserts orogastric tube: a. Gently passes tube into a. Gently passes tube into the selected nostril. oral cavity and instructs the b. When resistance is met, patient to swallow (if has the patient lower chin conscious). to chest. b. Slowly rotates tube while c. Then rotates tube inward inserting to desired length. toward the other nostril c. If resistance is met, while inserting. removes tube and red. Instructs patient to attempts. swallow (if conscious). e. If resistance is still met, removes and attempts other nostril. Advances N/G or O/G tube to previously measured location Confirms proper placement by: a. Aspiration of stomach contents. b. Injection of 30-60 ml of air into tube as you auscultate for the sound of air over the epigastric region. Secures tube to bridge of nose (N/G), or to side of mouth (O/G). Attaches tube to suction and adjust to low suction. Reassesses vital signs and notes response to therapy. San Joaquin County Emergency Medical Services Page 128 of 216 12 Lead ECG Performance Criteria EMS Policy No. 2551 Effective: January 1, 2012 Supersedes: January 1, 2010 2551 – 12 Lead ECG Performance Criteria Medical history and/or presenting complaints consistent with coronary ischemia. A. Indications: Only Patients with one or more of the following signs/symptoms: 1. Chest or upper abdominal discomfort suggestive of coronary ischemia. 2. Acute onset of unexplained hypotension. 3. Return of spontaneous circulation (ROSC). 4. Acute onset congestive heart failure. B. Precaution: 1. Performing a 12 lead ECG on a patient without proper indications increases the likelihood of obtaining a false positive STEMI finding. Performance Criteria 1. 2. 3. Uses universal precautions. Do not delay assessment and treatment. Follow appropriate policies regarding the patient’s clinical assessment. Explain to the patient the procedure and the importance of obtaining an ECG. San Joaquin County Emergency Medical Services Page 129 of 216 12 Lead ECG Performance Criteria EMS Policy No. 2551 Effective: January 1, 2012 Supersedes: January 1, 2010 States: Exposes the chest and prepare the patient’s skin for electrode placement. Dry the skin if it is excessively moist. If there is significant chest hair, use a razor to shave areas where leads will be placed. 5. Attach ECG leads to the patient: 1. Place the electrodes on the limbs. The limb leads can be placed anywhere from the shoulders to the wrist and the thighs to the ankles – not the torso. 2. Place the electrodes on the chest. The six precordial (chest) lead electrodes: a. V1: right 4th intercostal space, just to the right of the sternum. b. V2: left 4th intercostal space, to the left of the sternum. c. V3: Halfway between V2 and V4. d. V4: Left 5th intercostals space, midclavicular line. e. V5: Horizontal to V4, anterior axillary line. f. V6: Horizontal to V5, mid-axillary line. 6. Encourage the patient to remain as still as possible and not to talk. 7. Run the 12-Lead ECG. 8. The 12-Lead/Age menu will appear. Select the patient’s age. 9. If the monitor detects noise (such as patient motion or a disconnected electrode), the 12-Lead is interrupted. Take appropriate action and run the 12-Lead again. 10. If the 12-lead ECG indicates an acute STEMI, based on cardiac monitor/defibrillator manufacture’s operating instructions regarding STEMI alerting messages. LP12 (*** ACUTE MI SUSPECTED ***) LP15 (*** MEETS ST EVELVATION MI CRITERIA ***) Zoll E Series (** ** ** ** * ACUTE MI * ** ** ** **) 1. States: Notify the STEMI Receiving Center (SRC). 2. States: Transport to SRC. 11. Attaches a copy of the 12-lead ECG to the PCR. 4. San Joaquin County Emergency Medical Services Page 130 of 216 King Airway Performance Criteria EMS Policy No. 2552 Effective: October 16, 2013 Supersedes: October 1, 2012 2552 – King Airway Performance Criteria The KING LTS-D is an effective alternative to endotracheal intubation. The KING LTS-D also allows three additional benefits with the use of secondary lumen which is open at the distal tip of the tube: 1). Passage of gastric tube up to 18 French; 2). A channel for regurgitation, and; 3). A "vent" for gastric pressure and stomach decompression. A. Assessment/Treatment Indicators: 1. Inability to ventilate in a setting in which endotracheal intubation is not successful or the patient has a Cormack Lehan score is a 3 or 4. 2. Inability to ventilate or oxygenate the patient using a BVM and BLS airway. 3. Inability of patient to protect the airway (coma, decreased LOC without gag reflex). 4. Cardiac arrest. Adhere to sequence as specified in EMS Policy No. 5710 ALS Medical Cardiac Arrest as appropriate. 5. Agonal or failing respirations, respiratory arrest. B. Contraindications: 1. Patient with GCS > 3 2. Patient has a gag reflex. 3. Patient has a tracheostomy or stoma. 4. Patient height less than 4 feet C. Relative Contraindications: 1. Ingestion of caustic substance. 2. Known history of esophageal disease. 3. Inhalation Burns. D. Equipment: 1. King Airway LTS-D Kit (Size 3, 4, or 5) 2. Battery powered suction unit 3. Appropriate size suction catheter 4. Yankauer Tonsil Tip suction catheter 5. Disposable bag valve device – BVM San Joaquin County Emergency Medical Services Page 131 of 216 King Airway Performance Criteria EMS Policy No. 2552 Effective: October 16, 2013 Supersedes: October 1, 2012 6. End tidal CO2 device 7. Stethoscope Performance Criteria 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Uses universal precautions. Assures an adequate BLS airway. States: Indications and contraindications. States: Placement should be completed within 30 seconds. Ensures suction is available and working. Preoxyegnates with BVM for a minimum of (15) fifteen seconds with supplemental oxygen when conditions permit (unless transitioning to an advanced airway per EMS Agency Policy No. 5710 ALS Medical Cardiac Arrest).. States appropriate size tube based on height. a. Size 3 – 4 and 5 feet tall b. Size 4 – 5 and 6 feet tall c. Size 5 – Over 6 feet tall Prepares King LTS-D a. Tests cuffs for leaks b. Lubricates device with water-soluble lubricant to the beveled distal tip and posterior aspect of tube, taking care to avoid introduction of lubricant in or near ventilatory openings. States: Will have a spare King Airway available for immediate use. Positions the head. The ideal head position for insertion is the “sniffing position.” A neutral position can also be used (e.g. spinal injury concerns). Grasps the patient's tongue and jaw with gloved hand and pulls forward. A laryngoscope may be used. With the King LTS-D rotated laterally at 45-90 degrees such that the blue orientation line is touching the corner of the mouth, introduces tip into mouth and advances it behind base of tongue. Never force the tube into position. San Joaquin County Emergency Medical Services Page 132 of 216 King Airway Performance Criteria EMS Policy No. 2552 Effective: October 16, 2013 Supersedes: October 1, 2012 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. TIP As the tube tip passes under tongue, rotates tube back to midline (blue orientation stripe faces chin). Without exerting excessive force, advances tube until base of connector aligns with teeth or gums. Inflates cuff to required volume. States: Required cuff pressure based on tube size. Note: Do not exceed maximum recommended pressure. Connects the King LTS-D to a BVM and ventilates the patient. While ventilating the patient, gently withdraws the tube until ventilation becomes easy and free flowing (large tidal volume with minimal airway pressure). Adjusts cuff inflation if necessary to obtain a seal of the airway at the peak ventilatory pressure employed. Confirms proper position by auscultation, chest movement, and verification of CO2 by capnography. Do not use esophageal detector device with esophageal airway. The method of confirmation must be documented. Secures the tube. Notes depth marking on tube. If placement is unsuccessful, removes tube, ventilate with BVM and repeats sequence of steps. If unsuccessful on second attempt, BLS airway management shall be resumed. Continues to monitor the patient for proper tube placement throughout prehospital treatment and transport. Capnography should be done in all cases. Provides ventilations at 10 – 12/minute. States: Document King Airway placement on PCR. The key to insertion is to get the distal tip of the airway around the corner in the posterior pharynx, under the base of the tongue. It is important that the tip of the device is maintained at the midline. If the tip is placed or deflected laterally, it may enter the piriform fossa and cause the tube to appear to “bounce back” upon full insertion and release. San Joaquin County Emergency Medical Services Page 133 of 216 Endotracheal Intubation – Pediatric Performance Criteria EMS Policy No. 2553 Effective: January 1, 2010 Supersedes: NA 2553 – Endotracheal Intubation – Pediatric Performance Criteria In the absence of a protected airway, attempts to provide adequate lung inflation with a BVM may result in the generation of pharyngeal pressure high enough to cause gastric distention. In addition, gastric insufflation promotes regurgitation with the potential for aspiration of gastric contents into the lungs and may on occasion elevate the diaphragm enough to interfere with lung expansion. Pediatric intubation should only be attempted if an adequate BLS Airway cannot be maintained. A. Assessment/Treatment Indicators: 1. Inability of ALS personnel to ventilate or oxygenate the patient. 2. Inability of patient to protect the airway (coma, decreased level of consciousness with non-intact gag reflex). 3. Cardiac arrest, including traumatic arrest. 4. Agonal or failing respirations, respiratory arrest. 5. Base Hospital Physician Order B. Contraindications: Intubation may be contraindicated on patients that are known diabetics or narcotics overdoses, prior to the administration of Dextrose or Narcan. C. Potential Complications: 1. Esophageal Intubation 2. Mainstem Intubation 3. Perforation or laceration of upper esophagus, vocal cords, larynx 4. Laryngospasm or bronchospasm 5. Dental and soft-tissue trauma 6. Aspiration of oral or gastric contents 7. Dysrhythmias 8. Hypertension/Hypotension San Joaquin County Emergency Medical Services Page 134 of 216 Endotracheal Intubation – Pediatric Performance Criteria EMS Policy No. 2553 Effective: January 1, 2010 Supersedes: NA D. Equipment: 1. Broselow Pediatric Resuscitation Tape for sizing recommendations 2. Laryngoscope with appropriate size handle 3. Endotracheal tube 4. Malleable stylet 5. Water soluble lubricating jelly 6. Syringe: 10 ml 7. Magill forceps 8. Battery powered suction unit 9. Yankauer Tonsil Tip suction catheter 10. Appropriate size suction Catheter 11. ET tube holder 12. End tidal CO2 device Performance Criteria 1. Use universal precautions. 2. Assure an adequate BLS airway. 3. State indications and contraindications 4. States placement should be completed within 30 seconds. 5. Ensure suction and is available and working. . 6. Checks light source, ensures a bright, tight, white light. 7. Select appropriate size tube. 8. Check tube cuff for leaks by injecting air into cuff with syringe and deflates cuff if present. 9. Position stylet (if used) so that the end is recessed within tube, then lubricates the tube. 10. Instructs assistant to preoxyegnate the patient. 11. Positions the patient with neck slightly extended. Understands bimanual laryngoscopy and when and how it is used. 12. Perform tube insertion. Gently inserts laryngoscope blade into mouth and applies upward traction with left hand to visualize the vocal cords. Inserts tube through open cords with right hand when visualized. Does Not Use Teeth As A Fulcrum. San Joaquin County Emergency Medical Services Page 135 of 216 Endotracheal Intubation – Pediatric Performance Criteria EMS Policy No. 2553 Effective: January 1, 2010 Supersedes: NA 13. Remove laryngoscope from mouth and removes stylet while stabilizing tube manually. 14. Inflate cuff (if present) with 10 ml of air and detaches syringe. 15. Simultaneously maintains tube position, ventilates patient and confirms tube placement by: a. Notating capnography readings. b. Observing bilateral rise and fall of chest wall. c. Auscultating bilateral breath sounds with absence of sounds over abdomen. d. Confirm placement with end tidal CO2 device. 16. If initial attempt at intubation fails, reattempt after hyperventilation period of 15-30 seconds by BVM. 17. If air was heard only on the right side, what would you do? (Indicates would deflate the cuff, if present, pull tube back slightly -1 cm, re-inflate the cuff, and auscultate for bilateral air entry). 18. Note tube markers at front teeth, secures tube, and places oral airway. 19. Provide ventilations at 10 – 12/minute 20. Successfully intubates in no more than two (2) attempts per patient with hyperventilation between attempts. If unsuccessful after two (2) attempts, assure an adequate BLS airway. San Joaquin County Emergency Medical Services Page 136 of 216 Continuous Positive Airway Pressure (CPAP) Performance Criteria EMS Policy No. 2554 Effective: January 1, 2010 Supersedes: NA 2554 – Continuous Positive Airway Pressure (CPAP) Performance Criteria The goal of CPAP is to improve ventilation and oxygenation in an effort to avoid intubation in patients who present with severe respiratory distress. A. Assessment/Treatment Indicators: CPAP is authorized for use in patients who are age 8 or older with one of the following: 1. Congestive Heart Failure (CHF) with acute pulmonary edema 2. Near drowning/submersion 3. Other causes of severe respiratory distress, excluding trauma B. Contraindications: 1. Respiratory or cardiac arrest 2. Failing respirations 3. Inability to maintain airway 4. Severely depressed level of consciousness (LOC) 5. Systolic blood pressure < 90mmHg 6. Signs and symptoms of pneumothorax 7. Major trauma, especially head injury or suspected chest injury 8. Facial anomalies or inability to obtain a mask seal C. Relative Contraindications 1. Decreased LOC 2. Claustrophobia or unable to tolerate mask D. Equipment: 1. CPAP (pressure generator and circuit set with ability to deliver 7.5 cm to 10 cm of H20 pressure with appropriate sized facemask and straps). 2. Nebulizer, if required for bronchodilator administration 3. Oxygen source 4. Cardiac monitor Performance Criteria 1. Use universal precautions. San Joaquin County Emergency Medical Services Page 137 of 216 Continuous Positive Airway Pressure (CPAP) Performance Criteria EMS Policy No. 2554 Effective: January 1, 2010 Supersedes: NA 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. State indications and contraindications. Position the patient in a seated position with legs dependant. Apply cardiac monitor and assess vital signs. Repeat vital signs every five minutes; SpO2 must be used to continuously monitor the patient’s oxygen saturation. Treat the patient according to appropriate treatment policy (i.e. pulmonary edema). Set up the CPAP system following manufacturer directions. Explain the procedure to the patient. It is important to reassure the patient throughout the procedure. Verify that oxygen is flowing to the mask and then apply mask. Do not exceed 10 cm of H20 pressure. Continuously monitor patient for improvement or failure to improve. The patient should improve in the first five minutes with CPAP, evidenced by decreased heart rate and blood pressure, decreased respiratory rate and an increased SpO2. If the patient does not improve or becomes worse with CPAP, remove the CPAP device and assist ventilations with BVM as needed. Notify the receiving hospital of the type of CPAP device that is being used. DOCUMENTATION: A. The use of CPAP must be documented on the patient care record. B. Vital signs to include heart rate, blood pressure, respiratory rate, and SpO2 must be documented every 5 minutes. C. Narrative documentation should include a description of the patient’s response to treatment. D. Additional narrative documentation should include if the patient does not respond to CPAP and endotracheal intubation is required. San Joaquin County Emergency Medical Services Page 138 of 216 Nasotracheal Intubation – Adult Performance Criteria EMS Policy No. 2555 Effective: January 1, 2012 Supersedes: February 15, 2010 2555 – Nasotracheal Intubation – Adult Performance Criteria To provide an advanced airway in patients that cannot be intubated endotracheally. Nasotracheal intubation requires a Base Hospital Physician order. A. Assessment/Treatment Indicators: 1. Possible cervical spine injury with clenched jaw and gag reflex. 2. Trapped and inaccessible for direct laryngoscopy. 3. Severe respiratory distress secondary to smoke inhalation, asthma, emphysema 4. Patient nare is able to accommodate size 7.0, 7.5 or 8.0 endotracheal tubes. 5. Severe respiratory depression secondary to ETOH, OD, CVA. 6. Need to control and provide airway protection. 7. Compromised airway in spontaneously breathing patients. 8. Base Hospital Physician Order. B. Contraindications: 1. Apneic patient. 2. Lack of proper training. 3. Loss of nasal passage integrity. 4. Basilar skull fracture. 5. Pediatrics as defined in pediatric routine medical care policy. 6. Unstable mid-face fractures with loss of nasal passage integrity. C. Relative Contraindications: 1. For significant trauma to the face or nose and/or possible basilar skull fracture. 2. For patients on anticoagulant therapy. D. Potential Complications: 1. Epistaxis and/or emesis can be induced in patients with clenched teeth, further compromising the airway. 2. Perforation of pyriform sinus. 3. Perforation of the pharynx. 4. Cranial intubation and possible infection in the patient with a basal skull fracture. San Joaquin County Emergency Medical Services Page 139 of 216 Nasotracheal Intubation – Adult Performance Criteria EMS Policy No. 2555 Effective: January 1, 2012 Supersedes: February 15, 2010 E. .Equipment: 1. Endotracheal tube 2. Water soluble lubricating jelly 3. 10 ml syringe 4. BAMM 5. Oxygen 6. Neosynephrine 7. Battery powered suction unit 8. Yankauer Tonsil Tip suction catheter 9. Appropriate size suction catheter 10. ET tube holder 11. End tidal CO2 12. Disposable bag valve device – BVM Performance Criteria 1. 2. 3. 4. 5. 6. 7. 8. 9. Use universal precautions. Support ventilations with appropriate basic airway adjuncts and explain the procedure to a conscious patient. States: Indications and contraindications. Select the nostril to be used and inspect for patency and airflow. Select the appropriate cuffed tube and pre-oxygenate patient with 100% oxygen prior to attempting procedure. If patient becomes apneic, discontinue procedure and attempt oral intubation. Lubricate the distal tip of endotracheal tube with viscous Lidocaine. Position the patient as tolerated. Hold in-line cervical stabilization if neck injury is suspected. Administer one (1) metered dose, 0.5mg of phenylephrine HCL to the selected nostril. May be repeated once prior to additional attempt. If first attempt is unsuccessful, recontact Base Hospital Physician, for approval for second attempt. San Joaquin County Emergency Medical Services Page 140 of 216 Nasotracheal Intubation – Adult Performance Criteria EMS Policy No. 2555 Effective: January 1, 2012 Supersedes: February 15, 2010 10. 11. 12. 13. With one hand, advance ET tube into the selected nostril with bevel against septum. Monitor breath sounds continuously while gently guiding the tube into the trachea. Use BAAM device to assist in proper placement. Inflated cuff with 10 ml of air and detaches syringe. Simultaneously maintains tube position, ventilates patient and confirms tube placement: a. Notes capnography readings. PPV at the appropriate CO2 level as well as respiratory rate. b. Observes bilateral rise and fall of chest wall. c. Auscultates bilateral breath sounds with absence of sounds over abdomen. d. Confirms placement with end tidal CO2 device. States: Document Nasotracheal intubation placement on the PCR San Joaquin County Emergency Medical Services Page 141 of 216 Needle Cricothyrotomy – ENK Flow O2 Modulator Performance Criteria EMS Policy No. 2556 Effective: January 1, 2012 Supersedes: NA NEEDLE CRICOTHYROTOMY – ENK FLOW OXYGEN MODULATOR Transtracheal catheter ventilation is a temporary emergency procedure to provide oxygenation when airway obstruction cannot be relieved by other methods. A. Assessment/Treatment Indicators: 1. Patient is unconscious and unresponsive. 2. Total airway obstruction following unsuccessful attempts of BLS and ALS obstructed airway procedures. 3. Massive facial trauma in a patient who cannot be intubated by either oral or nasotracheal means. 4. Injury to the trachea/larynx in a patient who cannot be adequately ventilated or intubated by either oral or nasotracheal means. 5. Complete airway obstruction due to infection or allergic reaction. B. Contraindications: NONE. C. Potential Complications: 1. With the high pressure used during ventilation and the possibility of air entrapment, may produce a pneumothorax. 2. Hemorrhage may occur at the site of the needle insertion, especially if the thyroid is perforated. 3. Perforation of the esophagus. 4. Subcutaneous or mediastinal emphysema. 5. Usually does not allow enough ventilation to adequately eliminate carbon dioxide. D. .Equipment: 1. ENK Flow Oxygen Modulator Kit 2. Endotracheal tubes: 3.0 or 3.5 ET 3. Providone iodine 4. Oxygen supply @ 25 PSI 5. Battery powered suction device 6. Yankauer Tonsil Tip Suction Catheter Non-rigid 7. 10 ml syringe 8. End-tidal CO2 device 9. Tape San Joaquin County Emergency Medical Services Page 142 of 216 Needle Cricothyrotomy – ENK Flow O2 Modulator Performance Criteria EMS Policy No. 2556 Effective: January 1, 2012 Supersedes: NA 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. Uses universal precautions. States: Indications and contraindications. States: Extend the patient’s neck, if not a trauma victim. Locates and prepares insertion site at the cricothyroid membrane between the thyroid and cricoid cartilage of larnyx. Stabilizes the larynx by holding the cartilage between fingers. Places 5 ml of normal saline in the syringe. Attaches the IV catheter to the syringe and inserts the needle midline at 90 angle, slowly advances the needle ½” to ¾” with plastic catheter. Attempts to aspirate free air as needle advances. If the needle is in the correct location bubbles should be seen in the syringe. If unable to aspirate free air, back the needle up 1 cm at a time while aspirating until bubbles are seen in the syringe. States: Once free air has been aspirated, then directs the needle toward the sternal notch, advances the catheter over the needle, then withdraws the needle and syringe. Attaches the catheter to the ENK Flow Oxygen Modulator. Assesses for hemorrhage or subcutaneous emphysema, which may indicate improper placement. Directs assistant to attach distal end of ENK Flow Oxygen Modulator to oxygen source and set @ 15 – 25 LPM. Ventilates the patient by covering the holes on the modulator for four (4) seconds. Uncovers the holes for six (6) seconds to allow for passive exhalation. Auscultates lungs while manually holding needle. Secures needle hub in place by wrapping tape around the hub twice and then behind the patients neck and wrap the hub twice again after coming around the neck. States: Monitors end-tidal CO2 and/or pulse oximetry, and chest expansion. States: Transports immediately to closest hospital for airway management. San Joaquin County Emergency Medical Services Page 143 of 216 Needle Cricothyrotomy – ENK Flow O2 Modulator Performance Criteria EMS Policy No. 2556 Effective: January 1, 2012 Supersedes: NA 18. States: Contact the Base Hospital if unable to adequately ventilate patient. 19. States: Document needle cricothyrotomy placement on PCR. San Joaquin County Emergency Medical Services Page 144 of 216 Paramedic Scope of Practice EMS Policy No. 2560 Effective: January 1, 2012 Supersedes: February 15, 2010 2560 – Paramedic Scope of Practice PURPOSE: The purpose of this policy is to define the scope of practice of San Joaquin County EMS Agency accredited paramedics. AUTHORITY: Health and Safety Code, Division 2.5, Section 1797.220; 1798 et seq., Title 22, California Code of Regulations, Chapter 4 et seq. DEFINITIONS: A. “Emergency Medical Technician” or “EMT” means a person who has successfully completed a basic EMT course, which meets the requirements of Title 22, California Code of Regulations, and Chapter 2 and has been certified as an EMT by an EMT-I certifying authority. B. “Advanced EMT or Emergency Medical Technician – II” or “EMTII” means a person who has successfully completed a basic EMT course, which meets the requirements of Title 22, California Code of Regulations, Chapter 3 and has been certified as an EMT-II by an EMT-II certifying authority. C. “Paramedic” means a person who is educated and trained in all elements of the prehospital advanced life support and has been licensed by the State of California as a paramedic. POLICY: I. An accredited paramedic may perform any activity identified in the scope of practice of an EMT or any activity identified in the scope of practice of an Advanced EMT or EMT-II. II. As part of the State approved basic scope of practice, a paramedic student or accredited paramedic, as part of the organized EMS system in San Joaquin County, while caring for patients in a hospital as part of his/her training or continuing education under San Joaquin County Emergency Medical Services Page 145 of 216 Paramedic Scope of Practice EMS Policy No. 2560 Effective: January 1, 2012 Supersedes: February 15, 2010 direct supervision of a physician, registered nurse, or physician assistant, or while at the scene of a medical emergency or during transport, or during interfacility transfer may perform the following procedures or administer the following medications in accordance with the written policies of the San Joaquin County EMS Agency: A. Perform defibrillation. B. Perform cardioversion. C. Visualize the airway by use of laryngoscope and remove foreign body(ies) with forceps. D. Perform ECG’s. E. Perform pulmonary ventilation by use of the esophageal airway, lower airway lumen, endotracheal intubation or other airway adjuncts approved by the EMS Agency. F. Use of ventilators during transport as approved by the EMS Agency.1 G. Institute intravenous (IV) catheters, saline locks, needles, or other cannulae in peripheral veins; and monitor and administer medications through pre-existing vascular access. H. Administer intravenous glucose solutions or isotonic balanced salt solutions including Ringer’s lactate solution. I. Obtain venous blood samples. J. Use glucose and pulse oximetry measuring devices. K. Perform Valsalva’s maneuver. L. Perform needle cricothyrotomy. M. Perform needle thoracostomy. N. Monitor thoracostomy tubes. O. Monitor IV solution containing potassium equal to or less than 20 mEq./L. P. The following are the only authorized routes for administration of medications 1. Intravenous 2. Intraosseous 3. Subcutaneous 1 Use limited to specially approved ALS ambulance providers. San Joaquin County Emergency Medical Services Page 146 of 216 Paramedic Scope of Practice EMS Policy No. 2560 Effective: January 1, 2012 Supersedes: February 15, 2010 4. Intramuscular 5. Sublingual 6. Inhalation 7. Oral Q. Administer using prepackaged products when available: 1. 25% and 50% dextrose. 2. Activated charcoal. 3. Adenosine. 4. Aerosolized or nebulized beta-2 specific bronchodilators. 5. Aspirin. 6. Atropine sulfate. 7. Calcium chloride. 8. Diazepam2 9. Diphenhydramine hydrochloride. 10. Dopamine hydrochloride. 11. Epinephrine. 12. Furosemide3 13. Glucagon. 14. Lidocaine hydrochloride. 15. Midazolam. 16. Morphine sulfate. 17. Naloxone hydrochloride. 18. Nitroglycerine preparation – sublingual or oral spray. 19. Pralidoxime chloride (2 - PAM) 20. Sodium bicarbonate. III. An accredited paramedic in San Joaquin County is authorized, as part of the State approved expanded scope of practice, to perform the following procedures or administer the following medications in accordance with the written policies of the San Joaquin County EMS Agency: A. Perform pediatric oral endotracheal intubation. 2 As part of a nerve agent antidote kit. 3 As prescribed by the transferring physician during an interfacility transfer. San Joaquin County Emergency Medical Services Page 147 of 216 Paramedic Scope of Practice EMS Policy No. 2560 Effective: January 1, 2012 Supersedes: February 15, 2010 B. C. D. E. F. Perform adult naso-tracheal intubation. Perform intraosseous access. Perform nasogastric intubation and gastric suctioning. Perform transcutaneous cardiac pacing. Monitor and adjust heparin infusion during interfacility transport. 1 G. Monitor and adjust nitroglycerine infusion during interfacility transport. 1 H. Administer using prepackaged products when available the following medications by the routes specified in the ALS treatment protocols: 1. Magnesium sulfate. 2. Atrovent. ____________________ 1 Use limited to specially approved ALS ambulance providers. San Joaquin County Emergency Medical Services Page 148 of 216 Monitoring an Infusion with Potassium Chloride EMS Policy No. 5952 Effective: January 1, 2007 Supersedes: NA 5952 - Monitoring an Infusion with Potassium Chloride PURPOSE: The purpose of this policy is to provide a mechanism for paramedics to be permitted to monitor infusions of Potassium Chloride (KCL) during interfacility transfers. POLICY: I. All ALS Ambulance providers approved by the San Joaquin County EMS Agency Medical Director will be permitted to provide the service of monitoring potassium chloride infusions during interfacility transports from approved hospital(s) within their service area. II. Only those paramedics who have successfully completed training program(s) approved by the San Joaquin County EMS Agency Medical Director on potassium chloride infusions will be permitted to monitor them during interfacility transports. III. Patients that are candidates for paramedic transport will have preexisting KCL infusions in peripheral lines. Prehospital care providers are not allowed to start or add KCL to the I.V. solution. IV. Infusions containing KCL In accordance with the provisions of this policy, a paramedic may transport a patient who has a preexisting I.V. solution containing KCL only when following these parameters: A. Signed transfer orders from the transferring physician must be obtained prior to transport. Infusions containing KCL may be monitored only. B. C. Patient is placed on cardiac and pulse oximetry monitors and monitored continuously during transport. KCL infusion concentration will not exceed 20 mEq/liter San Joaquin County Emergency Medical Services Page 149 of 216 Monitoring an Infusion with Potassium Chloride EMS Policy No. 5952 Effective: January 1, 2007 Supersedes: NA D. E. F. V. administered at a mechanically controlled rate not to exceed 10 mEq/hour. If fluid bolus or I.V. medications are needed, the KCL infusion shall be discontinued and a new I.V. solution without KCL and administration device shall be used as replacement. DO NOT BOLUS FLUIDS CONTAINING KCL. Vital signs will be monitored and documented no less than every 10 minutes during patient transport. Monitor patient for adverse effects during transport including: 1. Cardiovascular: dysrhythmias, cardiac arrest 2. Respiratory: depression/arrest 3. Gastrointestinal: nausea/vomiting, diarrhea, abdominal pain 4. Neurological: paresthesia of extremities, muscular paralysis, confusion 5. I.V. infiltration: monitor I.V. site as infiltration may cause necrosis. If patient complains of burning or irritation at the insertion site, the I.V. should be checked for patency and the infusion rate slowed or discontinued. General Information on Potassium Chloride A. Potassium is an essential macromineral in human nutrition with a wide range of biochemical and physiological roles. Among other things, it is important in the transmission of nerve impulses, the contraction of cardiac, skeletal and smooth muscle, the production of energy, the synthesis of nucleic acids, the maintenance of intracellular tonicity and the maintenance of normal blood pressure. B. Indications for the use of Potassium Chloride 1. The treatment of potassium depletion in patients San Joaquin County Emergency Medical Services Page 150 of 216 Monitoring an Infusion with Potassium Chloride EMS Policy No. 5952 Effective: January 1, 2007 Supersedes: NA C. D. E. F. with hypokalemia when oral replacement is not feasible. 2. Treatment of digitalis intoxication. Contraindications: 1. Renal impairment with oliguria or azotemia 2. Untreated Addison's disease 3. Hyperadrenalism associated with adrenogenital syndrome 4. Extensive tissue breakdown as in severe burns 5. Adynamia episodica hereditaria 6. Hyperkalemia of any etiology Precautions: 1. Pregnancy Category C 2. Chronic renal disease 3. Adrenal insufficiency 4. Any other condition which impairs potassium excretion 5. Potassium should be used with caution in diseases associated with heart block Adverse Effects: 1. Fever 2. Venous Thrombosis, Infection at injection site 3. Extravasation, Phlebitis, Pain at Injection Site 4. Hypervolemia 5. Hyperkalemia 6. Abdominal Pain 7. Nausea/Vomiting; 8. Paresthesias of the extremities 9. ECG Abnormalities, Heart Block 10. Mental Confusion 11. Hypotension Interactions: 1. Cardiac arrest can occur with high potassium conditions, such as chronic renal failure, burns, acidosis, dehydration, and potassium sparing San Joaquin County Emergency Medical Services Page 151 of 216 Monitoring an Infusion with Potassium Chloride EMS Policy No. 5952 Effective: January 1, 2007 Supersedes: NA G. H. diuretic usage. 2. Drug interactions causing elevation of potassium can occur with ACE inhibitors (used to treat high blood pressure) and certain diuretics (aldactone and triamterene). Standard Dosages for Potassium Chloride Infusions: 1. For serum potassium level > 2.5mEq/L a. Continuous IV Infusion: 10mEq/hour in a concentration up to 40mEq/L. Max dose of 200mEq/day. 2. For serum potassium level < 2.0 with electrocardigraphic changes and/or muscle paralysis, potassium chloride may be administered at a rate up to 40mEq/hour. (This rate is not approved for EMS personnel). Special Considerations: 1. MUST BE DILUTED BEFORE ADMINISTRATION. 2. Administer at a rate not to exceed 10mEq/hour. 3. Monitor electrolyte, fluid, and acid-base balances. San Joaquin County Emergency Medical Services Page 152 of 216 Monitoring an Infusion of Heparin EMS Policy No. 5954 Effective: January 1, 2007 Supersedes: 530.14 5954 - Monitoring an Infusion of Heparin PURPOSE: The purpose of this policy is to authorize paramedics to monitor intravenous heparin infusions during interfacility transport. POLICY: I. Only those ALS Ambulance providers approved by the San Joaquin County EMS Agency will be permitted to provide the service of monitoring heparin infusions during interfacility transports from approved hospital(s) within their service area. II. Only those paramedics who have successfully completed training program(s) approved by the San Joaquin County EMS Agency on heparin infusions will be permitted to monitor them during interfacility transports. Training must include the use of mechanical infusion pumps. III. Patients that are candidates for paramedic transport will have preexisting heparin drips in peripheral lines. Prehospital personnel will not initiate heparin drips. IV. Paramedics may restart heparin infusions if the heparin infusion is interrupted due to infiltration, accidental disconnection of the IV line, malfunctioning pump, etc. All lines must be restarted in accordance with the transferring physician’s orders. Paramedics will ensure new IV line is patent prior to re-starting the infusion. V. Heparin Infusions: The following parameters shall apply in all cases where paramedics transport patients with preexisting heparin drips: A. Patient shall be placed on cardiac, blood pressure and San Joaquin County Emergency Medical Services Page 153 of 216 Monitoring an Infusion of Heparin EMS Policy No. 5954 Effective: January 1, 2007 Supersedes: 530.14 B. C. D. E. F. G. pulse oximetry monitors and monitored continuously during transport. Signed transfer orders from the transferring physician must be obtained prior to transport. Transfer orders must certify that the patient is stable for transfer and provide orders for maintaining the heparin infusion during transport. Infusion fluid must be D5W, NS or ½ NS. Medication concentration shall be 100 units/ml of IV fluid such as 25,000 units/250 ml. Infusion rates must remain constant during transport with no regulation rates being performed by the paramedic, except for the discontinuation the infusion. Infusion rates may not exceed 1600 units per hour. Vital signs shall be monitored and documented every 1520 minutes during transport. VI. Continuous Quality Improvement: All calls involving the transfer of patients with preexisting heparin infusions shall be reviewed through the ambulance provider’s CQI program to determine compliance with policy and transferring physician orders. Reports of audits will be submitted to the EMS agency on a monthly basis. VII. General Information on Heparin: A. B. Heparin is an anticoagulant which acts to: prevent the conversion of fibrinogen to fibrin, prevent the conversion of prothrombin to thrombin, inactivate Factor X and enhance the inhibitory effects of antithrombin III. Pharmacokinetics: 1. SC: Onset 20-60 minutes; duration 8-12 hours; 2. IV: Onset immediate; peak 5 minutes; duration 2-6 San Joaquin County Emergency Medical Services Page 154 of 216 Monitoring an Infusion of Heparin EMS Policy No. 5954 Effective: January 1, 2007 Supersedes: 530.14 C. D. E. F. hours; 3. Metabolized in the liver and the spleen; 4. Excreted in urine; 5. Half-life of 1.5 hours. Indications for the use of Heparin: 1. In preventing additional clot formation or growth in DVT, MI, pulmonary embolism, DIC, stroke or arterial thrombosis; 2. Prophylactically to keep IV lines open (i.e. heparin flushes and locks); 3. Prophylactically before open heart surgery; 4. Prophylactically post DVT, PE and MI to prevent clotting; 5. Atrial fibrillation to prevent embolization; 6. As an anticoagulant in transfusion and dialysis. Contraindications: 1. Allergy to heparin; 2. Bleeding disorders - hemophilia, etc. 3. Blood dyscrasias such as leukemia with bleeding; 4. Peptic ulcer disease; 5. Severe hypertension; 6. Severe hepatic disease; 7. Severe renal disease; 8. Subacute bacterial endocarditis; 9. Active bleeding from any site. Precautions: 1. Pregnancy (class C); 2. Alcoholism (due to decreased liver function); 3. Elderly (due to decrease liver and renal function and increased injury capability). Adverse Effects: 1. Hemorrhage from any site. May manifest as easy bruising, petechiae, epistaxis, bleeding gums, hemoptysis, hematuria, melena; 2. Fever, chills (due to allergy); San Joaquin County Emergency Medical Services Page 155 of 216 Monitoring an Infusion of Heparin EMS Policy No. 5954 Effective: January 1, 2007 Supersedes: 530.14 3. G. H. I. Abdominal cramps, nausea, vomiting, diarrhea (due to allergy); 4. Anorexia (secondary to above); 5. Rash, uticaria (due to allergy). Interactions: 1. Oral anticoagulants (coumadin, warfarin) - increase the actions of heparin; 2. Salicylates (aspirin) - increase the actions of heparin; 3. Corticosteriods - increase the actions of heparin; 4. Corticosteriods - actions are decreased; 5. Dextran - increases the action of heparin; 6. Nonsteriodal anti-inflammatory drugs (ibuprofen, Aleve, Midol, naprosyn, toradol, voltaren, feldene, indocin, clinoril) - increase the actions of heparin; 7. Diazepam - action increase by heparin. Standard Dosages and Routes: 1. DVT/PE prophylaxis: 5,000 units subcutaneous every 8-12 hours. 2. Active Clot Suppression: a) Loading Dose (1) Adult: 5000-7000 units IVP. (2) Child: 50-100 units/kg IVP. b) Maintenance (1) Adult: 1000-1600 units per hour IV titrated to PTT/ACT/INR level. (2) Child 15-25 units per hour IV titrated to PTT/ACT/INR level. Special Considerations: 1. Avoid IM injections or other procedures which may cause bleeding. 2. Overdoses are treated in hospital with protamine sulfate 1:1 solution (protamine is not authorized for paramedic use.) San Joaquin County Emergency Medical Services Page 156 of 216 Monitoring an Intravenous Infusion of Nitroglycerin EMS Policy No. 5955 Effective: January 1, 2007 Supersedes: NA 5955 - Monitoring an Intravenous Infusion of Nitroglycerin PURPOSE: The purpose of this policy is to authorize paramedics to monitor and adjust intravenous nitroglycerin (NTG) infusions in adult patients during interfacility transport. POLICY: I. Only those ALS Ambulance providers approved by the San Joaquin County EMS Agency are permitted to provide the service of monitoring nitroglycerin infusions during interfacility transports from approved hospital(s) within their service area. II. Only those paramedics who have successfully completed a training program(s) approved by the San Joaquin County EMS Agency on nitroglycerin infusions will be permitted to monitor and adjust them during interfacility transports. Training must include the use of mechanical infusion pumps. III. Patients that are candidates for paramedic transport will have preexisting nitroglycerin drips infusing into peripheral lines. Prehospital personnel will not initiate nitroglycerin drips. IV. Paramedics may restart nitroglycerin infusions if the nitroglycerin infusion is interrupted due to infiltration, accidental disconnection of the IV line, malfunctioning pump, etc. All lines must be restarted in accordance with the transferring physician’s orders. Paramedics will ensure new IV line is patent prior to restarting the infusion. V. Nitroglycerin Infusions The following parameters shall apply in all cases where paramedics transport patients with preexisting nitroglycerin drips: San Joaquin County Emergency Medical Services Page 157 of 216 Monitoring an Intravenous Infusion of Nitroglycerin EMS Policy No. 5955 Effective: January 1, 2007 Supersedes: NA A. B. C. D. E. F. G. H. I. VI. Patient shall be placed on cardiac, blood pressure and pulse oximetry monitors and monitored continuously during transport. Signed transfer orders from the transferring physician must be obtained prior to transport. Transfer orders must certify that the patient is stable for transfer and provide orders for maintaining the nitroglycerin infusion during transport. Nitroglycerin infusions must be regulated by a mechanical intravenous infusion pump. If pump failure occurs and cannot be corrected, the paramedic will stop the nitroglycerin infusion and notify the transferring hospital. Infusion fluid shall be D5W or NS. Nitroglycerin infusion concentration shall be 25 mg/250 ml or 50 mg/250 ml. Regulation of the drip rate will be within parameters as defined by the transferring physician, but in no case will changes be in greater than 5 mcg/minute increments every 10 minutes. In cases of hypotension (SBP < 90), the medication drip will be discontinued and the transferring hospital and base hospital will be notified. Maximum drip rate shall not exceed 200 mcg per minute. Vital signs shall be monitored and documented every 10 minutes during transport or every 5 minutes if an increase in the drip rate is ordered by the base physician. Continuous Quality Improvement All calls involving the transfer of patients with preexisting nitroglycerin infusions shall be reviewed through the ambulance provider’s CQI program to determine compliance with policy and transferring physician orders. Reports of audits will be submitted to the EMS agency on request. San Joaquin County Emergency Medical Services Page 158 of 216 Monitoring an Intravenous Infusion of Nitroglycerin EMS Policy No. 5955 Effective: January 1, 2007 Supersedes: NA VII. General Information on Nitroglycerin A. B. C. Nitroglycerin is a vasodilating agent that belongs to a group of drugs referred to as nitrates. Nitroglycerin acts to: relax vascular smooth muscle; vasodilate both arteries and veins (especially veins); increase venous pooling; decrease venous return to the heart; increase arterial relaxation; decrease systemic vascular resistance; decrease cardiac workload; decrease cardiac oxygen consumption; dilate the large epicardial arteries; and lower diastolic more than systolic blood pressure. Pharmacokinetics: 1. SL: Onset 1-3 minutes; duration 30 minutes; 2. Transdermal (patch): Onset 0.5 - 1 hour; duration 1224 hours; 3. Transdermal (ointment): Onset 0.5-1 hour; duration 212 hours; 4. PO (sustained release): Onset 20-40 minutes; duration 3-8 hours; 5. IV: Onset usually immediate; duration is variable; 6. Metabolized by the liver; 7. Excreted in urine; 8. Half-life of 1-4 minutes. Indications for the use of Nitroglycerin: 1. Sublingual: a. Relief of acute anginal pain or related ischemic symptoms; b. Congestive Heart Failure (CHF) to decrease myocardial workload. 2. Intravenous: a. Diagnosed MI or unstable angina pectoris, even in the absence of chest pain, to decrease myocardial workload; b. Relief of persistent ischemic chest pain that San Joaquin County Emergency Medical Services Page 159 of 216 Monitoring an Intravenous Infusion of Nitroglycerin EMS Policy No. 5955 Effective: January 1, 2007 Supersedes: NA D. E. F. G. does not respond to other medications; c. Hypertension when associated with diagnosed MI or unstable angina pectoris (not used solely for blood pressure control). Contraindications: 1. Allergy to nitrates; 2. Increased intracerebral pressure such as in cases of stroke, head trauma or intracerebral bleeding; 3. Hypotension; 4. Hypovolemia; 5. Treatment of hypertension without progressively worsening signs of organ damage, ischemia or neurologic deficit. Precautions: 1. Pregnancy (class C); 2. Glaucoma patients (can increase intraocular pressure); 3. Lactation (fetal effects in animal studies); 4. May require decreased dosing in patients with liver disease. Adverse Effects: 1. Hypotension; 2. Headache (from vasodilation); 3. Dizziness and syncope (from hypotension); 4. Nausea/Vomiting; 5. Tachycardia (in response to hypotension); 6. Paradoxical bradycardia (in rare instances); 7. Pallor, sweating (from hypotension); 8. Flushing, sweating (from vasodilation); 9. Rash, if allergic to nitrates. Interactions: 1. Alcohol - combined with nitroglycerin can worsen hypotension; 2. Aspirin - can increase serum nitrate concentrations; 3. Calcium channel blockers - combined with San Joaquin County Emergency Medical Services Page 160 of 216 Monitoring an Intravenous Infusion of Nitroglycerin EMS Policy No. 5955 Effective: January 1, 2007 Supersedes: NA H. I. nitroglycerin can worsen orthostatic hypotension; 4. ß-blockers, diuretics, anti-hypertensives - can increase actions of nitroglycerin. Standard Dosages for Nitroglycerin drips: 1. For diagnosed patients with ischemic symptoms: a. Continuous IV Infusion: starting at 10-20 mcg/min and increased by 5 or 10 mcg/min every 5 to 10 minutes until the desired hemodynamic or clinical response is achieved. Most patients respond to 50 to 200 mcg/minute and the lowest possible dose should be used. When indicated, rates should be decreased in 10 minute intervals. Special Considerations: 1. Glass infusion bottles and non-polyvinyl tubing must be used as plastics will absorb nitroglycerin and alter the dose administered. 2. Do not use in-line filters. Attach drip to port closest to catheter insertion. San Joaquin County Emergency Medical Services Page 161 of 216 San Joaquin County Emergency Medical Services Page 162 of 216 San Joaquin County EMS Agency SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES Related Policies San Joaquin County Emergency Medical Services Page 163 of 216 Authority for Medical Emergency Management EMS Policy No. 5001 Effective: November 14, 2006 Supersedes: 530.03 5001 - Authority for Medical Emergency Management PURPOSE: The purpose of this policy is to define the authority for patient health care management in the San Joaquin County EMS system. POLICY: I. In order to ensure accountability and medical control for patient care management throughout the pre-hospital process the following shall apply: A. In the event that both transport and non-transport emergency medical services personnel are on the scene with the same qualifications, patient health care management will rest with the San Joaquin County emergency ambulance service transport provider. The first arriving paramedic shall initiate care and shall transfer care to the transport provider as soon as the “task at hand” is completed (i.e., starting IV, etc.). All pre-hospital personnel shall cooperate with one another to ensure rapid and efficient care and transport of all patients. B. During multi-casualty incidents (MCIs) the senior most qualified representative from the exclusive emergency ambulance service provider, which may include field supervisors or management personnel, shall determine who shall serve as the “Medical Group Supervisor” or if established the “Medical Branch Director.” C. The list below defines the assignment of responsibility for patient care management in the San Joaquin EMS system based on resources available on scene from the lowest level to highest level with the emergency ambulance service transport provider paramedic having the highest level of responsibility for patient care management: 1. Public Safety First Aid; San Joaquin County Emergency Medical Services Page 164 of 216 Authority for Medical Emergency Management EMS Policy No. 5001 Effective: November 14, 2006 Supersedes: 530.03 2. 3. 4. 5. 6. 7. First responder; Non-transport EMT-I; Transport EMT-I; Non-transport Paramedic; Transport Paramedic. Notwithstanding paragraphs A, B, and C above, the authority of the San Joaquin County Health Officer and Medical Health Operational Area Coordinator shall not be infringed. San Joaquin County Emergency Medical Services Page 165 of 216 Determination of Death in the Field EMS Policy No. 5103 Effective: October 16, 2013 Supersedes: January 1, 2012 5103 - Determination of Death in the Field PURPOSE: The purpose of this policy is to provide EMS personnel and base hospital physicians with direction for determining death in the field. POLICY: I. All EMS personnel shall conduct an initial patient assessment and either initiate treatment or make a determination of obvious death. II. Obvious Death A. If a patient meets criteria for obvious death upon an initial assessment EMS personnel shall not initiate resuscitative measures including cardiopulmonary resuscitation (CPR) on the patient. B. Obvious death is defined as a patient exhibiting apnea and pulselessness accompanied by one or more of the following conditions: 1. Decomposition of tissue; 2. Decapitation; 3. Rigor mortis and post mortem lividity characterized by rigidity or stiffening of muscular tissues and joints in the body usually appearing in the head, face and neck muscles and the pooling of venous blood in dependent body parts; 4. Incineration of the torso and/or head; 5. Massive crush injury and/or penetrating injury with evisceration or total destruction of the heart, lung, and/or brain; 6. Gross dismemberment of the torso; 7. Submerged underwater for greater than sixty (60) minutes; 8. Presence of a valid Do-Not-Resuscitate (DNR) order. C. EMS personnel are not required to use a cardiac monitor (i.e. San Joaquin County Emergency Medical Services Page 166 of 216 Determination of Death in the Field EMS Policy No. 5103 Effective: October 16, 2013 Supersedes: January 1, 2012 “run a strip”) to confirm obvious death. D. Non-transport EMS personnel shall cancel a responding ambulance if obvious death is determined prior to arrival of the ambulance unless the responding ambulance is needed for another patient or patients on scene. III. Considerations for determining death after the initiation of resuscitative measures: A. If the initial patient assessment does not reveal obvious death, EMS personnel shall initiate treatment or resuscitative measures in accordance with applicable treatment protocols. B. EMS personnel shall initiate rapid transport and continue resuscitation until transfer of care in the emergency department when the following factors are present: 1. The patient has a return of spontaneous circulation. 2. Traumatic cardiac arrest when the time from on-set of cardiac arrest to arrival at the Trauma Center will be less than 10 minutes. a. Follow treatment regimen for patients in traumatic cardiac arrest as specified in EMS Policy No. 5783 ALS Adult Trauma Treatment. 3. Submerged underwater for less than thirty (30) minutes. C. In the absence of factors requiring rapid transport, as identified in the paragraph above, EMS personnel shall remain on scene and provide resuscitation to cardiac arrest patients per applicable treatment policies. D. If a patient in medical cardiac arrest remains pulseless and apneic following eight (8) minutes of MICR and ALS interventions appropriate for the ECG rhythm as indicated per EMS protocol for a combined total of fifteen (15) minutes, ALS personnel shall contact the base hospital and on-duty Base Hospital Physician and request orders to either transport the patient or to discontinue resuscitative measures. 1. The attending paramedic shall continue ALS resuscitative San Joaquin County Emergency Medical Services Page 167 of 216 Determination of Death in the Field EMS Policy No. 5103 Effective: October 16, 2013 Supersedes: January 1, 2012 measures while making base contact. 2. The BHP shall (after receiving the patient report): a. Determine death and grant permission to discontinue resuscitation, or; b. Order resuscitation to continue and the patient transported to the closest receiving hospital. E. If the BHP grants permission to discontinue resuscitative measures the attending paramedic shall: 1. Attach a code summary from the electrocardiograph to the Patient Care Report (PCR). 2. Document the name of the BHP authorizing the request for determination of death on the PCR. IV. Actions following a determination of death: A. EMS personnel shall follow their agency’s process to notify both the San Joaquin County Sheriff Coroner’s Office and the law enforcement agency with jurisdiction following a determination of death in the field. B. EMS personnel may not move or disturb a dead body until disposition has been made by law enforcement or coroner representative. C. EMS personnel shall leave in place all invasive therapeutic modalities initiated during the resuscitation for the coroner’s review. These modalities may include but are not limited to advanced and basic airways, intravenous catheters, cardiac electrodes, etc. D. EMS personnel shall not transport dead bodies by ambulance except in the extremely rare occurrence that a patient is determined to be dead during transport. In such situations, EMS personnel shall deliver the body to the intended hospital. E. If family or significant other request resuscitative efforts for a patient with obvious death ALS and BLS personnel shall decline the request to initiate resuscitation and provide an explanation, reassurance and support to the family or San Joaquin County Emergency Medical Services Page 168 of 216 Determination of Death in the Field EMS Policy No. 5103 Effective: October 16, 2013 Supersedes: January 1, 2012 significant other. V. EMS personnel shall utilize S.T.A.R.T. guidelines in determining death at the scene of multi-casualty incidents. As EMS resources become available patients initially determined to be dead per S.T.A.R.T may be re-assessed. San Joaquin County Emergency Medical Services Page 169 of 216 Do Not Resuscitate Orders EMS Policy No. 5105 Effective: February 1, 2007 Supersedes: 540.06 5105 - Do Not Resuscitate Orders PURPOSE: The purpose of this policy is to establish criteria for prehospital emergency medical care personnel working in the San Joaquin County EMS System to easily recognize and follow a Do Not Resuscitate (DNR) Order. DEFINITIONS: A. B. “Do Not Resuscitate (DNR”) means no chest compression, no assisted ventilation, no defibrillation, no intubation, and no cardiac medications. “Pre-hospital Emergency Medical Care Personnel” means those persons who have been certified or licensed as qualified to provide prehospital emergency medical care pursuant to the provisions of Health and Safety Code, Division 2.5. POLICY: I. All patients whose initial assessment does not reveal “obvious death” as defined in EMS Policy No. 5103 Determination of Death, shall be treated in accordance with applicable treatment protocols, unless the prehospital emergency medical care personnel are presented with a valid DNR Order evidenced by one of the following: A. A written and signed physician’s order in the patient’s medical record stating DNR; B. A completed State of California Prehospital DNR Request Form; C. A Medic Alert® bracelet inscribed “Do Not Resuscitate EMS”. San Joaquin County Emergency Medical Services Page 170 of 216 Do Not Resuscitate Orders EMS Policy No. 5105 Effective: February 1, 2007 Supersedes: 540.06 II. When prehospital emergency medical care personnel are presented with a valid DNR order no resuscitative measures shall be carried out. Prehospital Emergency Medical Care personnel shall otherwise provide the patient with appropriate medical treatment other than resuscitative measures. Appropriate treatment may include but is not limited to: A. Oxygen administration; B. Treatment of hemorrhage; C. Treatment for pain; D. Treatment of airway obstruction; E. Transport to a receiving facility. III. If the patient is conscious and states he/she wishes resuscitative measures, the DNR order shall be ignored. IV. If a patient with a valid DNR order is unconscious and family members request resuscitative measures prehospital emergency medical care personnel are to honor the DNR order. If necessary to preserve scene safety, prehospital emergency medical care personnel may initiate basic life support resuscitation while contacting the Base Hospital for assistance and direction. V. In the absence of a DNR order, if family members of an unconscious patient request that resuscitative measures are not to be undertaken, prehospital emergency medical care personnel are to initiate appropriate basic life support treatment while contacting the Base Hospital for assistance and direction. VI. If the patient is transported, the DNR order is to be transported with the patient to the receiving facility. DNR orders are to be honored during transport. VII. The presence of a DNR order is to be documented on the Patient Care Report. San Joaquin County Emergency Medical Services Page 171 of 216 Interaction with Physician or Other Health Care Provider On Scene EMS Policy No. 5106 Effective: October 15, 2010 Supersedes: August 31, 2010 5106 - Interaction with Physician or Other Health Care Provider On Scene PURPOSE: The purpose of this policy is to establish the procedures to be followed by Emergency Medical Service (EMS) personnel while at the scene of a medical emergency when bystanders identify themselves as a physician or a registered nurse (R.N.). POLICY: I. Physician At Scene A. B. In the event that an unknown physician offers assistance on scene, ask the person his/her name and request to see his/her State of California physician or surgeon’s license. If doubt about the person’s license request to see proof of identity, i.e. state driver’s license or identity card. Pre-hospital personnel have the following responsibilities in the event that a physician is on scene: 1. Remain tactful, calm, and courteous. 2. Provide the physician with a California Medical Association – EMS Authority physician involvement on scene card (Appendix A) describing his/her options. EMS personnel should keep these cards readily available. 3. The identity of a physician shall be confirmed prior to EMS personnel relinquishing responsibility for patient care. 4. Offer assistance to the physician on scene. The EMS provider cannot perform orders given outside normal scope of practice as defined in the San Joaquin County EMS Treatment Protocols. San Joaquin County Emergency Medical Services Page 172 of 216 Interaction with Physician or Other Health Care Provider On Scene EMS Policy No. 5106 Effective: October 15, 2010 Supersedes: August 31, 2010 5. C. D. E. Maintain control of medications and equipment from the unit, and inform the physician of drug and equipment availability. 6. Make initial contact with the base hospital physician (BHP), and communicate newly implemented plan for scene management. Once identification has been confirmed, the physician may choose one of the alternatives listed below: 1. Offer assistance with another pair of eyes or hands, or offer suggestions, but allow the ALS provider to remain under EMS on-line and off-line medical control; OR 2. Request to talk to a Base Hospital Physician (BHP) and directly offer medical advice and assistance; OR 3. Take total responsibility for the care given by the ALS provider and physically accompany the patient until the patient arrives at a hospital and the receiving physician assumes responsibility. Physicians exercising the right to assume patient care must document and sign for all care provided and instructions given to EMS personnel following transport to the receiving facility. Conflict Resolution: In the event that any unresolved conflict arises regarding the delivery of patient care, EMS personnel shall contact a BHP immediately. The BHP has final authority over medical care to be provided by EMS personnel. Private Physicians - If the patient's private physician intervenes in person or by telephone, EMS personnel shall inform the patient's physician that they will need to make BHP contact. San Joaquin County Emergency Medical Services Page 173 of 216 Interaction with Physician or Other Health Care Provider On Scene EMS Policy No. 5106 Effective: October 15, 2010 Supersedes: August 31, 2010 II. Other Non-physician Providers on Scene: A. B. C. D. If off-duty EMS personnel are on scene, they may assist with BLS patient care at the discretion of attending paramedic or EMT. An off-duty San Joaquin County accredited paramedic and an employee of the on scene ALS provider may provide ALS care and treatment under the direction of the attending paramedic. An off-duty paramedic not accredited in San Joaquin County or not an employee of the on scene ALS provider which provides proof of current paramedic licensure in California may at the discretion of the attending paramedic, and while under direct supervision provide assistance not to exceed the State’s basic paramedic scope of practice. All other types of licensed medical personnel (Physician Assistant, Registered Nurse, Respiratory Therapist, etc.) may, at the discretion of the attending paramedic or EMT, may assist with BLS patient care. San Joaquin County Emergency Medical Services Page 174 of 216 Note to Physician on Involvement with EMT-Ps EMS Policy No. 5106A Effective: January 1, 2009 Supersedes: NA 5106A - Note to Physician on Involvement with EMT-Ps San Joaquin County Emergency Medical Services Page 175 of 216 Use of Restraints EMS Policy No. 5107 Effective: November 1, 2006 Supersedes: NA 5107 - Use of Restraints PURPOSE: The purpose of this policy is to provide guidelines on the use of restraints in the field or during transport for patients who are violent, potentially violent, or who may harm themselves or others. DEFINITIONS: A. “Medical Restraint” means a physical restraint that is used to limit mobility or temporarily immobilize a patient for nonbehavioral management reasons. (e.g., to promote healing by preventing the dislodgment of medical devices, or to protect a child or adult who is confused and/or disoriented and unable to follow instructions for his/her personal safety). B. “Behavioral Restraint” means a physical restraint that is used to limit mobility or temporarily immobilize a patient who presents with behavior management symptoms. The use of behavioral restraint is used only in an emergency or crisis situations. Do not release the restraint until you have transported the patient to the hospital. C. “Chemical Restraint” means a medication used with the expressed intent to control behavior or to restrict the patient’s freedom of movement and is not a standard treatment for the patient’s medical or psychiatric condition. POLICY: I. When restraints are necessary such activity will be undertaken in a manner that protects the patient’s health and safely preserves his or her dignity, rights, and well-being. The safety of the patient, community, and responding personnel is of paramount concern when following this policy. The use of a restraint is a last resort after alternative interventions have either been considered or attempted. San Joaquin County Emergency Medical Services Page 176 of 216 Use of Restraints EMS Policy No. 5107 Effective: November 1, 2006 Supersedes: NA II. Behavioral restraints are to be used only when necessary in situations where the patient is potentially violent and is exhibiting behavior that is dangerous to self or others. Only reasonable force sufficient to restrain the patient shall be used. III. Prehospital personnel must consider that aggressive or violent behavior may be a symptom of medical conditions such as head trauma, alcohol, drug-related problems, metabolic disorders, stress, and psychiatric disorders. Appropriate protocols shall be followed for those conditions that require it. IV. EMS prehospital personnel shall determine medical intervention and patient destination. V. The method of restraint used shall allow for adequate monitoring of vital signs and shall not restrict the ability to protect the patient’s airway or compromise neurological or vascular status. PROCEDURES I. The following procedures should guide prehospital personnel in the application of restraints and the monitoring of a restrained patient: A. Restraint equipment, applied by prehospital personnel, must be either padded leather restraints or soft restraints. Both methods must allow for quick release. B. The following forms of restraint shall NOT be used by prehospital personnel: 1. Hard plastic ties or any restraint device requiring a key to remove. 2. Sandwiching patients between backboards, scoopstretchers, or flat, as a restraint. 3. Restraining a patient’s hands and feet behind the patient, i.e. hog-tying. 4. Methods or other materials applied in a manner that could San Joaquin County Emergency Medical Services Page 177 of 216 Use of Restraints EMS Policy No. 5107 Effective: November 1, 2006 Supersedes: NA cause respiratory, vascular, or neurological compromise, including prone restraints. C. Restraint equipment applied by law enforcement (handcuffs, plastic ties, or hobble restraints) must provide sufficient slack in the restraint device to allow the patient to straighten the abdomen and chest and to take full tidal volume breaths. D. Restraint devices applied by law enforcement require the officer’s continued presence to ensure patient and scene management safety. The officer should, if possible, accompany the patient in the ambulance, or follow by driving in tandem with the ambulance on a predetermined route. A method to alert the officer of any problems that may develop during transport should be discussed prior to leaving the scene. E. Patients shall not be transported in a prone position. Prehospital personnel must ensure that the patient’s position does not compromise the patient’s respiratory/circulatory systems, or does not preclude any necessary medical intervention to protect the patient’s airway should vomiting occur. F. Restrained extremities should be evaluated for pulse quality, capillary refill, color, nerve, and motor function every 15 minutes. It is recognized that the evaluation of nerve and motor status requires patient cooperation, and thus may be difficult or impossible to monitor. G. Restrained patients shall be transported to the most accessible basic emergency department facility within the guidelines of the Patient Destination Policy. San Joaquin County Emergency Medical Services Page 178 of 216 Use of Restraints EMS Policy No. 5107 Effective: November 1, 2006 Supersedes: NA DOCUMENTATION I. Documentation on the EMS Report Form shall include: A. The reasons restraints were needed. B. Which agency applied the restraints (i.e. EMS/law enforcement). C. Information and data regarding the monitoring of circulation to the restrained extremities. D. Information and data regarding the monitoring of respiratory status while restrained. San Joaquin County Emergency Medical Services Page 179 of 216 Care of Minors in the Field EMS Policy No. 5108 Effective: January 1, 2009 Supersedes: NA 5108 - Care of Minors in the Field PURPOSE: The purpose of this policy to provide guidance for field personnel providing emergency care to minors in the prehospital setting. DEFINITIONS: “Minor” means a person less than eighteen years of age who is not emancipated. Except for specific circumstances prescribed by law, a minor is not legally competent to consent to or refuse medical care. B. “Emancipated Minor” means a person less than eighteen years of age who: 1. Is married or previously married. 2. Is on active duty in the military. 3. Is an emancipated minor (decreed by court, identification card by DMV). C. “Legal Representative” means a person who is granted custody or conservatorship of another person by a court of law. D. “Emergency” means a condition or situation in which an individual has a need for immediate medical attention or where the potential for need is perceived by EMS personnel or a public safety agency. A. POLICY: I. Voluntary Consent: Treatment or transport of a minor child shall be with the verbal or written consent of the parents or legal representative. If the minor child is legally able to consent, then treatment or transport shall be with the verbal or written consent of the minor. II. Implied Consent: In the absence of a parent or legal representative, life or limb threatening emergency treatment San Joaquin County Emergency Medical Services Page 180 of 216 Care of Minors in the Field EMS Policy No. 5108 Effective: January 1, 2009 Supersedes: NA and/or transport of a minor child shall be initiated without consent. PROCEDURE: I. Life-threatening situations: If a parent or qualified legal representative is not present, treatment and/or transport to a medical facility shall be initiated immediately in accordance with SJCEMSA Policies II. Non-life-threatening situations: If, in the opinion of the base hospital physician, a minor child requires treatment and/or further evaluation at a hospital, EMS personnel should make a reasonable attempt to contact a parent or other legally qualified representative before initiating treatment or transport. However, if a parent or legally qualified representative cannot be reached, EMS personnel will transport the minor to the hospital. III. Parental consent is not required before initiating care or transport when: A. The minor is emancipated. B. The parent has given written authorization to procure medical care to any adult over 18 years of age taking care of the minor. C. A minor, 12 years or older, consents to the furnishing of hospital, medical and surgical care related to treatment or diagnosis of infectious, contagious or communicable diseases. D. A minor, living separate and apart from parent (for any period of time), managing own economic affairs, regardless of source of income and regardless of whether parent(s), consented to separation. Parents are not liable for care provided pursuant to this section. E. A minor, 12 years or older, is an alleged rape victim. F. A minor, is a victim of a sexual assault (applies to both boys and girls and has no age limit). G. A minor, seeks pregnancy prevention or treatment of pregnancy (does not include sterilization). San Joaquin County Emergency Medical Services Page 181 of 216 Care of Minors in the Field EMS Policy No. 5108 Effective: January 1, 2009 Supersedes: NA H. A minor, 12 years or older, seeks medical or hospital care or counseling relating to diagnosis and treatment of drug and alcohol related problem. IV. If a minor refuses any indicated treatment or transport, EMS personnel should attempt the following: A. To contact base hospital and advise them of the situation. B. To contact the minor’s parent(s) or legal representative for permission to treat or transport the minor. V. Provided the parent or legal representative is unavailable, contact law enforcement and request the minor be taken into temporary custody in order that treatment and/or transport can begin. San Joaquin County Emergency Medical Services Page 182 of 216 Anatomical Donor Cards EMS Policy No. 5110 Effective: March 1, 2008 Supersedes: 530.09 5110 - Anatomical Donor Cards PURPOSE: The purpose of this policy is to establish a process to search for anatomical donor information. DEFINITIONS: A. B. “Imminent Death”: means for the purpose of this policy any situation in which illness in the adult unconscious patient (18 years of age or older) are so severe that death is likely to occur prior to or shortly after the patient arrives at the hospital. “Reasonable Search”: means for the purpose of this policy a brief, rapid search by law enforcement, coroner, hospital, ambulance, or emergency medical personnel of an individual and his/her wallet/purse with the intention of locating an anatomical donor card attached to that individual’s driver’s license or state issued identification card. POLICY: I. If the patient requires medical attention, defer any search for an anatomical donor card until after arrival at the receiving hospital. At no time should the search for an anatomical donor card be at the expense of treatment and/or transport of the patient. II. If law enforcement personnel are present and time permits request that law enforcement perform the search. III. If the patient is declared dead by law enforcement personnel or determined to be obviously dead in accordance with EMS Policy No. 5103, ambulance or emergency medical personnel shall defer any search to coroner personnel. San Joaquin County Emergency Medical Services Page 183 of 216 Anatomical Donor Cards EMS Policy No. 5110 Effective: March 1, 2008 Supersedes: 530.09 IV. Document any search for an anatomical donor card on the patient care record and verbally report the presence or absence of an anatomical donor card to the receiving physician or registered nurse. V. When requesting an order for a determination of death in accordance with EMS Policy No. 5103, paramedic personnel shall report the presence or absence of an anatomical donor card to the base hospital physician or mobile intensive care nurse. San Joaquin County Emergency Medical Services Page 184 of 216 Cervical Spine Immobilization EMS Policy No. 5115 Effective: July 1, 2013 Supersedes: N/A 5115 – Cervical Spine Immobilization PURPOSE: The purpose of this policy is to provide direction to prehospital personnel on the application of cervical spine immobilization and to reduce the risk of negative effects caused by traditional spinal immobilization. POLICY: I. II. The San Joaquin County EMS Agency is supporting efforts to decrease unnecessary immobilizations in the field and reduce the risks and complications associated with spinal immobilization. Studies show immobilizing trauma patients may cause more harm than good to the patient especially penetrating trauma patients (stabbings and gunshot wounds) which benefit most from rapid assessment and transport to a trauma center. Prehospital personnel shall apply cervical spine immobilization to patients injured from blunt force trauma in the following circumstances: A. Conscious patients exhibiting one or more of the following signs or symptoms: 1. Posterior midline cervical tenderness or pain; 2. Distal numbness, tingling, weakness, or parethesia; 3. Paralysis; 4. Neck guarding or restricted range of motion; 5. Glasgow Coma Scale (GCS) motor score of less than 5 as a result of blunt force trauma or intoxicants, e.g. alcohol or other drugs. B. Unconscious adult patients suffering a blunt force mechanism of injury, except ground level falls. San Joaquin County Emergency Medical Services Page 185 of 216 Cervical Spine Immobilization EMS Policy No. 5115 Effective: July 1, 2013 Supersedes: N/A III. Prehospital personnel shall not apply cervical spine immobilization to patients in the following circumstances: A. Patients injured solely from penetrating trauma; B. Unconscious adult patients experiencing a ground level fall; C. Patients in cardiac arrest. IV. Pediatric cervical spine immobilization shall be performed as follows: A. Cervical spine immobilization shall be conducted using soft collars and should be immobilized using a Kendrick Extrication Device (KED) or other commercially available device approved by the EMS Agency. B. Pediatric Patients and Car Seats: 1. Infants restrained in a rear-facing car seat may be immobilized and extricated in the car seat. The child may remain in the car seat if the immobilization is secure and his/her condition allows (no signs of respiratory distress or shock.) 2. Children restrained in a car seat (with a high back) may be immobilized and extricated in the car seat; however, once removed from the vehicle, the child should be placed in a padded pediatric immobilization device or other commercially available immobilization device approved by the EMS Agency. If placing the child in the pediatric immobilization device causes increased agitation, movement, and potential further harm, the child may be immobilized in the car seat. 3. Children restrained in a booster seat (without back) need to be extricated using standard techniques and immobilized using a padded pediatric immobilization device or other commercially available immobilization device approved by the EMS Agency. San Joaquin County Emergency Medical Services Page 186 of 216 Cervical Spine Immobilization EMS Policy No. 5115 Effective: July 1, 2013 Supersedes: N/A 4. If applying spinal immobilization to a patient in a car seat, prehospital personnel shall conduct a posterior assessment by palpation. V. Adult cervical spine immobilization shall be performed by selecting the most effective methods and tools for the specific situation with the goal to prevent gross movement of the spine while allowing necessary treatment including airway management. VI. Equipment approved to perform cervical spine immobilization includes soft collars, Kendrick Extrication Device (KED) or Fasplint or similar device, or any combination of equipment including pillows and blankets or other commercially available immobilization device approved by the EMS Agency to ensure comfort and spinal immobilization on the gurney. VII. Long backboards and Miller Boards may be used for extrication or movement at the scene. However, backboards shall not to be used to transport a patient to the hospital. VIII. Movement on scene: A. Pull sheets, other flexible devices, scoops, scoop-like devices may be used. Unpadded long backboards should have limited utilization. B. If an unpadded longboard or scoop stretcher device is used to move patients on scene due to issues of space or distance, such devices should only be used as a temporary means of transporting the patient to a gurney prior to the application of the KED or other approved immobilization method. C. Keeping with the goals of restricting gross movement of the cervical spine and preventing further pain and discomfort, patient self-extrication is allowable. San Joaquin County Emergency Medical Services Page 187 of 216 Cervical Spine Immobilization EMS Policy No. 5115 Effective: July 1, 2013 Supersedes: N/A IX. Special Considerations: A. Patients who are agitated or restless due to shock, hypoxia, head injury or intoxication may be impossible to immobilize adequately. It may be necessary to remove immobilization devices or modify immobilization techniques to reduce the risk of further injury. B. Paramedics may discontinue or clear spinal immobilization initiated by BLS personnel, if in the opinion of the paramedic cervical spine is not required by policy or compromises the ability to render patient care. Paramedics are required to document on the patient care record each instance of discontinuing cervical spine immobilization and their basis for removal. C. When using spinal immobilization, patients may be placed in semi or high fowlers position to address respiratory conditions or for patient comfort. D. Prohibited equipment and practices: 1. Hard collars; 2. Adhesive tape applied to the patient’s skin. X. EMS Policy No. 5506 BLS Spinal Immobilization is hereby rescinded. San Joaquin County Emergency Medical Services Page 188 of 216 ALS Without Base Hospital Contact EMS Policy No. 5130 Effective: January 1, 2009 Supersedes: 540.02 5130 - ALS Without Base Hospital Contact PURPOSE: The purpose of this policy is to provide a mechanism for advanced life support (ALS) personnel to perform skills and administer medications requiring a base hospital order when base hospital contact cannot be established and immediate treatment of the patient is required. POLICY: I. ALS personnel are authorized to perform skills and administer medications requiring a base hospital order when base hospital contact cannot be established and immediate treatment of the patient is required. II. ALS personnel shall complete an ALS without Base Hospital Contact Report (Appendix A). III. Each occurrence shall be reported using one or more of the following classification(s): A. Patient's clinical status demanded intervention prior to voice contact with the base hospital. B. Field communication equipment not available at the patient's side. C. No response from the base hospital, after three (3) attempts D. Scene environment not suitable for radio and/or land line communications. E. EMS communication equipment malfunction(s). F. Radio interference/inability to establish radio contact. IV. Upon completion of the call requiring ALS without base hospital contact ALS personnel shall: San Joaquin County Emergency Medical Services Page 189 of 216 ALS Without Base Hospital Contact EMS Policy No. 5130 Effective: January 1, 2009 Supersedes: 540.02 A. Determine the cause of the communications failure and report or replace faulty equipment. B. Complete the ALS without Base Hospital Contact Report and submit the report to their provider’s quality improvement coordinator before close of shift but no later than 24 hours after the occurrence. C. The Provider’s quality improvement coordinator shall complete a review and submit the ALS without Base Hospital Contact Report with their findings and a copy of the patient care report (PCR) to EMS Agency CQI Coordinator within 72 hours of the occurrence. San Joaquin County Emergency Medical Services Page 190 of 216 5130A - ALS WITHOUT BASE HOSPITAL CONTACT REPORT Paramedics must compete this form whenever base hospital contact is required, yet cannot be made. A copy of the PCR must be attached and submitted to the organizations CQI liaison within 24 hours of the incident. The CQI liaison must submit the report to SJCEMSA with 24 hours of receipt. Attach additional pages if necessary. Report initiated by: License #: Employer: Phone: Address: Base Hospital: Receiving Facility: Reason for initiating treatment without a base hospital order: (check all that apply) □ Patient's clinical status demanded intervention prior to voice contact with the base hospital □ Field communication equipment not available at the patient's side □ No response from the base hospital after three (3) attempts □ Scene environment not suitable for radio and/or land line communications (please explain) □ EMS communication equipment malfunction □ Radio interference/inability to establish radio contact □ Other (please attach additional sheets as necessary) Treatment(s) performed without a base hospital order: Patients condition prior to treatment: Patients condition after treatment: Signature: San Joaquin County Emergency Medical Services Date of Report: Page 191 of 216 EMS Agency Evaluation: Treatment initiated was: □ □ appropriate for the patient’s condition appropriate for the patient’s condition but could have been delayed pending radio contact or upon arrival at the emergency department □ questionable but discussion and resolution of concerns occurred after patient arrival □ questionable and not resolved at time of call □ inappropriate for the patient’s condition EMS CQI Document - Do Not Place in the Patient Medical Record San Joaquin County Emergency Medical Services Page 192 of 216 Medical Patient Destination EMS Policy No. 5201 Effective: July 24, 2014 5201 – Medical Patient Destination PURPOSE: The purpose of this policy is to provide direction to EMS personnel on determining the appropriate destination for medical patients. DEFINITIONS: A. B. C. D. E. “Base Hospital” and “Disaster Control Facility (DCF)” means San Joaquin General Hospital which is responsible for directing the prehospital care system in accordance with the policies and procedures of the EMS Agency. “Life Threatening Condition” means a patient with unmanageable airway, or uncontrolled bleeding, or rapidly deteriorating vital signs, or with CPR in progress. “Receiving Hospital” means a licensed general acute care hospital with a permit for basic or comprehensive emergency services. “STEMI Receiving Center” or “SRC” means a licensed acute care hospital with the capability to perform PCI which has satisfied the requirements for designation as set forth by the EMS Agency. “Unmanageable Airway” means a patient without the ability to manage their own airway, or a patient without an established BLS or ALS airway, or a patient being ventilated through a needle cricothyrotomy. POLICY: I. Patients in the San Joaquin County EMS System shall be transported to an appropriately staffed and equipped emergency department of a licensed general acute care hospital. San Joaquin County Emergency Medical Services Page 193 of 216 Medical Patient Destination EMS Policy No. 5201 Effective: July 24, 2014 II. Priorities in determining transport destinations for medical patients : A. Medical patients shall be transported to a receiving hospital based on the following priorities: 1. Multi-casualty incident – destination based on DCF direction. 2. Acute STEMI – closest STEMI Receiving Center. 3. Life threatening condition – closest receiving hospital or base hospital direction. 4. High Risk Obstetrical or Neonate – San Joaquin General Hospital or Doctors Medical Center, whichever is closest. 5. Active labor with complications – closest hospital with labor and delivery (L&D) service. 6. Non-emergent condition – patient choice. 7. No preference specified – closest receiving hospital. III. Parameters affecting transport destinations for medical patients: A. Acute ST Elevated Myocardial Infarction (STEMI) Patient Considerations: 1. Patients with signs and symptoms of an acute STEMI as specified in EMS Policy No. 5719 Chest Pain, shall be transported to a designated STEMI Receiving Center (SRC) by-passing all other receiving hospitals. 2. The following receiving hospitals are designated as SRCs for the San Joaquin County EMS System: a. Dameron Hospital. b. St. Joseph’s Medical Center. c. Doctors Medical Center. d. Memorial Medical Center. 3. The travel distance between Dameron Hospital and San Joaquin County Emergency Medical Services Page 194 of 216 Medical Patient Destination EMS Policy No. 5201 Effective: July 24, 2014 B. C. St. Joseph’s Medical Center is determined to be inconsequential. If a STEMI patient expresses a preference the patient may be transported to either SRC in Stockton. The same patient preference applies to the choice between Doctors Medical Center and Memorial Medical Center. High Risk Obstetrical or Neonate: 1. High Risk Obstetrical patients are patients without prenatal care or patients with an estimated pregnancy of 20 to 33 weeks. 2. High Risk Obstetrical with signs and symptoms of vaginal bleeding or active labor without complications shall be transported to San Joaquin General Hospital or Doctors Medical Center whichever is closest. 3. High Risk Neonatal patients are prehospital live births with an estimated gestational age of 20 to 33 weeks. 4. High Risk Neonatal patients shall be transported to San Joaquin General Hospital or Doctors Medical Center whichever is closest. Active Labor Considerations: 1. Active labor without complications is deemed to be a non-emergent condition and these patients may be taken to the receiving hospital with labor and delivery services (L&D) of their choice as listed in subparagraph D. 3. 2. Active labor with complications (prolapsed cord, breech presentation) shall be transported to the closest receiving hospital with L&D services. 3. The following is a list of receiving hospitals with L&D services in San Joaquin County and in areas immediately adjacent to San Joaquin County: a. Dameron Hospital. b. Doctors Hospital of Manteca. San Joaquin County Emergency Medical Services Page 195 of 216 Medical Patient Destination EMS Policy No. 5201 Effective: July 24, 2014 c. d. e. f. g. h. i. j. D. Lodi Memorial Hospital. San Joaquin General Hospital. St. Joseph’s Medical Center. Sutter-Tracy Community Hospital. Kaiser Medical Center, Modesto. Oak Valley District Hospital, Oakdale. Doctors Medical Center, Modesto. Memorial Medical Center, Modesto. Non-Emergent Medical Patient Destination Considerations: 1. In a non-emergent situation, as determined by EMS personnel on scene or following base hospital consultation, the patient may be transported to the receiving hospital of their choice. If the patient is unable or unwilling to express a choice, defer to the wishes of the patient’s private physician and/or family. In the absence of such direction, patients should be transported to the closest receiving hospital. a. Whenever possible ambulance personnel should determine where the patient normally receives their medical care and encourage the patient to return to that hospital. b. EMS personnel should only provide the patient and/or family with the available destination options. EMS personnel should not endorse a receiving facility or otherwise provide their personal opinion on the quality or merits of any receiving hospital. c. If the patient is a member of a health plan with a preferred hospital an attempt should be made to transport the patient to a participating or preferred receiving hospital. San Joaquin County Emergency Medical Services Page 196 of 216 Medical Patient Destination EMS Policy No. 5201 Effective: July 24, 2014 2. 3. IV. Medical Multi-casualty Incidents: A. V. Non-emergent medical patients may choose to be transported to any of the following receiving hospitals in San Joaquin County: a. Dameron Hospital. b. Doctors Hospital of Manteca. c. Kaiser Hospital Manteca. d. Lodi Memorial Hospital. e. San Joaquin General Hospital. f. St. Joseph’s Medical Center. g. Sutter-Tracy Community Hospital. Non-emergent medical patients may choose to be transported to receiving hospitals outside of San Joaquin County as follows: a. From Ambulance Zone A (Lodi): i. Methodist Hospital, Sacramento. ii. Kaiser Medical Center South Sacramento. b. From Ambulance Zones D (Manteca); E (Ripon); and F (Escalon): i. Doctors Medical Center, Modesto. ii. Kaiser Medical Center, Modesto. iii. Memorial Medical Center, Modesto. iv. Oak Valley District Hospital, Oakdale. During a medical MCI the DCF may direct the transport of patients to receiving hospitals outside of San Joaquin County. Hospital Diversion: A. B. Non-emergent patients shall not be transported to a receiving hospital with a facility status of diversion. Patients shall not be transported to a receiving hospital with a facility status of internal disaster/closed. San Joaquin County Emergency Medical Services Page 197 of 216 Medical Patient Destination EMS Policy No. 5201 Effective: July 24, 2014 C. Patients requiring specialty care services (e.g. STEMI, labor and delivery, neonatal intensive care) should not be transported to a receiving hospital with a facility status advising that such specialty services are unavailable. In such instances another receiving hospital offering such services should be utilized. San Joaquin County Emergency Medical Services Page 198 of 216 Medical Patient Destination Estimated Distance Time EMS Policy No. 5201A Effective: October 1, 2011 5201A – Medical Patient Destination Ground Ambulance Estimate of Driving Time and Distance Chrisman Road and Hwy 132 Southwest San Joaquin Co. Sutter-Tracy 9.5 14 mins miles Kaiser Manteca SJMC DMC 33 mins 142 S. Stockton St. Ripon CA Ripon 19 mins 18 miles 33 mins 25 miles Kaiser South Sac 71 mins 69 miles UCDMC 75 mins 76 miles Kaiser Modesto DHM 5.5 miles 9 mins Sutter-Tracy 24 mins 21 miles Oak Valley Kaiser South Sac 64 mins 57 miles UCDMC San Joaquin County Emergency Medical Services 26 mins 71 mins 22 mins DHM 34 mins 25 mins 26 miles Emanuel Turlock 36.5 46 mins miles DMC 7 miles 13 mins 28 mins 23 miles Kaiser Manteca 10 SJMC 18 miles Dameron 22 miles MMC 28 miles 8 mins SJGH 13 mins 10.5 Dameron 22 miles 28 mins 64 miles Page 199 of 216 23 miles 30 mins 28 miles Kaiser Modesto 24 30 mins miles Lodi Memorial 42 47 mins miles Oak Valley MMC SJGH 14 mins 11 miles Emanuel Turlock 24 29 mins miles 51 mins 20 mins 37.5 miles 19 miles Lodi Memorial 31.5 37 mins miles Medical Patient Destination Estimated Distance Time EMS Policy No. 5201A Effective: October 1, 2011 Kaiser Modesto Hwy 120 and McHenry Ave Escalon 12 mins 9 miles SJGH 23 mins Hwy 4 x Escalon-Bellotta Rd Farmington DHM 15 mins DMC 11 miles SJMC Dameron 18 miles 31 mins 24 miles Kaiser South Sac 67 mins 58 miles UCDMC 75 mins 66 miles SJMC Dameron 25 mins 19 miles DMC 28 mins 28 mins 31 mins 16 mins 10 miles Sutter-Tracy 24 miles 32 mins 16 mins 10 miles Emanuel Turlock 27 miles 38 mins 28 miles DHM 19 miles Oak Valley 25 18.5 mins miles Lodi Memorial 35 mins 28 miles Sutter-Tracy 19 miles Kaiser Manteca 32 26.5 mins miles UCDMC 69 mins Oak Valley Kaiser Modesto 25 18.5 mins miles MMC 18.5 miles Kaiser South Sac 53.5 61 mins miles San Joaquin County Emergency Medical Services 25 mins 15 mins MMC 10 miles 60.5 miles Page 200 of 216 26 mins 44 mins Kaiser Manteca 20 16 mins miles Lodi Memorial 41 33.5 mins miles SJGH 21.5 miles 40 miles 27 mins 23 miles Emanuel Turlock 36 48 mins miles Medical Patient Destination Estimated Distance Time EMS Policy No. 5201A Effective: October 1, 2011 Lodi Memorial I-5 and Highway 12 Flag City 9 mins 6.5 miles 18 mins SJGH 14.5 miles Kaiser South Sac 33 mins 30 miles Methodist Hospital 28.5 33 mins miles DMC 49 mins MMC 45.5 miles Lodi Memorial Hwy 99 and Hwy 12 E Victor Rd, Lodi Dameron 7 mins 4 miles 50 mins Kaiser Manteca DMC 45 mins MMC 40 miles San Joaquin County Emergency Medical Services 46 mins 22 mins 35 miles Sutter General 36.5 37 mins miles Sutter-Tracy 37 mins Dameron 13 miles Kaiser South Sac 29 26.5 mins miles 31 mins 21 mins 16.5 miles Kaiser Manteca 29.5 31 mins miles DHM UCDMC Kaiser Modesto 38 mins 37.5 miles 32 mins 30 miles 43 mins 41 miles 46 miles SJMC 17 mins SJMC 19 miles 26.5 20 mins SJGH 14 miles Sutter General 33 35 mins miles 24 mins Methodist Hospital 27 mins 25 miles DHM 21 miles Kaiser Modesto 39 35.5 mins miles Sutter-Tracy 33.5 miles UCDMC 37 mins 41 miles Page 201 of 216 28 mins 40 mins 25 miles 36 miles Major Trauma Triage Criteria EMS Policy No. 5210 Effective: August 1, 2013 5210 – Major Trauma Triage Criteria PURPOSE: The purpose of this policy is to define criteria for identifying major trauma patients. DEFINITIONS: A. “Adult major trauma patient” means a patient 15 years of age or older that meets one or more of the major trauma triage criteria. B. “Pediatric major trauma patient” means a patient 14 years of age or younger that meets one or more of the major trauma triage criteria. POLICY: I. Prehospital personnel shall assess all patients suffering acute injury or suspected acute injury using the trauma triage criteria established in this policy and shall document the findings of such an assessment on the patient care record. II. Major Trauma Triage Criteria: A. Physiologic : 1. Glasgow coma scale (GCS) motor score of less than 5 (patient withdraws from painful stimuli.) 2. Systolic blood pressure of less than: a. 90 for age 14 and older. b. 80 for age 7 to 14 years. c. 70 for age 1 to 6 years. 3. Respiratory rate <10 or >29 (<20 in infant < one year). San Joaquin County Emergency Medical Services Page 202 of 216 Major Trauma Triage Criteria EMS Policy No. 5210 Effective: August 1, 2013 B. Anatomic: 1. Penetrating injuries to the head, neck, chest, abdomen, and proximal to the elbow or knee. 2. Flail chest. 3. Two or more long bone fractures (humerus or femur). 4. Crushed, degloved, or mangled extremity. 5. Amputation proximal to wrist or ankle. 6. Pelvic fracture. 7. Open or depressed skull fracture. 8. Traumatic paralysis. 9. Extremity injury with loss of distal circulation. 10. Partial or full thickness thermal, chemical, or electrical burns greater than 9% total body surface. 11. Inhalation burns. C. Mechanism of Injury: 1. Auto versus pedestrian or bicyclist with the patient being: a. Run over. b. Thrown a significant distance. 2. Falls involving a pediatric patient from a height greater than 10 feet or twice the height of the child. D. Paramedic judgment: Paramedics may use their judgment to classify a patient as major trauma patient when the patient: 1. Has a significant complaint or obvious signs of injury, and; 2. Has experienced a high risk mechanism of injury; and 3. Has one or more of the following comorbid factors: a. Age greater than 55 or less than 10. b. Anticoagulation therapy. c. Burns. San Joaquin County Emergency Medical Services Page 203 of 216 Major Trauma Triage Criteria EMS Policy No. 5210 Effective: August 1, 2013 E. III. d. Time-sensitive extremity injury. e. Pregnancy greater than 20 weeks. 4. Examples of high risk mechanism of injury include: a. High energy motor vehicle or motorcycle crash. b. Blast injuries. c. Falls involving an adult patient greater than 20 feet. Examples of the application of paramedic judgment include: 1. Motor vehicle crash, with a pregnant patient complaining of abdominal pain, with seatbelt marks across abdomen. 2. Fall from the top of a bunk bed, with a child less than 5 years of age, with an obvious femur fracture. 3. Fall from an extension ladder, adult greater than 60 years of age, on anticoagulation therapy, complaining of pain all over. Multi-casualty Incidents (MCIs): A. B. Initial triage: 1. Prehospital personnel shall use START triage methodology for the initial assessment of patients during a trauma MCI. 2. Patients classified as “Immediate” using START criteria are major trauma patients. Secondary triage: 1. When resources and circumstances allow prehospital personnel shall re-triage patients using the criteria in this policy. 2. Patients meeting physiologic or anatomic criteria shall be classified as “Immediate” patients. 3. Patients meeting mechanism of injury or paramedic judgment criteria shall be classified as “Delayed” patients. San Joaquin County Emergency Medical Services Page 204 of 216 Trauma Patient Destination EMS Policy No. 5215 Effective: July 24, 2014 Supersedes: August 1, 2013 5215 – Trauma Patient Destination PURPOSE: The purpose of this policy is to guide prehospital, base hospital, and disaster control facility personnel in determining the appropriate destination for trauma patients. DEFINITIONS: A. “Adult major trauma patient” means a patient 15 years of age or older that meets one or more of the major trauma triage criteria. B. “Pediatric major trauma patient” means a patient 14 years of age or younger that meets one or more of the major trauma triage criteria. C. “Unmanageable Airway” means a patient whose upper airway is compromised by an obstruction (e.g. mandibular fractures, tongue, hematoma, blood, vomitus) preventing effective ventilations, or a patient being ventilated through a needle cricothyrotomy. POLICY: I. Prehospital personnel shall assess all patients suffering acute injury or suspected acute injury using the trauma triage criteria established in EMS Policy No. 5210 Major Trauma Triage Criteria. II. San Joaquin County is divided into two (2) primary trauma center catchment areas: A. Northern Catchment Area – All of San Joaquin County, San Joaquin County Emergency Medical Services Page 205 of 216 Trauma Patient Destination EMS Policy No. 5215 Effective: July 24, 2014 Supersedes: August 1, 2013 B. except for the southern catchment area. Southern Catchment Area – South of State Highway 120 in San Joaquin County Ambulance Zones E and F; and the area east of Escalon Bellota Road and south of Lone Tree Road. III. Adult Major Trauma Patient Destinations: A. Northern catchment area – San Joaquin General Hospital. B. Southern catchment area – Doctors Medical Center or Memorial Medical Center. C. If the assigned trauma center is unavailable or at capacity, adult major trauma patients shall be transported to the next closest trauma center. IV. Pediatric Major Trauma Patients: A. Northern catchment area – U.C. Davis Medical Center. B. Southern catchment area – U.C. Davis Medical Center. C. If the U.C. Davis Medical Center is unavailable or at capacity, pediatric major trauma patients shall be transported to the closest trauma center. V. Multi-casualty Incidents (MCIs): A. Trauma patients triaged as “Immediate” shall be preferentially transported to designated trauma centers utilizing available trauma centers in San Joaquin, Stanislaus, and Sacramento Counties. B. When possible pediatric trauma patients triaged as “Immediate” shall be preferentially transported to the U.C. Davis Medical Center. C. During a trauma MCI, the Disaster Control Facility (DCF) shall include at a minimum all of the following trauma centers in their emergency department poll: 1. San Joaquin General Hospital; 2. Doctors Medical Center; San Joaquin County Emergency Medical Services Page 206 of 216 Trauma Patient Destination EMS Policy No. 5215 Effective: July 24, 2014 Supersedes: August 1, 2013 D. 3. Memorial Medical Center; 4. U.C. Davis Medical Center; 5. Kaiser Hospital South Sacramento. As specified in EMS Policy No. 5210, on secondary triage an “Immediate” patient includes patients meeting START criteria and patients meeting physiologic or anatomic major trauma triage criteria. VI. Specialty Considerations: A. Unmanageable Airway: Transport to closest receiving hospital. B. Isolated Burn Injuries: 1. Patients with partial or full thickness thermal, chemical or electrical burns greater than 9% total body surface shall be transported to the trauma center at the UC Davis Medical Center. 2. Inhalation burns with a manageable airway shall be transported to the closest trauma center based on assigned trauma service area. 3. Paramedics should consult with the base hospital on all other types of burns injuries to obtain a destination. C. Isolated Spinal Cord Injuries: Patients with spinal cord trauma or traumatic paralysis without comorbid trauma injuries shall be transported to the trauma center at the UC Davis Medical Center. VII. Trauma Center Bypass: A. When San Joaquin General Hospital (SJGH) places itself on trauma center bypass due to the unavailability of a trauma surgeon, operating suite, CT scanner: 1. The DCF shall place an advisory notice on EMResource stating: “Contact DCF for major trauma patient destination”. 2. The DCF shall direct prehospital personnel to San Joaquin County Emergency Medical Services Page 207 of 216 Trauma Patient Destination EMS Policy No. 5215 Effective: July 24, 2014 Supersedes: August 1, 2013 B. transport major trauma patients meeting physiologic or anatomic major trauma triage criteria to an unencumbered trauma center in Sacramento County or Stanislaus County. San Joaquin General Hospital may continue to accept major trauma patients meeting mechanism of injury and paramedic judgment criteria, when on trauma center bypass. VIII. Air ambulance transport considerations: A. When ground ambulance transport is readily available air ambulance scene time should be kept to an absolute minimum. B. Ground ambulance transport of a major trauma patient should not be delayed for the arrival of an air ambulance. IX. Non-Emergent Trauma Patient Destination Considerations: A. In a non-emergent situation (patient does not meet major trauma triage criteria) the patient may be transported to the receiving hospital of their choice. If the patient is unable/unwilling to express a choice, defer to the wishes of the patient’s physician and/or family. In the absence of such direction, patients should be transported to the closest receiving hospital. 1. Whenever possible prehospital personnel should determine where the patient normally receives their medical care and encourage the patient to return to that hospital. 2. Prehospital personnel should only provide the patient and/or family with the available destination options. Prehospital personnel should not endorse a receiving hospital or otherwise provide their personal opinion on the quality or merits of any receiving hospital. 3. If the patient is a member of a health plan with a San Joaquin County Emergency Medical Services Page 208 of 216 Trauma Patient Destination EMS Policy No. 5215 Effective: July 24, 2014 Supersedes: August 1, 2013 B. C. preferred hospital an attempt should be made to transport the patient to a participating or preferred receiving hospital. Non-emergent trauma patients may choose to be transported to any of the following receiving hospitals in San Joaquin County: 1. Dameron Hospital. 2. Doctors Hospital of Manteca. 3. Kaiser Hospital Manteca. 4. Lodi Memorial Hospital. 5. San Joaquin General Hospital. 6. St. Joseph’s Medical Center. 7. Sutter-Tracy Community Hospital. Non-emergent trauma patients may choose to be transported to receiving hospitals outside of San Joaquin County as follows: 1. From Ambulance Zone A (Lodi): a. Methodist Hospital, Sacramento. b. Kaiser Medical Center South Sacramento. 2. From Ambulance Zones D (Manteca); E (Ripon); and F (Escalon): a. Doctors Medical Center, Modesto. b. Kaiser Medical Center, Modesto. c. Memorial Medical Center, Modesto. d. Oak Valley District Hospital, Oakdale. San Joaquin County Emergency Medical Services Page 209 of 216 Ground Ambulance Transport (Time/Distance) Ground Ambulance Transport (times/distance) Chrisman Road and Hwy 132, SW San Joaquin Co. 142 S. Stockton St, Ripon Hwy 120 and McHenry Ave, Escalon Hwy 4 and EscalonBellotta Rd, Farmington I-5 and Hwy 12, Flag City Hwy 99 and Hwy 12 E Victor Road, Lodi SJGH DMC MMC Kaiser South Sacramento UCDMC 22 min. 22 miles 33 min. 25 miles 34 min. 26 miles 71 min. 69 miles 75 min. 76 miles 20 min. 19 miles 13 min. 10 miles 14 min. 11 miles 64 min. 57 miles 71 min. 64 miles 23 min. 18 miles 15 min. 10 miles 16 min. 10 miles 67 min. 58 miles 75 min. 66 miles 27 min. 23 miles 28 min. 18.5 miles 28 min. 19 miles 61 min. 53.5 miles 69 min. 60.5 miles 21 min. 19 miles 49 min. 45.5 miles 50 min. 46 miles 33 min. 30 miles 38 min. 37.5 miles 24 min. 21 miles 45 min. 40 miles 46 min. 41 miles 29 min. 26.5 miles 37 min. 33.5 miles San Joaquin County Emergency Medical Services Page 210 of 216 San Joaquin County Emergency Medical Services Page 211 of 216 San Joaquin County Emergency Medical Services Page 212 of 216 San Joaquin County Emergency Medical Services Page 213 of 216 San Joaquin County Emergency Medical Services Page 214 of 216 San Joaquin County Emergency Medical Services Page 215 of 216 San Joaquin County Emergency Medical Services Page 216 of 216 San Joaquin County Emergency Departments Dameron Hospital E.D. 209-461-3166 525 W Acacia St Stockton, CA 95203 Doctors Hospital Manteca E.D. 209-239-8301 1205 E North St Manteca, CA 95336 Kaiser Hospital Manteca E.D. 209-825-3555 1777 E Yosemite Ave Manteca, CA 95336 Lodi Memorial E.D. 209-339-7576 975 S Fairmont Ave Lodi, CA 95240 San Joaquin General Hospital E.D. 209-468-6322 or 209-468-6301 500 W Hospital Rd French Camp, CA 95231 St. Josephs Medical Center E.D. 209-467-6400 or 209-467-6469 1800 N California St Stockton, CA 95204 Sutter-Tracy Community Hospital E.D. 209-832-6018 1420 N Tracy Blvd Tracy, CA 95376 San Joaquin County Base Hospital San Joaquin General Hospital Recorded Line: 209-982-1975 EMS Duty Officer Emergency Contact Number: 209-236-8339 San Joaquin County Emergency Medical Services Agency Mailing Address: PO Box 220 French Camp, CA 95231 Physical Address: Health Care Services Complex Benton Hall 500 W. Hospital Rd. French Camp, CA 95231 Website: http://www.sjgov.org/ems Phone Number: (209) 468-6818 Fax Number: (209) 468-6725 Follow us on Twitter@SJCEMSA
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