CARE MANUAL contra costa county emergency medical services agency
contra costa county emergency medical services agency CARE MANUAL for updates throughout the year, visit www.cccems.org INSTRUCTIONS FOR USE The Contra Costa EMS Agency Prehospital Care Manual contains both treatment guidelines and additional reference materials relevant to EMS care. www.cccems.org Updates and corrections to this manual will be posted at Treatment guidelines are divided into three main groupings, Adult, General and Pediatric. The General Guidelines include treatment guidelines that pertain to both adult and pediatric treatments. Treatment Guidelines A1 (Adult Patient Care) and P1 (Pediatric Patient Care) address basic concepts of care that are pertinent to all patients. This information is not repeated in other treatment guidelines. More detailed information on performance of specific patient procedures is posted at www.cccems.org Policy summaries reflect critical information for field personnel. For full policies, please refer to www.cccems.org table of contents—adult treatment guidelines A1—ADULT PATIENT CARE............................................................................................................... 3 A2—CHEST PAIN—SUSPECTED ACUTE CORONARY SYNDROME/STEMI..................4–5 A3—CARDIAC ARREST—INITIAL CARE AND CPR............................................................... 6–7 A4—VENTRICULAR FIBRILLATION— PULSELESS VENTRICULAR TACH.......................8–9 A5—PULSELESS ELECTRICAL ACTIVITY/ASYSTOLE........................................................ 10–11 A6—SYMPTOMATIC BRADYCARDIA.................................................................................. 12–13 A7—VENTRICULAR TACHYCARDIA WITH PULSES......................................................... 14–15 A8—SUPRAVENTRICULAR TACHYCARDIA....................................................................... 16–17 A9—OTHER CARDIAC DYSRHYTHMIAS........................................................................... 18–19 A10—SHOCK/HYPOVOLEMIA..............................................................................................20–21 A11—POST-CARDIAC ARREST CARE....................................................................................22–23 A12—PUBLIC SAFETY DEFIBRILLATION BLS/LAW ENFORCEMENT..........................24–25 §1 Adult Treatment Guidelines Adult Treatment Guidelines 2§ A1–ADULT ADULT PATIENT CARE These basic concepts should be addressed for all adult patients (age 15 and over) SCENE SAFETY BSI Use universal blood and body fluid precautions at all times DETERMINE PRIMARY IMPRESSION • Apply appropriate field treatment guideline(s) • Explain procedures to patient and family as appropriate SYSTEMATIC ASSESSMENT BASE CONTACT TRANSPORT MONITORING DOCUMENT • Assure open and adequate airway. Management of ABCs is a priority. • Place patient in position of comfort unless condition mandates other position (e.g. shock, coma) • Consider spinal motion restriction if history or possibility of traumatic injury exists • Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines are considered • Use SBAR to communicate with base • Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure • Transport patient medications or current list of patient medications to the hospital • Give report to receiving facility using SBAR • At a minimum, vital signs and level of consciousness should be re-assessed every 15 minutes and should be assessed after every medication administration or following any major change in the patient’s condition • For critical patients, more frequent vital signs should be obtained when appropriate Document patient assessment and care per policy Adult Treatment Guidelines §3 CHEST PAIN—SUSPECTED ACUTE CORONARY SYNDROME/STEMI A2–ADULT OXYGEN CARDIAC MONITOR ASPIRIN 12 – LEAD ECG IV BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% 325 mg po to be chewed by patient—DO NOT administer if patient has allergies to aspirin or salicylates or has apparent active gastrointestinal bleeding Repeat ECGs are encouraged. Continue 12-lead monitoring. TKO If ECG Does Not Indicate Acute MI or STEMI NITROGLYCERIN 0.4 mg sublingual or spray—May repeat every 5 minutes until pain subsides, maximum 3 doses. Contact base hospital if further dosages indicated. IV placement prior to NTG recommended for patients who have not taken NTG previously. PRECAUTIONS: Do not administer NTG if: • Blood pressure below 90 systolic; • Heart rate below 50; • Patient has recently taken erectile dysfunction (ED) drugs: • Viagra, Levitra, Staxyn or Stendra within 24 hours, or Cialis within 36 hours Consider FLUID BOLUS 500 ml NS if BP less than 90, lungs clear and unresponsive to supine positioning with legs elevated. May repeat X 1 Consider FENTANYL 50–200 mcg IV titrated in 25–50 mcg increments (consider 25 mcg increments in elderly patients). Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort 4§ Adult Treatment Guidelines A2–ADULT CHEST PAIN—SUSPECTED ACUTE CORONARY SYNDROME/STEMI Acute MI / STEMI Noted by 12-Lead ECG NITROGLYCERIN Do not administer Nitroglycerin if Acute MI/STEMI noted on 12-lead ECG. Exception: Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs) STEMI ALERT EARLY TRANSPORT FLUID BOLUS Consider FENTANYL Transmit ECG to STEMI Center and contact as soon as possible to notify facility of transport. Enter patient identifiers prior to transmission Minimize scene time • 500 ml NS for Inferior MI (elevation in leads II, III, aVF) if lungs clear (regardless of blood pressure) • 500 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat up to 3 times 50–200 mcg IV in 25–50 mcg increments (consider 25 mcg increments in elderly patients). Consider earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory effort. Caution: If Inferior MI suspected, use 25-50 mcg increments and observe carefully for hypotension Key Treatment Consider ations • Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm, nausea, diaphoresis, dyspnea (shortness of breath), anxiety • Diabetic, female or elderly patients more frequently present atypically • Atypical symptoms can include syncope, weakness or sudden onset fatigue • Many STEMIs evolve during prehospital period and are not noted on initial 12-lead ECG • ECG should be obtained prior to treatment for bradycardia if condition permits • Transmit all 12-lead ECGs—whether STEMI is detected or not detected §5 Adult Treatment Guidelines A3–ADULT CARDIAC ARREST—INITIAL CARE AND CPR ESTABLISH TEAM LEADER CONFIRM ARREST • First agency on scene assumes leadership role • Leadership role can be transferred as additional personnel arrive • Unresponsive, no breathing or agonal respirations, no pulse COMPRESSIONS Begin Compressions: • Rate —100–120 per minute. Use metronome • Depth—2 inches in adults—allow full recoil of chest (lift heel of hand) • Rotate compressors every 2 minutes if manual compression used Minimize interruptions. If necessary to interrupt, limit to 10 seconds or less • Perform CPR during charging of defibrillator • Resume CPR immediately after shock (do not stop for pulse or rhythm check) Prepare mechanical compression device (if available) • Apply with minimal interruption • Should be placed following completion of at least one 2-minute manual CPR cycle or at end of subsequent cycle AED or • Apply pads while compressions in progress MONITOR/ • Monitor/defibrillator should be in paddle mode DEFIBRILLATOR during resuscitation • Determine rhythm and shock, if indicated • Check rhythm every 2 minutes • Follow specific treatment guideline based on rhythm 6§ Adult Treatment Guidelines A3–ADULT CARDIAC ARREST—INITIAL CARE AND CPR BASIC AIRWAY • Open airway and provide 2 breaths after every 30 compressions MANAGEMENT • Avoid excessive ventilation—no more than 8–10 ventilations per minute & VENTILATION • Ventilations should be about 1 second each, enough to cause visible chest rise • Use two-person BLS Airway management (one holding mask and one squeezing bag) • If available, use ResQPOD with two-person BLS airway management IV/IO ACCESS • Intraosseous or antecubital IV are preferred sites for vascular access • Hand veins and other smaller veins should not be used in cardiac arrest ADVANCED • Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless NO ventilation is occurring AIRWAY with basic maneuvers • Exception: If ResQPOD used, early use of King Airway is appropriate • Placement of King Airway or endotracheal tube should not interrupt compressions for more than 10 seconds • For endotracheal intubation, position and visualize airway prior to cessation of CPR for tube passage. Immediately resume compressions after tube passage • Confirm tube placement and provide on-going monitoring using end-tidal carbon dioxide monitoring TREATMENT • Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions, which may be detrimental to ON SCENE patient outcome • Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC) • If resuscitation does not attain ROSC, consider cessation of efforts per policy §7 Adult Treatment Guidelines A4–ADULT VENTRICULAR FIBRILLATION— PULSELESS VENTRICULAR TACHYCARDIA INITIAL CARE See Cardiac Arrest—Initial Care and CPR (A3) CPR For 2 minutes or 5 cycles between rhythm check IO or IV TKO. Should not delay shock or interrupt CPR EPINEPHRINE 1:10,000—1 mg IV or IO every 3–5 minutes DEFIBRILLATION 200 joules VENTILATION/ • BLS airway is preferred method during first 5–6 minutes of CPR AIRWAY • If no visible chest rise occurring with basic maneuvers, proceed to advanced airway DEFIBRILLATION 300 joules DEFIBRILLATION 360 joules AMIODARONE 300 mg IV or IO DEFIBRILLATION 360 joules as indicated after every CPR cycle ADVANCED AIRWAY • Should not interfere with initial 5–6 minutes of CPR— minimize interruptions • Do not interrupt compressions more than 10 seconds to obtain airway Consider If rhythm persists, 150 mg IV or IO, 3–5 minutes after repeat initial dose AMIODARONE TRANSPORT Consider SODIUM BICARBONATE If indicated. If return of spontaneous circulation (ROSC), patient should be transported to a STEMI center. Patients without ROSC who merit transport should be transported to closest facility 1 mEq/kg IV or IO for suspected hyperkalemia or pre-existing acidosis If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11) 8§ Adult Treatment Guidelines A4–ADULT VENTRICULAR FIBRILLATION— PULSELESS VENTRICULAR TACHYCARDIA Key Treatment Consider ations • Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications • To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) • Rotate compressors every 2 minutes • Avoid excessive ventilation. Provide no more than 8–10 ventilations per minute. • Ventilations should be about one second each, enough to cause visible chest rise • If advanced airway placed, perform CPR continuously without pauses for ventilation • If available, ResQPOD impedance threshold device may be used with BLS airway or King / ET tube • If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage • Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement. Continuous monitoring with ETCO2 is mandatory—if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earliest indicator of return of circulation • Prepare drugs before rhythm check and administer during CPR • Follow each drug with 20 ml NS flush • Fingerstick glucose determinations are unreliable during cardiac arrest. Glucose checks should be reserved for patients with return of spontaneous circulation • Transmit “ALL” data to the monitor site identified by your provider agency §9 Adult Treatment Guidelines A5–ADULT PULSELESS ELECTRICAL ACTIVITY/ ASYSTOLE INITIAL CARE See Cardiac Arrest—initial care and CPR (A3) EPINEPHRINE 1:10,000 1 mg IV or IO every 3–5 minutes Consider Treatable Causes-treat if Applicable: Consider FLUID BOLUS VENTILATION Consider SODIUM BICARBONATE Consider CALCIUM CHLORIDE Consider WARMING MEASURES Consider NEEDLE THORACOSTOMY For hypovolemia: 500–1000 ml NS IV or IO For hypoxia: Ensure adequate ventilation (8–10 breaths per minute) For pre-existing acidosis (e.g. kidney failure), hyperkalemia, or tricyclic antidepressant overdose are suspected: • 1 mEq/kg IV or IO if indicated • Should not be used routinely in cardiac arrest For hyperkalemia or calcium channel blocker overdose: • 500 mg IV or IO—may repeat in 5–10 minutes • Should not be used routinely in cardiac arrest For hypothermia For tension pneumothorax If Return of Spontaneous Circulation, see Post-Cardiac Arrest Care (A11) 10§ Adult Treatment Guidelines A5–ADULT Consider TERMINATION OF RESUSCITATION TRANSPORT PULSELESS ELECTRICAL ACTIVITY/ ASYSTOLE Patients who have all of the following criteria are highly unlikely to survive: • Unwitnessed Arrest and; • No bystander CPR and; • No shockable rhythm seen and no shocks delivered during resuscitation and; • No return of spontaneous circulation (ROSC) during resuscitation Patients with asystole or PEA whose arrests are witnessed and/or who have had bystander CPR administered have a slightly higher likelihood of survival. If unresponsive to interventions these patients should be considered for termination of resuscitation. Note: These criteria should not be applied if profound hypothermia is present. If indicated. If return of spontaneous circulation (ROSC), patient should be transported to a STEMI Center. Patients without ROSC who merit transport should be transported to closest facility. Key Treatment Consider ations • Atropine is no longer used in cardiac arrest • Pre-existing acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if suspected diabetic ketoacidosis • In clear-cut traumatic arrest situations, epinephrine is not indicated in PEA or asystole. If any doubt as to cause of arrest, treat as a non-traumatic arrest (e.g. solo motor vehicle accident at low speed in older patients). • Fingerstick glucose determinations are unreliable during cardiac arrest. Glucose checks should be reserved for patients with return of spontaneous circulation. • Transmit “ALL” data to the monitor site identified by your provider agency §11 Adult Treatment Guidelines A6–ADULT SYMPTOMATIC BRADYCARDIA Heart rate less than 50 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock). Correction of hypoxia should be addressed prior to other treatments. OXYGEN CARDIAC MONITOR 12-LEAD ECG IV Consider FLUID BOLUS BLS: High flow initially ALS: Titrate to SpO2 of at least 94% TKO. If not promptly available, proceed to external cardiac pacing. Consider IO ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. 250–500 ml NS if clear lung sounds and no respiratory distress TRANSCUTANEOUS PACING Set rate at 80. Start at 10 mA, and increase in 10 mA increments until capture is achieved Consider ATROPINE May be used as a temporary measure while awaiting transcutaneous pacing but should not delay initiation of pacing Consider SEDATION TRANSPORT If pacing urgently needed, sedate after pacing initiated • MIDAZOLAM—initial dose 1 mg IV or IO, titrated in 1–2 mg increments (maximum dose 5 mg), and/or • FENTANYL 25–100 mcg IV or IO in 25–50 mcg increments for pain relief if BP 90 systolic or greater • 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective • Consider repeat 0.5 mg IV or IO every 3–5 minutes to maximum of 3 mg Use with caution in patients with suspected ongoing cardiac ischemia Atropine should not be used in wide-QRS second—and third-degree blocks Related guideline: Chest Pain/Suspected ACS/STEMI (A2) 12§ Adult Treatment Guidelines A6–ADULT SYMPTOMATIC BRADYCARDIA Key Treatment Consider ations • Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor/observe) • Sinus bradycardia is often seen in patients with STEMI or ischemia. Early 12-lead ECG should be obtained to assess for STEMI • Fluid bolus may address hypotension and lessen need for pacing or treatment with atropine • Sedation prior to starting pacing is not required. Patients with urgent need should be paced first • The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness. Patients who are in need of pacing are unstable and sedation should be done with great caution • Monitor respiratory status closely and support ventilation as needed • Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in these patients) • Patients with wide-QRS second–and third–degree blocks will not have a response to atropine because these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur §13 Adult Treatment Guidelines A7–ADULT VENTRICULAR TACHYCARDIA WITH PULSES Widened QRS Complex (greater than or equal to 0.12 sec)—generally regular rhythm Initial Ther apy OXYGEN CARDIAC MONITOR 12-LEAD ECG IV BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% 12–lead ECG pre-and post-treatment may be useful for comparisons at hospital. The computerized rhythm analysis on 12-lead printout should not be used for determination of rhythm. TKO STABLE VENTRICULAR TACHYCARDIA AMIODARONE Consider Repeat AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) If rhythm persists and patient remains stable, 150 mg IV over 10 minutes UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF Consider SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION: If awake and aware, sedate with MIDAZOLAM—initial dose 1 mg IV, titrate in 1–2 mg increments (max. dose 5 mg) 100 joules 200 joules 300 joules 360 joules If VT recurs, use lowest energy level previously successful 14§ Adult Treatment Guidelines A7–ADULT VENTRICULAR TACHYCARDIA WITH PULSES Key Treatment Consider ations • Document rhythm during treatment with continuous strip recording • Rhythm analysis should be based on recorded strip, not monitor screen • Be prepared for previously stable patient to become unstable • Give AMIODARONE via Infusion or slow IV push only • Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. • AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should be considered unstable and should not receive AMIODARONE. • If sedation done for cardioversion, monitor respiratory status closely and support ventilations as needed §15 Adult Treatment Guidelines A8–ADULT SUPRAVENTRICULAR TACHYCARDIA Heart rate greater than 150 beats per minute—regular rhythm usually with narrow QRS complex Initial Ther apy OXYGEN CARDIAC MONITOR 12-LEAD ECG IV BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% 12-lead ECG pre-and post-treatment may be useful for comparisons at hospital. The computerized rhythm analysis on 12-lead printout should not be used for determination of rhythm. TKO—Antecubital IV needed for rapid medication administration Stable Supr aventricular Tachycardia (SVT) May have mild chest discomfort VALSALVA Consider ADENOSINE 6 mg rapid IV—followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1–2 minutes after initial dose, followed by 20 ml normal saline flush 16§ Adult Treatment Guidelines A8–ADULT Unstable SVT SUPRAVENTRICULAR TACHYCARDIA • May need immediate synchronized cardioversion • Signs of poor perfusion include moderate to severe chest pain, dyspnea, altered mental status, blood pressure less than 90 or CHF • If rhythm not regular, SVT unlikely • If wide QRS complex, consider ventricular tachycardia Consider ADENOSINE Consider SEDATION SYNCHRONIZED CARDIOVERSION 6 mg rapid IV—followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1–2 minutes after initial dose, followed by 20 ml normal saline flush Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM—initial dose 1 mg IV, titrate in 1–2 mg increments (max. dose 5 mg) 100 joules 200 joules 300 joules 360 joules Key Treatment Consider ations • Document rhythm during treatment with continuous strip recording • Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen or computerized readout of 12-lead ECG • Be prepared for previously stable patient to become unstable • Proceed to cardioversion if patient becomes unstable • Hypoxemia is a common cause of tachycardia. Initial evaluation should focus on determining if oxygenation is adequate. • Adenosine should not be administered to patients with acute exacerbation of asthma • If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed §17 Adult Treatment Guidelines A9–ADULT OTHER CARDIAC DYSRHYTHMIAS SINUS TACHYCARDIA—Heart rate 100–160, regular ATRIAL FIBRILLATION—Heart rate highly variable, irregular ATRIAL FLUTTER—Variable rate depending on block. Atrial rate 250–350, “sawtooth” pattern. Initial Ther apy OXYGEN CARDIAC MONITOR Consider 12-LEAD ECG Consider IV BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% 12-lead ECG pre-and post-treatment may be useful for comparisons at hospital. The computerized rhythm analysis on 12-lead printout should not be used for determination of rhythm TKO Unstable Atrial Fibrillation Or Atrial Flutter Ventricular rate greater than 150, and BP less than 80, or unconsciousness/ obtundation, or severe chest pain or severe dyspnea OXYGEN Consider SEDATION SYNCHRONIZED CARDIOVERSION High flow. Be prepared to support ventilation. Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM—initial dose 1 mg IV, titrate in 1–2 mg increments (max. dose 5 mg) Atrial Flutter: • Initial: 100 joules • Subsequent: 200, 300, 360 joules Atrial Fibrillation: • Initial: 200 joules • Subsequent: 300, 360 joules 18§ Adult Treatment Guidelines A9–ADULT OTHER CARDIAC DYSRHYTHMIAS Key Treatment Consider ations • Sinus tachycardia commonly present because of pain, fever, anemia, or hypovolemia • Atrial fibrillation may be well-tolerated with moderately rapid rates (150–170) and often requires no specific treatment other than observation (oxygen, monitoring and transport) • If sedation used for cardioversion, monitor respiratory status closely and support ventilation as needed • Rhythm analysis should be based on review of P and QRS waves on printed strip, not monitor screen or computerized readout of 12-lead ECG • Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI Suspected*** or ***Meets ST-Elevation MI Criteria*** message encountered, the patient’s heart rate is important information to relate to the STEMI center at time of activation. §19 Adult Treatment Guidelines A10–ADULT SHOCK/HYPOVOLEMIA HYPOVOLEMIC OR SEPTIC SHOCK—Signs and symptoms of shock with dry lungs, flat neck veins • May have poor skin turgor, history of GI bleeding, vomiting or diarrhea, altered level of consciousness • May be warm and flushed, febrile, may have respiratory distress • Sepsis patients may or may not have an associated fever CARDIOGENIC SHOCK—Signs/symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema HYPOVOLEMIA WITHOUT SHOCK—No signs of shock, but history of poor fluid intake or fluid loss (e.g. vomiting, diarrhea). • May have tachycardia, poor skin turgor. OXYGEN Consider CPAP BLS/ALS: High flow. Be prepared to support ventilations as needed If suspected pulmonary edema/cardiogenic shock ADDRESS HYPOTHERMIA Keep patient warm if suspected hypothermia EARLY TRANSPORT CODE 3 CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline IV or IO TKO only if suspected pulmonary edema FLUID BOLUS • For hypovolemic or septic shock, 500 ml NS bolus. May repeat once. • For hypovolemia (poor intake/fluid loss), 250 ml NS bolus. May repeat once. Do not administer bolus if pulmonary edema or cardiogenic shock suspected 20§ Adult Treatment Guidelines A10–ADULT Consider 12-LEAD ECG SEPSIS SCREEN BLOOD GLUCOSE SHOCK/HYPOVOLEMIA If cardiac etiology for shock suspected Check temperature, use sepsis screening tool and advise hospital of positive sepsis screen if indicated A positive sepsis screen in adults occurs in the setting of suspected infection when 2 of 3 conditions are met: • Heart rate/pulse greater than 90; • Respiratory rate greater than 20; • Temperature above 100.4 or below 96 Check and treat if indicated Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12) §21 Adult Treatment Guidelines A11–ADULT POST-CARDIAC ARREST CARE Following resuscitation from cardiac arrest in adults OXYGEN END-TIDAL CO2 MONITORING BLS: High flow initially ALS: Titrate to SpO2 of at least 94% Be prepared to support ventilations as needed. Avoid excessive ventilation. CARDIAC MONITOR If intubated, monitor and maintain respirations to keep ETCO2 between 35 and 40 Treat dysrhythmias per specific treatment guideline TRANSPORT Code 3 to STEMI Receiving Center 12-LEAD ECG IV or IO FLUID BOLUS BLOOD GLUCOSE Consider THERAPEUTIC HYPOTHERMIA Evaluate for possible STEMI. Alert STEMI center if ECG indicates ***ACUTE MI*** or equivalent STEMI message If not previously established For BP less than 90 systolic, begin infusion up to 1 liter NS Treat if indicated See Indications and contraindications below: Expose patient and apply eight (8) ice packs • 2 on head, 2 on the neck over the carotid arteries, 1 on each axilla, 1 over each femoral artery Discontinue ice packs if shivering occurs or increasing level of consciousness. Advise Emergency Department that hypothermia has been initiated 22§ Adult Treatment Guidelines A11–ADULT POST-CARDIAC ARREST CARE Ther apeutic Hypothermia—Indications And Contr aindications INDICATIONS All the following must be present: • Must be age 18 or greater • Return of spontaneous circulation for at least five minutes • GCS < 8 • Unresponsive without purposeful movements. Brainstem reflexes and posturing movements may be present • Blood pressure 90 systolic or greater • Pulse oximetry–85% or greater • Blood glucose–50 or greater CONTRAINDICATIONS • Traumatic cardiac arrest • Responsive post-arrest with GCS 8 or greater or rapidly improving GCS • Pregnancy • DNR or known terminal illness • Dialysis patient • Uncontrolled bleeding Consider and treat other potential causes of altered level of consciousness (e.g. hypoxia or hypoglycemia) Key Treatment Consider ations • Transmit “ALL” data to the monitor site identified by your provider agency §23 Adult Treatment Guidelines A12-ADULT PUBLIC SAFETY DEFIBRILLATION BLS/ LAW ENFORCEMENT SCENE SAFETY/BSI Use universal blood and body fluid precautions at all times COMPRESSIONS • Begin compressions at a rate of 100–120 per minute • Compress chest at least 2 inches and allow full recoil of chest (lift heel of hand) • Change compressors every 2 minutes • Minimize interruptions in compressions. If necessary to interrupt, limit to 10 seconds or less. • Stop compressions for analysis only—resume compressions while AED is charging • Resume compressions immediately after any shock • If available, place mechanical compression device after first rhythm analysis or after subsequent rhythm analysis (LUCAS or Auto-Pulse) CONFIRM AUTOMATED EXTERNAL DEFIBRILLATOR (AED) Unconscious, pulseless patient with no breathing or no normal breathing • Priority of second rescuer is to apply pads while compressions are in progress • With infants and children, use pediatric pads if available. Adult pads may be used with usual placement position if pads do not touch. Adult pads may be placed anteriorposterior if usual placement would cause the pads to touch. • (*) Allow AED to analyze heart rhythm • If the rhythm is shockable • Resume compressions until charging of unit is complete • Clear bystanders and crew (stop compressions) • Deliver shock • Resume CPR for 2 minutes, beginning with chest compressions—then return to (*) • If the rhythm is NOT shockable (“No Shock Advised”) • Resume CPR for 2 minutes, beginning with chest compressions – then return to (*) 24§ Adult Treatment Guidelines A12-ADULT BASIC AIRWAY MANAGEMENT AND VENTILATION PUBLIC SAFETY DEFIBRILLATION BLS/ LAW ENFORCEMENT Open airway and provide 2 breaths after every 30 compressions • avoid excessive ventilation—Provide no more than 8–10 ventilations per minute • Ventilations should be about one second each, enough to cause visible chest rise. Use two-person BLS Airway management (one holding mask and one squeezing bag—compressor can squeeze the bag) CHECK BLOOD PRESSURE DOCUMENTATION If patient begins to breathe or becomes responsive: • Maintain airway • Assist ventilations as necessary If patient begins to breathe or becomes responsive: • Check blood pressure if equipment available • Complete AED Use Report • Forward report to EMS whenever an AED is used (whether shock administered or not) • Upload AED data for EMS review if upload capability available §25 Adult Treatment Guidelines 26§ table of contents—general treatment guidelines G1–ANAPHYLAXIS/ALLERGY.................................................................................................28–29 G2–ALTERED LEVEL OF CONSCIOUSNESS........................................................................30–31 G3–BEHAVIORAL EMERGENCY........................................................................................... 32–33 G4–BURNS..................................................................................................................................34–35 G5–CHILDBIRTH—ROUTINE OR COMPLICATED............................................................36–37 G6–DYSTONIC REACTIONS.......................................................................................................... 38 G7–ENVENOMATIONS (BITES, STINGS)................................................................................... 39 G8–HEAT ILLNESS/HYPERTHERMIA...................................................................................40–41 G9–HYPOTHERMIA..................................................................................................................42–43 G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC)........................................ 44–45 G11–POISONING—OVERDOSE............................................................................................ 46–48 G12–RESPIRATORY DEPRESSION OR APNEA.....................................................................50–51 G13–RESPIRATORY DISTRESS.................................................................................................52–53 G14–SEIZURE/STATUS EPILEPTICUS................................................................................... 54–55 G15–STROKE................................................................................................................................56–57 G16–TRAUMA—GENERAL.................................................................................................... 58–59 G16–TRAUMA—HEAD INJURY.................................................................................................... 60 G16–TRAUMA—EXTREMITY.........................................................................................................61 G17–VOMITING AND SEVERE NAUSEA..............................................................................62–63 G18–INTERFACILITY TRANSFER OF STEMI PATIENTS........................................................... 64 G19–INTERFACILITY TRANSFER OF INTUBATED PATIENTS................................................ 65 G20–INTERFACILITY TRANSFER OF STROKE PATIENTS............................................... 66–67 §27 General Treatment Guidelines G1–GENERAL ANAPHYLAXIS/ALLERGY • Systemic reactions (anaphylaxis) include upper and lower respiratory tracts, gastrointestinal or vascular system. Symptoms include dyspnea, stridor, change in voice, wheezing, anxiety, tachycardia, tightness in chest, vomiting, diarrhea, abdominal pain, dizziness or hypotension • Serious systemic reactions may involve hypotension alone without respiratory or skin findings • Skin and mucous membrane reactions (swelling of face, lip, tongue, palate), may be seen in either uncomplicated allergic reactions or in anaphylaxis OXYGEN EPI-PEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% May assist with administration of patient’s auto-injector CARDIAC MONITOR If systemic reaction (anaphylaxis): EPINEPHRINE 1:1000 • Adult—0.3–0.5 mg IM (use 0.3 mg in elderly, small patients or mild symptoms) IM ALBUTEROL IV Consider FLUID BOLUS Pediatric—0.01 mg/kg IM—maximum dose 0.3 mg May repeat in 15 minutes if systemic symptoms persist. Lateral thigh site should be used for IM injection (fastest absorption) Adult and pediatric—5 mg/6 ml saline via nebulizer—may repeat as needed TKO • Adult—wide-open NS if hypotensive. Recheck vitals after every 250 ml Pediatric—20 ml/kg NS bolus if hypotensive, may repeat X 2 If skin or mucous membr ane reactions (itching, hives or facial/or al swelling), consider: DIPHENHYDRAMINE • Adult—50 mg slow IV or IM. Consider 25 mg dose if patient has taken po diphenhydramine Pediatric—1 mg/kg IV or IM—Maximum dose 50 mg Consider 0.5 mg/kg dose if patient has taken po diphenhydramine 28§ General Treatment Guidelines G1–GENERAL ANAPHYLAXIS/ALLERGY If serious progression of symptoms after treatment with IM epinephrine: • Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, severe respiratory distress or respiratory arrest Consider IO If IV access not immediately available Consider EPINEPHRINE 1:10,000 IV If patient not responsive to IM epinephrine treatment in 5–10 minutes: • Adult—titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg. Use extreme caution with patients with cardiac history, angina, hypertension Pediatric—titrate in up to 0.1 mg doses slow IV or IO to a maximum of 0.01 mg/kg FLUID BOLUS • Adult—wide open NS. Recheck vitals after every 250 ml Pediatric—20 ml/kg NS bolus, may repeat X 2 Key Treatment Consider ations • Epinephrine IM administered early is the cornerstone of treatment in anaphylaxis • Epinephrine is well tolerated in pediatric patients and healthy young adults • In patients with prior history of coronary artery disease (angina, MI, stent placement), use of epinephrine IM is still indicated if symptoms are moderate to severe. If symptoms mild, careful observation is prudent. Consider base contact if any questions • Diphenhydramine and albuterol are secondary considerations in anaphylaxis • Up to 20% of anaphylaxis patients may present without any skin findings (e.g. hives) • Gastrointestinal symptoms may predominate in some patients, especially with serious reactions to food • In pediatric patients, hypotension is late sign of shock Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §29 General Treatment Guidelines G2–GENERAL ALTERED LEVEL OF CONSCIOUSNESS Glasgow Coma Scale less than 15 —uncertain etiology. Consider AEIOU/TIPPS OXYGEN ORAL GLUCOSE CARDIAC MONITOR BLS: High flow initially. ALS: Titrate to SpO2 of at least 94%. Be prepared to support ventilations as needed. Consider if known diabetic, conscious, able to sit upright, able to self-administer • Adult—30 g po Pediatric—15–30 g po BLOOD GLUCOSE Check level IV TKO EARLY TRANSPORT In patients with ALOC without low blood sugar DEXTROSE 10% If glucose 60 or less: • Adult—DEXTROSE 10% 100 ml IV Pediatric—DEXTROSE 10% 0.5 g/kg IV (5 ml/kg) — maximum initial dose 10g (100 ml) GLUCAGON BLOOD GLUCOSE DEXTROSE 10% If unable to establish IV (at least 2 attempts or if unable to find suitable site): • Adult—1 mg IM Pediatric—24 kg or more–1 mg IM Pediatric—Less than 24 kg–0.5 mg IM Recheck if symptoms not resolved. If GLUCAGON has been administered, change in glucose/mentation may require 15 minutes or more. Give additional DEXTROSE 10% 150 ml IV if glucose remains 60 or less. Pediatric—Give additional DEXTROSE 10% in 50 ml increments to total 150 ml if Glucose remains 60 or less Related guideline: Respiratory Depression or Apnea (G12) 30§ General Treatment Guidelines G2–GENERAL ALTERED LEVEL OF CONSCIOUSNESS Key Treatment Consider ations • Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 12 breaths per minute) • After treatment(s) for hypoglycemia, recheck glucose before considering repeat treatment • Mental status improvement may lag behind improved glucose levels (especially in elderly patients or prolonged hypoglycemia). Further treatment when glucose is 60 or above is not indicated • Oral glucose is the preferred treatment when patient is able to take medication orally • Dextrose 10% is the preferred treatment when patient is unable to take oral medication • Glucagon should not be administered if patient is able to take oral glucose and should be administered only if IV starts are unsuccessful or no suitable IV sites found. It may not be effective in patients with starvation, poor oral intake, alcoholism or alcohol intoxication • Glucagon may take 10–15 minutes or longer to increase glucose level (peak effects in 45–60 minutes) • Wait for 10–15 minutes and recheck glucose before considering additional treatment • For diabetics with insulin pumps, the amount of insulin administered by the pump is very small and should not impede treatment of hypoglycemia. Insulin pumps should not be discontinued because of the development of hypoglycemia • The presence of the pump should be identified during patient report at the hospital • Transport is highly recommended in patients with hypoglycemia as a result of oral diabetic medications and patients over 65 years of age (higher risk of recurrent hypoglycemia) • Transport is also highly recommended for any hypoglycemic patient who is not a diabetic (may occur with renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses and sulfa drugs or following bariatric surgery) • Consider transport earlier in patients with poor vascular access who are not responding to glucagon or have reasons listed above for possible impaired response to glucagon Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for D10 dose §31 General Treatment Guidelines G3–GENERAL BEHAVIORAL EMERGENCY • A behavioral emergency is defined as combative or irrational behavior not caused by medical illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated states or other conditions • Combative or irrational behavior may be caused by psychiatric or other behavioral disorder • History of event and past history are important in patient evaluation • Past history of psychiatric condition does not eliminate need to assess for other illnesses SCENE SAFETY ASSESS PATIENT VITAL SIGNS Consider OXYGEN CARDIAC MONITOR Consider BLOOD GLUCOSE • Many patients merit a weapons search by law enforcement • Physical restraints may be needed if patient exhibits behavior that presents a danger to him/herself or others • Assess for evidence of hypoxia, hypoglycemia, trauma • Consider other medical causes for behavioral symptoms Obtain vital signs as possible BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% Place as possible/safe Obtain as possible/safe 32§ General Treatment Guidelines G3–GENERAL Consider CHEMICAL RESTRAINT MONITOR PATIENT BEHAVIORAL EMERGENCY Despite verbal de-escalation and physical restraint, if adult patient (15 years or older) remains extremely combative and struggling against restraints, consider: • MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small patients (under 50 kg). • MIDAZOLAM 1–3 IV mg in 1 mg increments if IV established and patent. Contact base if further medication needed. Monitor closely for respiratory compromise. Assess and document mental status, vital signs, and extremity exams (if restrained) at least every 15 minutes. Related guidelines: Altered Level of Consciousness (G2), Trauma (G16) Key Treatment Consider ations • Calming measures may be effective and may preclude need for restraint in some circumstances • Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if possible, but maintain contact with other personnel and ability to exit rapidly. • Avoid violating patient’s personal space, making direct eye contact or sudden movements. Frequent reassurance and calm demeanor of personnel are important. • Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. • Assure adequate resources available to manage patient’s needs. Restraint may require up to five persons to safely control patient. • Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior • In pediatric patients, consider child’s developmental level when providing care • Sedation with Midazolam intended for adult patients only (age 15 and over) • Not all patients will respond to Midazolam. Repeat dosage is not recommended—requires base order. §33 General Treatment Guidelines G4–GENERAL BURNS • Damage to the skin caused by contact with caustic material, electricity, or fire • Second or third degree burns involving 20% of the body surface area, or those associated with respiratory involvement, are considered major burns SCENE SAFETY Move patient to safe area OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% STOP BURNING PROCESS BURN CARE ASSESS FOR INJURIES • Remove contact with agent, unless adhered to skin • Brush off chemical powders • Flush with water to stop burning process or to decontaminate Protect the burned area. Do not break blisters. Cover with clean dressings or sheets. Remove restrictive clothing/jewelry if possible. Assess for associated injuries if other trauma suspected Consider IV or IO TKO Consider FENTANYL Intranasal If IV or IO access not available: • Adult—100 mcg Intranasal—may repeat once in 15 minutes Pediatric—1.5 mcg/kg Intranasal—See Pediatric Drug Chart Consider FENTANYL IV For pain relief in the absence of hypotension (systolic BP less than 90), significant other trauma, altered level of consciousness: • Adult—50–200 mcg IV or IO, titrated in 25–50 mcg increments (consider 25 mg increments in elderly patients). Pediatric—1 mcg/kg IV—See Pediatric Drug Chart 34§ General Treatment Guidelines G4–GENERAL Consider FENTANYL IM BURNS If IV or IO access not available and intranasal route not advisable: • Adult—50–100 mcg IM—may repeat once in 15 minutes Pediatric —1 mcg/kg IM—See Pediatric Drug Chart Key Treatment Consider ations • Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or edematous mucosa in mouth are clues) • Transport to closest receiving facility for advanced airway management if it cannot be done on scene in a timely manner. Do not wait for helicopter (air ambulance) if airway patency is a concern and care can be provided more rapidly at a receiving facility • Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia • Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose §35 General Treatment Guidelines G5–GENERAL CHILDBIRTH—ROUTINE IMMINENT DELIVERY—Regular contractions, bloody show, low back pain, feels like bearing down, crowning PREPARE FOR DELIVERY Consider IV DELIVER INFANT CLAMP/CUT CORD WARMING MEASURES Reassure mother, instruct during delivery TKO if time allows • As head is delivered, apply gentle pressure to prevent rapid delivery of the infant • Gently suction baby’s mouth, then nose, keeping the head dependent • If cord is wrapped around neck and can’t be slipped over the infant’s head, double-clamp and cut between clamps Immediately double-clamp cord 6–8 inches from baby and cut between clamps (if not done before delivery) Dry baby and keep warm, placing baby on mother’s abdomen or breast PLACENTA DELIVERY If placenta delivers, save it and bring to the hospital with mother and child. DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA POST-DELIVERY OBSERVATION TRANSPORT Observe mother and infant frequently for complications. To decrease post-partum hemorrhage, perform firm fundal massage, put baby to mother’s breast. Prepare mother and infant for transport. Neonatal care or resuscitation as indicated. 36§ General Treatment Guidelines G5–GENERAL CHILDBIRTH—COMPLICATED BREECH DELIVERY—Presentation of buttocks or feet OXYGEN DELIVERY TRANSPORT BLS/ALS: High flow • Allow delivery to proceed passively until the baby’s waist appears • Rotate baby to face-down position (DO NOT PULL) • If the head does not readily deliver in 4–6 minutes, insert a gloved hand into the vagina to create an air passage for the infant Early transport if available—notify receiving hospital as soon as possible PROLAPSED CORD—Cord presents first and is compressed, compromising infant circulation OXYGEN BLS/ALS: High flow POSITION PATIENT Place mother in trendelenburg position with hips elevated MANAGE CORD TRANSPORT • Insert gloved hand into vagina and gently push presenting part off of the cord • Do not attempt to reposition the cord • Cover cord with saline soaked gauze Early transport if available—notify receiving hospital as soon as possible §37 General Treatment Guidelines G6–GENERAL DYSTONIC REACTIONS • History of ingestion of phenothiazine or related compounds, primarily antipsychotic and anti-emetic medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis. Consider OXYGEN IV BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% TKO DIPHENHYDRAMINE • Adult— 25–50 mg IV or 50 mg IM if unable to establish IV access Pediatric—1 mg/kg IV or 1 mg/kg IM if unable to establish IV access Key Treatment Consider ations Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications: • Prochlorperazine (Compazine) • Haloperidol (Haldol) • Metoclopromide (Reglan) • Phenergan (Promethazine) • Fluphenazine (Prolixin) • Chlorpromazine (Thorazine) • Many other antipsychotic and anti-depressant drugs • Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. 38§ General Treatment Guidelines G7–GENERAL ENVENOMATIONS (BITES, STINGS) SNAKE BITES • If the snake is positively identified as non-poisonous, treat with basic wound care INSECT STINGS • Symptoms of stings usually occur at the site of injury and have no specific treatment • Allergic reactions can be severe, and may cause anaphylactic shock CALM PATIENT With snake bite, keep patient still and calm WOUND MANAGEMENT Snake bite: Splint extremity and keep at level of heart ASSESS EXTREMITIES OXYGEN CONSIDER CARDIAC MONITOR CONSIDER IV Remove rings, bracelets or other constricting items from affected extremity Insect Stings: Flick stinger off—do not squeeze stinger. Apply cold pack. BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94%. Be prepared to support ventilation. Consider if patient potentially unstable TKO Related guidelines: Shock/Hypovolemia (A10, P9), Anaphylaxis/Allergy (G1) §39 General Treatment Guidelines G8–GENERAL HEAT ILLNESS/HYPERTHERMIA HEAT EXHAUSTION • Presentation: Flu-like symptoms, cramps, normal mental status HEAT STROKE • Presentation: Altered level of consciousness, absence of sweating, tachycardia, and hypotension OXYGEN COOLING MEASURES IV Consider FLUID BOLUS Consider BLOOD GLUCOSE BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% • Move patient to cool environment • Promote cooling by fanning • Remove clothing and splash/sponge with water • Place cold packs on neck, in axillary and inguinal areas TKO. Perform if heat stroke or marked symptoms with heat exhaustion If hypotensive or suspected heat stroke: • Adult—500 ml NS bolus May repeat X 1 Pediatric—20 ml/kg NS bolus. May repeat X 1 Check level if altered level of consciousness, treat as indicated 40§ General Treatment Guidelines G8–GENERAL HEAT ILLNESS/HYPERTHERMIA Related guidelines: Altered Level of Consciousness (G2), Seizure (G14) Key Treatment Consider ations • Seizures may occur with heat stroke—treat as per treatment guideline for seizure • Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat exhaustion, movement to cooler environment and fanning may suffice. • Conditions that may lead to or worsen hyperthermia include: • Psychiatric Disorders • Heart Disease • Diabetes • Alcohol • Medications • Fever • Fatigue • Obesity • Pre-existent dehydration • Extremes of age (Elderly and pediatric) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §41 General Treatment Guidelines G9–GENERAL HYPOTHERMIA MODERATE HYPOTHERMIA • Conscious and shivering but lethargic, skin pale and cold SEVERE HYPOTHERMIA • Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations • Severe hypothermia patients may appear dead. When in doubt, begin resuscitation. OXYGEN SPINAL PRECAUTIONS WARMING MEASURES CARDIAC MONITOR BLS: Low flow unless ALOC/respiratory distress/shock. ALS: Titrate to SpO2 of at least 94% Use warm humidified oxygen if available For patients with possible trauma or submersion Gently move to sheltered area (warm environment) Minimize physical exertion or movement of the patient Cut away wet clothing and cover patient with warm, dry sheets or blankets Consider EARLY TRANSPORT Do not delay transport if patient unconscious BLOOD GLUCOSE Check and treat if indicated IV TKO CONSIDER NALOXONE If respiratory rate less than 12 and narcotic overdose suspected CONSIDER ADVANCED AIRWAY Only if unable to ventilate using BVM 42§ General Treatment Guidelines G9–GENERAL HYPOTHERMIA Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Consider ations • Avoidance of excess stimuli is important in severe hypothermia as the heart is sensitive and interventions may induce arrhythmias. Needed interventions should be done as gently as possible. • Check for pulselessness for 30–45 seconds to avoid unnecessary chest compressions • Defer ACLS medications until patient warmed • If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer further shocks • Patients with prolonged hypoglycemia often become hypothermic—blood glucose check is essential • Patients with narcotic overdose may develop hypothermia §43 General Treatment Guidelines G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC) • Patients of all ages expressing verbal or behavioral indicators of pain shall have an appropriate assessment and management of pain • Fentanyl should be given in sufficient amount to manage pain but not necessarily to eliminate it Consider OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% IV TKO PAIN RELIEF MEASURES • Psychological measures and BLS measures, including cold packs, repositioning, splinting, elevation, and/or traction splints, are important considerations for patients with pain • If pain cannot be managed using above measures, consider FENTANYL, especially in patients reporting pain levels of 5 or greater ASSESS PAIN Consider FENTANYL IV Consider FENTANYL Intranasal Consider FENTANYL IM • Assess and document the intensity of the pain using the visual analog scale • Reassess and document the intensity of the pain after any intervention that could affect pain intensity See contraindications and cautions on next page: For pain relief: • Adult—50–200 mcg IV, titrated in 25–50 mcg increments to pain relief (consider 25 mg increments in elderly patients) Pediatric—1 mcg/kg IV—See Pediatric Drug Chart If no IV access: • Adult—100 mcg Intranasal. May repeat once in 15 minutes. Pediatric—1.5 mcg/kg Intranasal—See Pediatric Drug Chart If no IV access and intranasal route not suitable: • Adult— 50–100 mcg IM. May repeat once in 15 minutes. Pediatric—1 mcg/kg IM—See Pediatric Drug Chart 44§ General Treatment Guidelines G10–GENERAL PAIN MANAGEMENT (NON-TRAUMATIC) Contr aindications and Cautions for Fentanyl CONTRAINDICATIONS FOR FENTANYL: • Closed head injury • Altered level of consciousness • Headache • Respiratory failure or worsening respiratory status • Childbirth or suspected active labor • Hypotension • Adults—Systolic BP less than 90 • Pediatric—Hypotension or impaired perfusion (e.g. capillary refill > 2 seconds) • Infants 1 mo–1 yr systolic—BP < 60 mmHg • Toddler 1–4 yrs systolic—BP < 75 mmHg • School age 5–13 yrs systolic—BP < 85 mmHg • Adolescent >13 yrs systolic—BP < 90 mmHg CAUTIONS FOR FENTANYL: • Use with caution in patients with suspected hypovolemia • Older patients may be more sensitive to Fentanyl—consider 25 mcg increments IV initially Key Treatment Consider ations • Have Naloxone available to reverse respiratory depression should it occur • Preferred route of administration for Fentanyl is IV • Intranasal route is preferred if IV not available and patient does not have suspected hypovolemia Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §45 General Treatment Guidelines G11–GENERAL POISONING—OVERDOSE • If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. • Be careful not to contaminate yourself and others DECONTAMINATION OXYGEN CARDIAC MONITOR Consider IV Remove contaminated clothing, brush off powders, wash off liquids. Irrigate eyes if affected BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94%. Be prepared to support ventilation. TKO if unstable patient or suspected serious ingestion Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), Seizures (G14), Shock/Hypovolemia (A10, P8) TRICYCLIC ANTIDEPRESSANT OVERDOSE Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes and associated ventricular dysrhythmias are generally signs of a life-threatening ingestion. SODIUM BICARBONATE For adults only: For life-threatening hemodynamically significant dysrhythmias, 1 mEq/kg slow IV or IO ORGANOPHOSPHATE POISONING Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness, small/pinpoint pupils, muscle twitching, and/or seizures may occur ATROPINE For adults only: 1–2 mg IV • Repeat every 3–5 minutes as necessary until relief of symptoms • Large doses of Atropine may be required 46§ General Treatment Guidelines G11–GENERAL POISONING—OVERDOSE HYDROFLUORIC ACID EXPOSURE CALCIUM CHLORIDE For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% solution) Consider FENTANYL IV Consider FENTANYL Intranasal Consider FENTANYL IM For adults only: In the absence of hypotension, significant other trauma or altered level of consciousness: 50–200 mcg IV, titrated in 25–50 mcg increments to pain relief (consider 25 mg increments in elderly patients) For adults only: If no IV access, 100 mcg intranasal. May repeat once in 15 minutes. For adults only: If no IV access, 50–100 mcg IM. May repeat once in 15 minutes Key Treatment Consider ations • Few overdoses have specific antidotes. Supportive care is the mainstay of treatment • Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium Channel Blocker overdose) Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients • Poison Control Center can offer information but cannot provide medical direction to EMS §47 General Treatment Guidelines G11–GENERAL POISONING—OVERDOSE SUSPECTED CARBON MONOXIDE POISONING • Symptoms may be diverse and often non-specific. Headache, dizziness, fatigue and nausea are most common symptoms. • Neurologic symptoms may include confusion, lethargy, drowsiness, agitation, coma, syncope, seizure or bizarre neurologic symptoms. • Other symptoms may include chest pain, palpitations, dyspnea, weakness, or flu-like symptoms. • Evaluate for CO poisoning in suspected smoke inhalation • Suspect and evaluate in situations when multiple patients have symptoms • Consider evaluation when other causes for symptoms are not obvious OXYGEN CARDIAC MONITOR CO-OXIMETRY 12-LEAD ECG Consider BASE CONTACT TRANSPORT IV BLS/ALS: High flow. Be prepared to support ventilations as needed Measure using manufacturer’s recommendation. May be unreliable if low perfusion, excessive patient motion, or excessive ambient light. Contact base if patient has significant symptoms (e.g., altered level of consciousness, arrhythmia), has CO level greater than 20% or if patient is pregnant to determine appropriate destination. TKO Related Guidelines: Chest Pain/Suspected ACS (A2), Seizure (G14) 48§ General Treatment Guidelines §49 General Treatment Guidelines G12–GENERAL RESPIRATORY DEPRESSION OR APNEA Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest BVM VENTILATION Assist ventilation or provide ventilation if no spontaneous respirations OXYGEN BLS: High flow initially ALS: Titrate to SpO2 of at least 94%. Be prepared to support ventilations as needed ETCO2 MONITORING In borderline cases, non-invasive ETCO2 monitoring (when available) may be valuable in detection of hypoventilation and can help follow respiratory trend before and after treatment. ETCO2 monitoring is not reliable in patients with hypotension or poor perfusion. CARDIAC MONITOR NALOXONE INTRANASAL OR IM • Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected • Adult not in shock but unsuitable for IN (copious secretions): 1–2 mg IM Pediatric—0.1 mg/kg IM—maximum dose 2 mg Consider IV TKO if intravenous treatment indicated Repeat NALOXONE IV or IM if no response and narcotic overdose suspected —maximum dose 10 mg NALOXONE IV Consider TITRATION OF DILUTED NALOXONE IV ADVANCED AIRWAY If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already available for another reason: • Adult— 1–2 mg IV Pediatric—0.1 mg/kg IV—maximum dose 2 mg Consider for patients with chronic narcotic use for terminal disease or chronic pain: Dilute 1:10 with normal saline and administer in 0.1 mg (1 ml) increments—titrate to increased respiratory rate Consider when indicated—only if naloxone ineffective and BVM ventilation not adequate 50§ General Treatment Guidelines G12–GENERAL RESPIRATORY DEPRESSION OR APNEA Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13) Key Treatment Consider ations SAFETY WARNING! Naloxone will cause acute withdrawal symptoms in patients who are habituated users of narcotics (whether prescribed or from abuse) • Use of diluted Naloxone IV and titration with small increments may help decrease adverse effects of naloxone in patients who have chronic narcotic usage for terminal disease or pain relief • Naloxone treatment should only be given to patients with respiratory depression (rate less than 12) • Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management • Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1–2%) • Older patients are at higher risk for cardiovascular complications • Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose • In patients without hypotension or poor perfusion, ETCO2 readings below 45 generally do not require treatment with naloxone for respiratory depression. ETCO2 should be used to help monitor respiratory trend. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §51 General Treatment Guidelines G13–GENERAL RESPIRATORY DISTRESS • Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema • Rales may be present in pneumonia, pulmonary edema, and many other conditions INITIAL THER APY OXYGEN CARDIAC MONITOR Consider CPAP Consider IV BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% If respiratory rate greater than 25, accessory muscle use, pulse ox less than 94% TKO. Do not delay transport for vascular access if in extremis. ASTHMA ALBUTEROL Adult and Pediatric—5 mg in 6 ml NS via nebulizer. Repeat as needed. Consider For use in asthma only: Use only if respiratory status EPINEPHRINE 1:1000 deteriorating despite repeat treatment with Albuterol SC (subcutaneously) and transport time more than 10 minutes Do not use in patients with history of coronary artery disease or hypertension • Adult—0.3 mg SC Pediatric—0.01 mg/kg SC—max dose 0.3 mg Never give Epinephrine 1:1000 intravenously! EPINEPHRINE 1:1000 If respiratory arrest from asthma or bronchospasm: IM • Adult—0.3 mg IM Pediatric—0.01 mg/kg IM—max dose 0.3 mg COPD EX ACERBATION ALBUTEROL 5 mg in 6 ml NS via nebulizer. Repeat as needed. 52§ General Treatment Guidelines G13–GENERAL RESPIRATORY DISTRESS SUSPECTED PULMONARY EDEMA (ADULTS ONLY) NITROGLYCERIN 0.4 mg sublingual if systolic BP between 90 and 149 0.8 mg sublingual if systolic BP 150 or greater Repeat every 5 minutes until symptoms improve Maximum dose 4.8 mg (12–0.4 mg doses) Discontinue if hypotension develops Caution: Do not administer if patient has taken erectile dysfunction medications Viagra, Levitra, Staxyn or Stendra within prior 24 hours or Cialis within 36 hours Related guidelines—Chest pain/Suspected ACS (A2), Shock (A10) Key Treatment Consider ations • CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of respiration will need assistance with BVM • Patients requiring advanced airway management in these situations are best handled in the hospital setting and CPAP may be a valuable “bridge” in care to potentially delay need for emergent intubation • Patients with potential respiratory failure should be transported emergently • IV access should not delay transport • For patients with significant anxiety or claustrophobia with CPAP, consider base contact for midazolam. Midazolam should be administered in 0.5–1 mg increments and patients should be monitored carefully for potential respiratory depression • For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg • Patients with suspected pulmonary edema and STEMI should receive nitroglycerin if no other contraindications (e.g. hypotension, bradycardia or use of erectile dysfunction drugs) • Consider cardiac etiology for diabetic patients with respiratory distress Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §53 General Treatment Guidelines G14–GENERAL SEIZURE/STATUS EPILEPTICUS • Tonic-clonic movements followed by a period of unconsciousness (post-ictal period) • A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or recurrent seizures without patient regaining consciousness OXYGEN BLS: High flow initially ALS: Titrate to SpO2 of at least 94% PROTECT PATIENT Do not forcibly restrain but protect from injuring self Consider IV TKO Consider MIDAZOLAM IV For continuous or recurrent seizures: • Adult—initial dose 1 mg IV - titrate in 1–2 mg increments—max. dose 5 mg Pediatric—titrate in up to 1 mg IV increments—up to 0.1 mg/kg CARDIAC MONITOR BLOOD GLUCOSE Consider MIDAZOLAM IM MONITOR PATIENT Check and treat if indicated If IV access unavailable: • Adult—0.1 mg/kg IM—maximum dose 5 mg Pediatric—0.1 mg/kg IM—maximum dose 5 mg Carefully observe vital signs, respiratory status— support ventilations as needed Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) SAFETY WARNING: • Use caution when treating with Midazolam in pediatric patients previously treated by family or caretaker with rectal diazepam (Valium, Diastat) as a higher incidence of respiratory depression may occur • Wait five (5) minutes after last rectal dose to determine effect and need for further treatment. Consider using reduced dosage of Midazolam 54§ General Treatment Guidelines G14–GENERAL SEIZURE/STATUS EPILEPTICUS Key Treatment Consider ations • Most seizures are self-limiting and do not require prehospital medication • Seizures may appear frightening to observers. Provide reassurance to parents/family. • Consider spinal motion restriction if history of fall or trauma • Early administration of Midazolam IM is preferable to IV route in smaller children and in other patients with potential difficult intravenous access • Febrile seizures in children are generally self-limiting • For febrile patients, remove or loosen clothing, remove blankets to address cooling measures Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §55 General Treatment Guidelines G15–GENERAL STROKE • Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit—may be associated with headache • Determination of time of onset of symptoms is the most crucial historical information needed • If patient awoke with symptoms, time patient last seen normal is the time that should be noted OXYGEN CARDIAC MONITOR STROKE SCALE TRANSPORT BLOOD GLUCOSE IV Consider FLUID BOLUS CONTACT STROKE CENTER OR RECEIVING HOSPITAL ENSURE FAMILY/ GUARDIAN COMMUNICATION BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94%. Be prepared to support ventilation. Note findings of stroke scale and time of onset of symptoms Minimize scene time Check and treat if indicated TKO 250–500 ml if hypotensive or poor perfusion—reassess Stroke Alert is indicated only when Cincinnati Stroke Scale (CSS) findings are abnormal and onset (time last seen normal) is less than 4 hours from time of patient contact. Report time last seen normal (clock time), ETA, physical exam and findings of CSS using SBAR format. If family member/patient guardian available, ensure their availability by either transporting them in ambulance, telling them to go immediately to the hospital or obtain phone number to allow physician to contact them Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12), Seizure (G14) 56§ General Treatment Guidelines G15–GENERAL STROKE CINCINNATI STROKE SCALE If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and may indicate an acute stroke FINDING Facial Droop Arm Weakness Speech Abnormality PATIENT ACTIVITY Ask patient to smile and show teeth or grimace Ask patient to close both eyes and extend both arms out straight for 10 seconds Have the patient say the words, “The sky is blue in Cincinnati” INTERPRETATION Normal: Symmetrical smile or face Abnormal: Asymmetry (one side droops or does not move) Normal: Both arms move symmetrically or do not move Abnormal: One arm drifts down or arms move asymmetrically Testing with patient holding palms upward is most sensitive way to check. Patients with arm weakness will tend to pronate (turn from palms up to sideways or palms down). Normal: The correct words are used and no slurring of words is noted Abnormal: If the patient slurs words, uses the wrong words, or is unable to speak (aphasia) §57 General Treatment Guidelines G16–GENERAL TRAUMA—GENERAL SPINAL MOTION RESTRICTION As indicated EARLY TRANSPORT Limit scene time to less than 10 minutes when possible. Load and go if high risk. OXYGEN WOUND/GENERAL CARE Consider NEEDLE THORACOSTOMY IV Consider FLUID BOLUS BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% Place splints, cold packs, dressings and pressure on bleeding sites as needed. Keep patient warm— minimize exposure after assessment Evaluate for and treat tension pneumothorax if indicated TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS. Fluid resuscitation appropriate in adults if: • Head injury and hypotension (BP < 90 or unable to detect peripheral pulses) • No head injury but markedly hypotensive and unable to converse due to shock Administer 250–500 ml NS, recheck vitals. Titrate to presence of peripheral pulses. BLOOD GLUCOSE CARDIAC MONITOR In pediatric patients with signs of poor perfusion or shock: Pediatric—20 ml/kg NS. If continued poor perfusion, may repeat X2 Test if GCS less than 15. See Altered Level of Consciousness (G2). 58§ General Treatment Guidelines G16–GENERAL TRAUMA—GENERAL INDICATIONS AND PRECAUTIONS FOR FENTANYL USE Fentanyl may be used for relief of pain in the absence of head trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in elderly patients. FENTANYL IV See precautions above • Adult—50–200 mcg IV in 25–50 mcg increments. Titrate to pain relief and systolic BP greater than 100. Pediatric —1 mcg/kg IV—See Pediatric Drug Chart FENTANYL Intranasal See precautions above If no IV access: • Adult—100 mcg intranasal—may repeat once in 15 minutes Pediatric—1.5 mcg/kg intranasal—See Pediatric Drug Chart FENTANYL IM See precautions above IF no IV access and intranasal route not suitable: • Adult—50–100 mcg IM—may repeat in 15 minutes Pediatric—1 mcg/kg IM—See Pediatric Drug Chart Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment Consider ations • ALS procedures in the field (IV or advanced airway) do not improve outcome in critical trauma patients • IV starts should be done en route on these patients • Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers • Repeated IV attempts in non-critical pediatric patients should be avoided Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §59 General Treatment Guidelines G16–GENERAL AIRWAY CONTROL VENTILATION CONTROL HEMORRHAGE TREAT HYPOTENSION PATIENT POSITION Consider ONDANSETRON TRAUMA–HEAD INJURY • Basic airway management is preferred unless unable to manage with BLS maneuvers. Utilize jaw thrust technique to open airway. • Intubation in head injury patients is best addressed at the hospital or with RSI (aeromedical capability) • King Airway should be used only in arrest unless no other method to ventilate • Avoid hyperventilation if BVM used or patient with advanced airway. • Support respiratory rate to 10–12 per minute if slow. • Monitor patient with pulse oximetry and end-tidal CO2. Ideal ETCO2 is 35 mm Hg—may be unreliable if multiple system trauma or poor perfusion. • In patients with a dilated pupil on one side or decerebrate/ decorticate posturing indicating impending brainstem herniation, modest hyperventilation (rate of 12–16 per minute) is appropriate (keep ETCO2 30 or above) Scalp hemorrhage can be life threatening. Treat with direct pressure and pressure dressing. In adult patients, in the setting of hypotension (systolic BP 90 or less or absence of peripheral pulses), administer NS 250–500 ml. Repeat if necessary. In pediatric patients with signs of poor perfusion or shock: Pediatric—20 ml/kg NS. If continued poor perfusion, may repeat X 2 Elevate head 30 degrees unless contraindicated. Position patient on side if needed for vomiting/airway protection Adults—for vomiting/nausea, 4 mg IV/IM. May repeat every 10 minutes to a total dose of 12 mg. Pediatric—Limited to patients 4 years of age or older—4 mg IV/IM. For patients 40 kg and greater only, may repeat every 10 minutes to a total dose of 12 mg 60§ General Treatment Guidelines G16–GENERAL Consider TOURNIQUET DISLOCATION AMPUTATIONS PAIN RELIEF TRAUMA–EXTREMITY If vigorous hemorrhage not controlled with elevation and direct pressure on wound. May be used in pediatric patients. May be appropriate for hemorrhage control in multi-casualty situations. If dislocation suspected or noted, splint in position found • For partial amputations, splint in anatomic location and elevate extremity • If complete amputation, place amputated part in a dry container or bag and place on ice. Seal or tie off bag and place in second container or bag. DO NOT place amputated part directly on ice or in water. Elevate extremity and dress with dry gauze. Consider Fentanyl as directed in G16 Trauma—General Guideline CRUSH INJURY SYNDROME • Caused by muscle crush injury and cell death. Most patients have an extensive area of involvement such as a large muscle mass in a lower extremity and/or pelvis. May develop after 1 hour in severe crush, but usually requires at least 4 hours of compression • Hypovolemia and hyperkalemia may occur, particularly in extended entrapments • Hyperkalemia should be suspected if ECG monitor reveals peaked ‘T’ waves, absent ‘P’ waves or widened QRS complexes FLUID BOLUS IF ECG CHANGES SUGGEST HYPERKALEMIA: 20 ml/kg NS prior to release of compression ALBUTEROL—5 mg in 6 ml NS continuously via nebulizer CALCIUM CHLORIDE—1 gm slow IV over 60 seconds. Note: Flush tubing after administration of calcium chloride to avoid precipitation with sodium bicarbonate SODIUM BICARBONATE—1 mEq/kg IV. Additionally, consider 1 mEq/kg added to IV 1L NS—use second IV line as other medications may not be compatible §61 General Treatment Guidelines VOMITING AND SEVERE NAUSEA G17–GENERAL Vomiting or nausea may be due to viral illness (gastroenteritis) or other medical conditions including acute coronary syndrome, stroke, head injury, or toxic ingestion. It may be associated with a number of painful abdominal conditions, and may also occur as a result of treatment of pain with Fentanyl. Consider OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% POSITION PATIENT Position patient to avoid aspiration NON-INVASIVE MEASURES Fresh air, oxygen, and removal of noxious odors may lessen nausea Consider IV TKO 12-LEAD ECG Consider FLUID BOLUS Cardiac ischemic events are often accompanied by gastrointestinal symptoms. 12-lead ECG appropriate in all patients age 35 and over. Consider if patient has prolonged history of vomiting or poor intake, if vital signs or exam suggest volume depletion (rapid pulse, low blood pressure, dry mucous membranes, poor skin turgor, or capillary refill greater than 2 seconds) • Adult—250–500 ml. Recheck vitals—may repeat X 1 Pediatric—20 ml/kg. Recheck vitals —may repeat X 1. 62§ General Treatment Guidelines G17–GENERAL Consider ONDANSETRON VOMITING AND SEVERE NAUSEA For severe nausea or persistent vomiting: • Adult—4 mg IV, IM, or po (oral disintegrating tablet–ODT). May repeat every 10 minutes to a total of 12 mg. Pediatric—limited to patients 4 years of age or older—4 mg IV, IM, or po (ODT). For patients 40 kg and greater only, may repeat every 10 minutes to a total of 12 mg NOTE: Administer IV dosage over 1 minute. Ondansetron is contraindicated if patient has a history of hypersensitivity to other similar drugs: dolasetron (Anzemet), granisetron (Kytril), or palonosetron (Aloxi) Related guidelines: Shock/Hypovolemia (A10), Pain Management (Non-Traumatic) (G10) Key Treatment Consider ations • Rapid administration of ondansetron has been associated with increased incidence of side effects—most notably syncope. Ondansetron must be administered intravenously over 1 minute • Rare side effects of ondansetron include headache, dizziness, tachycardia, sedation, hypotension, or syncope. Rarely QT prolongation has been seen (with higher doses and rapid administration) • Ondansetron can be used in pregnancy and with breast-feeding mothers • Oral disintegrating tablets should be handled with care as moisture may cause premature breakdown of tablets before administration • Oral disintegrating tablets can be placed on tongue and do not need to be chewed. Medication will dissolve and be swallowed with saliva Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose §63 General Treatment Guidelines G18–GENERAL INTERFACILITY TRANSFER OF STEMI PATIENTS Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional cardiac care require timely transfer. A scene time of 10 minutes or less at the sending facility is ideal. OXYGEN BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% MONITOR IV Maintain TKO or other existing flow rate PROMPT TRANSPORT Transfer for definitive care is the priority in STEMI patients Consider FENTANYL IV 50–200 mcg IV in 25–50 mcg increments (consider 25 mcg increments in elderly patients). Patients with STEMI often do not get complete relief with medication. Caution: If Inferior MI suspected, use 25–50 mcg increments and observe carefully for hypotension Key Treatment Consider ations Treatment during interfacility transfer varies from field approach to chest pain/ACS: • Confirmatory ECG for STEMI has been done by hospital and does not need repeat prior to transfer or en route to accepting facility • Nitroglycerin treatment is not required and generally ineffective in patients with confirmed STEMI • Aspirin or other anti-platelet treatment if indicated should be administered by sending hospital prior to patient departure • Patients generally will be directed directly to catheterization laboratory • Outcome in STEMI patients is directly related to timeliness of intervention to relieve coronary artery blockage. Minimizing time delay in transfer is essential. 64§ General Treatment Guidelines INTERFACILITY TRANSFER OF INTUBATED PATIENTS G19–GENERAL Patients requiring specialty care (most commonly trauma or neurosurgical care) may be transferred with an established endotracheal tube. Sedation may be required if patient agitation present because of risk of inadvertent extubation. NOTE: This treatment guideline pertains to sedation of intubated patients during interfacility transport only (not for patients with field response who are intubated). OXYGEN VENTILATION CARDIAC MONITOR END-TIDAL CO2 MONITORING PULSE OXIMETRY Consider MIDAZOLAM MONITOR PATIENT 100% As needed if patient with apnea or inadequate respiratory rate or effort • Continuous monitoring with waveform capnography is required and must be established prior to departure from sending facility. • Maintain end-tidal CO2 between 35 and 45. ETCO2 may not be reliable in patients with shock or significant lung injury. Maintain at least a minimum respiratory rate of 8–10 breaths per minute. For sedation in agitated or uncooperative patient: 2–5 mg IV in up to 2 mg increments. Repeat dosing with base contact only. Follow vital signs and ETCO2 closely. If Midazolam administered, anticipate potential respiratory depression. Key Treatment Consider ations • Some patients may need paralysis and require additional nursing or physician staff to administer these medications • If inadvertent extubation occurs, manage with basic airway maneuvers unless ventilation cannot be adequately maintained §65 General Treatment Guidelines G20–GENERAL INTERFACILITY TRANSFER OF STROKE PATIENTS Patients with acute stroke that may not qualify for thrombolytic therapy or that may not respond to thrombolytic therapy, necessitating transfer for potential interventional care OXYGEN CARDIAC MONITOR MONITOR VITAL SIGNS MONITOR IV PROMPT TRANSPORT BLS: Low flow unless ALOC/respiratory distress/shock ALS: Titrate to SpO2 of at least 94% • Monitor blood pressure and Glasgow Coma Scale at least every 15 minutes. • Use pulse oximetry—consider non-invasive endtidal carbon dioxide monitoring if any respiratory difficulty. Maintain TKO or other existing flow rate Transfer for definitive care is the priority in stroke patients. Minimizing time delay is essential. 66§ General Treatment Guidelines G20–GENERAL INTERFACILITY TRANSFER OF STROKE PATIENTS Key Treatment Consider ations • Stroke patients who are transferred may have already received thrombolytic therapy or may not have qualified for thrombolysis based on length of time from stroke onset or other medical contraindications • Ongoing administration of thrombolytic therapy requires additional qualified staff (nurse or physician) for transport • Thrombolytic therapy in stroke patients is associated with around a 6% incidence of symptomatic intracerebral hemorrhage, and around a 1% of serious hemorrhage elsewhere • Close monitoring is important. Significant changes in patient vital signs/ GCS during transport should be reported immediately to receiving facility staff as it may affect immediate treatment: • Hypotension may occur because of external or internal hemorrhage • Hypertension may be related to acute intracranial process or underlying disease • Respiratory depression or airway compromise may occur due to stroke or intracerebral hemorrhage • Decreasing level of consciousness may occur due to stroke or intracerebral hemorrhage Cardiac dysrhythmias may occur in stroke patients (bradycardia or tachyarrhythmia) Observe for external hemorrhage in patients with prior administration of thrombolytics. Place direct pressure if hemorrhage noted. Related guidelines: Shock/Hypovolemia (A10), Altered level of consciousness (G2), Respiratory Depression or apnea (G12) §67 General Treatment Guidelines 68§ table of contents—pediatric treatment guidelines P1–PEDIATRIC PATIENT CARE........................................................................................................70 P2–APPARENT LIFE-THREATENING EVENT (ALTE)..................................................................71 P3–CARDIAC ARREST—INITIAL CARE AND CPR.............................................................72–73 P4–NEONATAL CARE AND RESUSCITATION.....................................................................74–75 P5–VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA........76–77 P6–PULSELESS ELECTRICAL ACTIVITY/ASYSTOLE..........................................................78–79 P7–SYMPTOMATIC BRADYCARDIA............................................................................................ 80 P8–TACHYCARDIA....................................................................................................................82–83 P9–SHOCK................................................................................................................................. 84–85 §69 Pediatric Treatment Guidelines P1–PEDIATRIC PEDIATRIC PATIENT CARE Pediatric patient is defined as age 14 or less. Neonate is 0–1 month. These basic treatment concepts should be considered in all pediatric patients SCENE SAFETY BSI SYSTEMATIC ASSESSMENT DETERMINE PRIMARY IMPRESSION BASE CONTACT TRANSPORT MONITORING DOCUMENT Use universal blood and body fluid precautions at all times • Management and support of ABCs are a priority • Identify pre-arrest states • Assure open and adequate airway • Place in position of comfort unless condition mandates other position • Consider spinal motion restriction if history or possibility of traumatic injury exists • Assess environment to consider possibility of intentional injury or maltreatment • Apply appropriate field treatment guidelines • Explain procedures to family and patient as appropriate • Provide appropriate family support on scene • Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines is considered • Use SBAR to communicate with base • Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure • Transport patient medications or current list of patient medications to the hospital • Give report to receiving facility using SBAR • At a minimum, vital signs and level of consciousness should be re-assessed every 15 minutes and should be assessed after every medication administration or following any major change in the patient’s condition • For critical patients, more frequent vital signs should be obtained when appropriate Document patient assessment and care per policy 70§ Pediatric Treatment Guidelines P2–PEDIATRIC APPARENT LIFE-THREATENING EVENT (ALTE) An Apparent Life-Threatening Event (ALTE) is an event that is frightening to the observer (may think the infant has died) and involves some combination of apnea, color change, marked change in muscle tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with symptoms described under 2 years of age may be considered an ALTE. Most patients have a normal physical exam when assessed by responding personnel. Approximately half of the cases have no known cause, but the remainder of cases have a significant underlying cause such as infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS. Because of the high incidence of problems and the normal assessment usually seen, there is potential for significant problems if the child's symptoms are not seriously addressed. OBTAIN DETAILED HISTORY ASSESSMENT TREATMENT TRANSPORT • Obtain history of event, including duration and severity, whether patient awake or asleep at time of episode, and what resuscitative measures were done by the parent or caretaker • Obtain past medical history, including history of chronic diseases, seizure activity, current or recent infections, gastroesophageal reflux, recent trauma, medication history • Obtain history with regard to mixing of formula if applicable Perform comprehensive exam, including general appearance, skin color, interaction with environment, or evidence of trauma Treat identifiable cause if appropriate If treatment/transport is refused by parent or guardian, contact base hospital to consult prior to leaving patient. Document refusal of care. §71 Pediatric Treatment Guidelines P3–PEDIATRIC ESTABLISH TEAM LEADER CONFIRM ARREST COMPRESSIONS AED OR MONITOR/ DEFIBRILLATOR CARDIAC ARREST— INITIAL CARE AND CPR • First agency on scene assumes leadership role • Leadership role can be transferred as additional personnel arrive • Unresponsive, no breathing or agonal respirations, no pulse • Begin compressions at a rate of 100–120 per minute. Use metronome. • Compress chest approximately 1/3 of AP diameter of chest: • In children (age 1–8)—around 2 inches • In infants (under age 1)—around 1 1/2 inches • Allow full chest recoil (lift heel of hand) • Change compressors every 2 minutes • Minimize any interruptions in compressions. If necessary to interrupt, limit to 10 seconds or less. • Do not stop compressions while defibrillator is charging • Resume compressions immediately after any shock • Apply pads while compressions in progress • Determine rhythm and shock, if indicated • Follow specific treatment guideline based on rhythm BASIC AIRWAY • Open airway—For 2-person CPR: • Provide 2 breaths: 30 compressions for children MANAGEMENT AND over age 8 VENTILATION • Provide 2 breaths: 15 compressions for infants > 1 month & children to age 8 • Avoid Excessive Ventilation • Ventilations should last one second each, enough to cause visible chest rise • Use 2-person BLS Airway management (one holding mask and one squeezing bag) 72§ Pediatric Treatment Guidelines P3–PEDIATRIC MEDICATIONS AND DEFIBRILLATION ADVANCED AIRWAY MANAGEMENT and END-TIDAL CO2 MONITORING BLOOD GLUCOSE PREVENT HYPOTHERMIA TRANSPORT CARDIAC ARREST— INITIAL CARE AND CPR • Use length-based tape to determine weight • If child is obese and length-based tape used to determine weight, use next highest color to determine appropriate equipment and drug dosing • See Pediatric Drug Chart for medication dose and defibrillation energy levels For patients 40 kg or greater only: • Placement of advanced airway is not a priority during the first 5 minutes of resuscitation unless no ventilation is occurring with basic maneuvers. • Placement of endotracheal tube or King Airway should not interrupt compressions for a period of more than 10 seconds • For endotracheal intubation, position and visualize airway prior to cessation of CPR for tube passage. • Confirm tube placement and provide ongoing monitoring using end-tidal carbon dioxide monitoring Treat if indicated. Glucose may be rapidly depleted in pediatric arrest. Move to warm environment and avoid unnecessary exposure • Pediatric arrest victims are at risk for hypothermia due to their increased body surface area, exposure and can be exacerbated by rapid administration of IV/IO fluids Consider rapid transport to definitive care §73 Pediatric Treatment Guidelines P4–PEDIATRIC NEONATAL CARE AND RESUSCITATION WARM PATIENT CLEAR AIRWAY DRY AND STIMULATE EVALUATE RESPIRATIONS, HEART RATE AND COLOR REASSESS/BEGIN CPR IF INDICATED Provide warmth—move to warm environment immediately If needed, position airway or suction. Rapidly suction secretions from mouth or nares. Dry child thoroughly, stimulate, reposition if needed, place hat on infant • If breathing, heart rate above 100 and pink, observational care only • If breathing, heart rate above 100 and central cyanosis—OXYGEN 100% by mask—reassess in 30 seconds • If cyanosis resolves (skin pink)—observational care only • If persistent central cyanosis after oxygen, initiate bag mask ventilation at rate of 40–60/minute • If apneic, gasping, or heart rate below 100—initiate bag mask ventilation at a rate of 40–60/minute with OXYGEN 100%—reassess in 30 seconds • If heart rate increases to above 100 and patient ventilating adequately, discontinue bag mask ventilation and continue close observation • If heart rate persists below 100 continue bag mask ventilation If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR (3:1 ratio— 90 compressions and 30 ventilations/minute). Reassess in 30 seconds. 74§ Pediatric Treatment Guidelines P4–PEDIATRIC NEONATAL CARE AND RESUSCITATION If heart r ate remains less than 60 despite adequate ventilation and chest compressions: IV/IO EPINEPHRINE Consider FLUID BOLUS TKO. 100–500 ml NS bag (use care to avoid inadvertent fluid administration). Do not delay transport for IV or IO access. 1:10,000–0.01 mg/kg IV or IO. Repeat every 3–5 minutes if heart rate remains below 60. 10 ml/kg NS IV or IO. May repeat once if needed. Consider NALOXONE 0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if long-term use of opioids during pregnancy known or suspected. Key Treatment Consider ations • For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant • Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not breathing or crying or if newborn does not have good muscle tone Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §75 Pediatric Treatment Guidelines VENTRICULAR FIBRILLATION P5–PEDIATRIC PULSELESS VENTRICULAR TACHYCARDIA INITIAL CARE DEFIBRILLATION CPR BVM VENTILATION IO or IV DEFIBRILLATION EPINEPHRINE DEFIBRILLATION AMIODARONE TRANSPORT See Cardiac Arrest—Initial Care and CPR (P3) 2–4 joules/kg • Use manual defibrillator if available • If AED utilized, use pediatric pads if available. Adult pads may be used with usual placement position if pads do not touch. Adult pads may be placed anterior-posterior if usual placement would cause the pads to touch. For 2 minutes or 5 cycles between rhythm check For patients 40 kg and over, defer advanced airway unless BLS airway inadequate TKO. Should not delay defibrillation or interrupt CPR. 4 joules/kg 1:10,000–0.01 mg/kg IV or IO every 3–5 minutes 4 joules/kg. Higher energy levels may be considered— not to exceed 10 joules/kg or the adult maximum. 5 mg/kg IV or IO If Return of Spontaneous Circulation—see guidelines for Shock (P9) if treatment indicated 76§ Pediatric Treatment Guidelines VENTRICULAR FIBRILLATION P5–PEDIATRIC PULSELESS VENTRICULAR TACHYCARDIA Key Treatment Consider ations • Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. • To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) • Avoid excessive ventilation with BLS airway management, which may cause gastric distention and limit chest expansion. Provide breaths over 1 second, with movement of chest wall as guide for volume needed. • If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation • Confirm placement of advanced airway with end-tidal carbon dioxide measurement. Continuous monitoring with ETCO2 is mandatory—if values less than 10 mm Hg seen, assess quality of compressions for adequate rate and depth. Rapid rise in ETCO2 may be the earliest indicator of return of circulation. • Prepare drugs before rhythm check and administer during CPR • Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) • Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication dose and defibrillation energy levels. • Transmit “ALL” data to the monitor site identified by your provider agency §77 Pediatric Treatment Guidelines PULSELESS ELECTRICAL ACTIVITY/ ASYSTOLE P6–PEDIATRIC INITIAL CARE BVM VENTILATION IV OR IO EPINEPHRINE See Cardiac Arrest—Initial Care and CPR (P3) Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate TKO 1:10,000–0.01 mg/kg IV or IO every 3–5 minutes Consider treatable causes—treat if applicable: Consider FLUID BOLUS VENTILATION Consider WARMING MEASURES Consider NEEDLE THORACOSTOMY BASE CONTACT 20 ml/kg NS—may repeat X 2 for hypovolemia Ensure adequate ventilation (8–10 breaths per minute) for hypoxia For hypothermia For tension pneumothorax To determine treatment for other identified potentially treatable causes—Hydrogen Ion (Acidosis), Hyperkalemia, Toxins If Return of Spontaneous Circulation—see guidelines for Shock (P9) if treatment indicated 78§ Pediatric Treatment Guidelines P6–PEDIATRIC PULSELESS ELECTRICAL ACTIVITY/ ASYSTOLE Key Treatment Consider ations • Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway management and administration of medications • If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for ventilation • Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second • Prepare drugs before rhythm check and administer during CPR • Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. • Transmit “ALL” data to the monitor site identified by your provider agency §79 Pediatric Treatment Guidelines P7–PEDIATRIC SYMPTOMATIC BRADYCARDIA • 90% of pediatric bradycardias are related to respiratory depression and respond to support of ventilation • Only unstable, severe bradycardia causing cardiorespiratory compromise will require further treatment • Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill, hypotension, respiratory difficulty, altered level of consciousness OXYGEN CARDIAC MONITOR IV or IO Consider CPR EPINEPHRINE BLS: High flow initially ALS: Titrate to SpO2 of at least 94% TKO. Use IO only if patient unstable and requires medication. Use 100–500 ml NS bag. If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation, perform CPR 1:10,000–0.01 mg/kg IV or IO. Repeat every 3–5 minutes. SAFETY WARNING: Atropine should be considered only after adequate oxygenation/ventilation has been ensured Consider ATROPINE 0.02 mg/kg IV, IO (0.1 mg minimum dose). Maximum single dose 0.5 mg. If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO Key Treatment Consider ations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. 80§ Pediatric Treatment Guidelines §81 Pediatric Treatment Guidelines P8–PEDIATRIC TACHYCARDIA Sinus tachycardia is by far the most common pediatric rhythm disturbance UNSTABLE SINUS TACHYCARDIA (narrow QRS less than or equal to 0.09) • ‘P’ waves present/normal, variable R-R interval with constant P-R interval • Unstable sinus tachycardia is usually associated with shock and may be pre-arrest UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less or equal to 0.09) • ‘P’ waves absent/abnormal, heart rate not variable • History generally vague, non-specific and/or history of abrupt heart rate changes • Infants’ rate usually greater than 220 bpm, Children (ages 1–8) rate usually greater than 180 bpm UNSTABLE—POSSIBLE VENTRICULAR TACHYCARDIA—(Wide QRS greater than 0.09 sec) • In some cases, wide QRS can represent supraventricular rhythm INITIAL THER APY— ALL TACHYCARDIA RHYTHMS OXYGEN CHECK PULSE and PERFUSION CARDIAC MONITOR IV or IO FLUID BOLUS BLS: Low flow unless ALOC/respiratory distress/shock. ALS: Titrate to SpO2 of at least 94%. Be prepared to support ventilation. Determine stability: • Stable—Normal perfusion: Palpable pulses, normal LOC, normal capillary refill, and normal BP for age • Unstable—Poor perfusion: ALOC, abnormal pulses, delayed cap. refill, difficult/unable to palpate BP. If unstable, transport early and treat as below. Run strip to evaluate QRS Duration TKO. Use 100–500 ml bag NS 20 ml/kg NS if hypovolemia suspected. May repeat X1 82§ Pediatric Treatment Guidelines P8–PEDIATRIC TACHYCARDIA UNSTABLE SUPR AVENTRICULAR TACHYCARDIA (narrow QRS less or equal to 0.09) VAGAL MANEUVERS Consider if will not result in treatment delays. ICE PACK to face of infant/child. BASE CONTACT SYNCHRONIZED CARDIOVERSION If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT delay cardioversion to obtain IV or IO access or sedation. ADENOSINE Consider SEDATION SYNCHRONIZED CARDIOVERSION For all treatments listed below: 0.1 mg/kg rapid IV push followed by 10–20 ml NS flush (maximum dose 6 mg). If not converted, 0.2 mg/kg rapid IV push followed by 10–20 ml NS flush (maximum dose 12 mg) Consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) 0.5–1 joule/kg. If not effective, repeat at 2 joules/kg. UNSTABLE—POSSIBLE VENTRICULAR TACHYCARDIA (Wide QRS greater than 0.09 sec) BASE CONTACT Consider SEDATION If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) SYNCHRONIZED CARDIOVERSION SYNCHRONIZED CARDIOVERSION For all treatments listed below: Prepare for CARDIOVERSION while attempting IV/IO access, but do not unduly delay care for IV access or medications 0.5–1 joule/kg. If not effective, repeat at 2 joules/kg. Key Treatment Consider ations • Early transport appropriate in unstable patients. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. §83 Pediatric Treatment Guidelines P9–PEDIATRIC SHOCK • Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2 seconds; tachycardia; blood pressure less than 70 systolic • Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may indicate sepsis, meningitis OXYGEN PREVENT HYPOTHERMIA CARDIAC MONITOR BLS/ALS: High flow. Be prepared to support ventilations as needed. Move to warm environment. Avoid unnecessary exposure. EARLY TRANSPORT CODE 3 FLUID BOLUS 20 ml/kg NS—may repeat X2 IV or IO BLOOD GLUCOSE Check and treat if indicated Related guidelines: Altered level of consciousness (G2), Tachycardia (P8) 84§ Pediatric Treatment Guidelines P9–PEDIATRIC SHOCK Key Treatment Consider ations Successful pediatric resuscitation relies on early identification of the pre-arrest state • Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates compensated shock in children • Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure • Systolic blood pressure in children may not drop until the patient is 25–30% volume depleted. This may occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis) • Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children • Sinus tachycardia is the most common cardiac rhythm encountered • Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1–8) or greater than 220 in infants • Hypoglycemia may be found in pediatric shock, especially in infants • Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose §85 Pediatric Treatment Guidelines 86§ table of contents—ems policy summaries Policy 9–DESTINATION DETERMINATION—BASIC PROCEDURE.................................... 89 Policy 9–DESTINATION DETERMINATION—5150/OBSTETRIC........................................ 90 Policy 9–DESTINATION DETERMINATION—DIALYSIS/ROSC/BURN..............................91 Policy 10–DECLINING MEDICAL CARE OR TRANSORT (AMA)...........................................92 Policy 13–TRAUMA TRIAGE—ACTIVATION CRITERIA............................................................93 Policy 13–TRAUMA TRIAGE—DESTINATION CRITERIA.................................................94–95 Policy 19–DETERMINATION OF DEATH.................................................................................... 96 Policy 20–DNR AND POLST ORDERS..........................................................................................97 Policy 23–ABUSE REPORTING RESPONSIBILITIES...........................................................98–99 Policy 30–RESTRAINTS................................................................................................................100 Policy 33c–HELICOPTER TRANSPORT CRITERIA................................................................... 101 Policy 36–HAZARDOUS MATERIALS—EXPOSURE MANAGEMENT................... 102–103 Policy 39–911 ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS...........................................................................................104–105 §87 Policy Summaries 88§ Policy Summaries EMS POLICY 9 SUMMARY DESTINATION DETERMINATION— BASIC PROCEDURE • Field personnel shall assess a patient to determine if the patient is unstable or stable • Patient stability must be considered along with a number of additional factors in making destination and transport code decisions FACTORS TO CONSIDER • Patient or family’s choice of receiving hospital and ETA to that facility • Recommendations from a physician familiar with the patient’s current condition • Patient’s regular source of hospitalization or health care • Ability of field personnel to provide field stabilization or emergency intervention • ETA to the closest basic emergency department • Traffic conditions • Hospitals with special resources • Hospital diversion status UNSTABLE PATIENTS • Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated • If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest. STABLE PATIENTS • Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient’s/family preference • If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered §89 Policy Summaries EMS POLICY 9 SUMMARY PATIENTS ON 5150 HOLDS OBSTETRIC PATIENTS DESTINATION DETERMINATION— 5150/OBSTETRIC A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable. Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center. Unstable patients on 5150 holds shall be transported to the closest acute care hospital: • A patient with a current history of overdose of medications is to be considered unstable • A patient with history of ingestion of alcohol/illicit street drugs is considered unstable if: • Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or • Significantly abnormal vital signs; or • Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis) A patient is considered “Obstetric” if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: • Patients in labor • Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy • Injured patients who do not meet trauma criteria or guidelines Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother’s life should be transported to the nearest basic emergency department Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy 90§ Policy Summaries EMS POLICY 9 SUMMARY DIALYSIS PATIENTS CARDIAC ARREST PATIENTS WITH ROSC DESTINATION DETERMINATION— DIALYSIS/ROSC/BURN Dialysis patients often require definitive care at a center that provides acute dialysis services. The preferable destination for this type of patient is the hospital at which the patient has received dialysis care (if applicable). Patients in extremis will need transport to the closest ED. Cardiac arrest patients who have return of spontaneous circulation (ROSC) should be transported to the closest STEMI Receiving Center. BURN PATIENT DESTINATION GENERAL DESTINATION PRINCIPLES PATIENT SELECTION FOR INITIAL TRANSPORT TO BURN CENTER PROCEDURE FOR BURN CENTER DESTINATION • Burned patients with unmanageable airways should be transported to the closest basic ED • Patients with minor burns and moderate burns can be cared for at any acute care hospital • Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center The following patients may be appropriate for initial transport to a Burn Center: • Partial thickness (2nd degree) greater than 20% TBSA • Full thickness (3rd degree) greater than 10% • Chemical or high voltage electrical burns • Smoke inhalation with external burns • Contact Burn Center prior to transport to confirm bed availability • Consult base hospital if any questions regarding destination decision §91 Policy Summaries EMS POLICY 10 SUMMARY DECLINING MEDICAL CARE OR TRANSPORT (AMA) All qualified persons are permitted to make decisions affecting care, including the ability to decline care PATIENT COMPETENCY QUALIFIED PERSON BASE CONTACT REQUIREMENTS Any person encountered by EMS personnel who demonstrates any known or suspected illness or injury OR is involved in an event with significant mechanism that could cause illness or injury OR who requests care or evaluation The ability to understand and to demonstrate an understanding of the nature of the illness/injury and the consequence of declining medical care A competent person making decision for him/herself or another qualified by: • An adult patient defined as a person who is at least 18 years old; • A minor (under 18 years old) who qualifies based on one of the following conditions: • A legally married minor; • A minor on active duty with the armed forces; • A minor seeking prevention / treatment of pregnancy or treatment related to sexual assault; • A minor, 12 years of age or older, seeking treatment of contact with an infectious, contagious or communicable disease or sexually transmitted disease; • A self-sufficient minor at least 15 years of age, living apart from parents and managing his/her own financial affairs; • An emancipated minor (must show proof); OR • The parent of a minor child or a legal representative of the patient (of any age). Spouses or relatives cannot consent to or decline care for the patient unless they are legally designated representatives. • When, in the field personnel’s opinion, patient’s decision to decline care poses a threat to his/her well being • If the patient’s competency status is unclear (neither competent nor clearly incompetent) and treatment or transport is felt to be appropriate • Any other situation in which, in the field personnel’s opinion, that base contact would be beneficial in resolving treatment or transport issues 92§ Policy Summaries EMS POLICY TRAUMA ACTIVATION CRITERIA 13 SUMMARY (DIRECT TRAUMA CENTER TRANSPORT) The following meet activation criteria and merit direct transport to the trauma center: PHYSIOLOGIC CRITERIA • BP < 90 in adults • GCS 13 or below if not pre-existing ANATOMIC CRITERIA • Penetrating injury to head, neck, torso, groin, pelvis or MECHANISM CRITERIA COMBINED CRITERIA (COMBINED MECHANISM AND PHYSICAL FINDINGS) buttocks • Fracture of femur • Fracture of long bone(s) resulting from penetrating trauma • Traumatic Paralysis • Amputation above wrist or ankle • Major burns associated with trauma • Crushed, mangled, or degloved extremity • Motor vehicle crash with: • Extrication > 20 minutes • Fatalities in the same vehicle • Ejection • Unrestrained motor vehicle crash with: • Head on mechanism > 40 mph • Extrication required • Fall 15 feet or greater • Auto vs. pedestrian/bicyclist thrown, run over, or struck with significant impact (>20 mph) Note: In the absence of significant symptoms or physical findings with these mechanisms, call base hospital for destination determination • Motorcycle crash with: • Abdominal or chest tenderness, or • Suspected loss of consciousness • Unrestrained motor vehicle crash with abdominal tenderness Note: Patients with unmanageable airways or traumatic arrest not meeting field determination criteria should be transported to the closest receiving facility. §93 Policy Summaries EMS POLICY 13 SUMMARY BASE CONTACT REQUIRED FOR DESTINATION DETERMINATION MECHANISMS OF INJURY TRAUMA— DESTINATION CRITERIA If not meeting activation criteria (direct transport), base contact should be made in the following situations to determine destination: • High-energy mechanisms of injury • Low-energy mechanisms with risk factor(s) and/or symptoms/physical findings • Uncertain mechanism with risk factor(s) and/or symptoms/physical findings • EMS Provider Concern High-energy mechanisms include: • Motor vehicle crash with one or more of the following: • Intrusion of passenger space by one foot or greater • Impact estimated 40 mph or greater • Person requiring disentanglement • Vehicle rollover with unrestrained occupant • Person struck by vehicle (less than 20 mph) • Person ejected from moving object (motorcycle, horse, etc.) • Blunt assault with weapon (e.g. pipe, bat) Lower energy mechanisms of injury include: • Ground level or short fall • Blunt assault without weapon • Lower-speed motor vehicle crash • Other blunt trauma (e.g. sports injury) Other: • Uncertain trauma mechanism but trauma suspected • Patients with trauma remote to time of EMS call (e.g. several hours) 94§ Policy Summaries EMS POLICY 13 SUMMARY RISK FACTORS SYMPTOMS AND PHYSICAL FINDINGS TRAUMA—DESTINATION CRITERIA • Age 60 and over • Patient taking anticoagulants or known bleeding disorder • Pregnancy over 20 weeks • Communication barrier with patient (e.g. age, language, psychiatric or developmental issues) Significant signs or symptoms of injury, including: Vital Signs: • Any concerns due to hypotension, tachycardia, or tachypnea • Systolic BP under 110 in patient age 60 or over • Pain level greater than 5 related to torso, head or neck injury Head Injury: • Loss of consciousness • Repetitive questioning • Abnormal or combative behavior • New onset of confusion • Vomiting • Headache Torso Injury: • Tenderness to palpation of abdomen, chest/ribs or back/flank • Suspected hip dislocation or pelvis injury §95 Policy Summaries EMS POLICY 19 SUMMARY OBVIOUS DEATH MEDICAL ARREST DETERMINATION OF DEATH Pulseless, non-breathing patients with any of the following: • Decapitation, Total Incineration, Decomposition • Total destruction of the heart, lungs, or brain, or separation of these organs from the body • Rigor mortis or post-mortem lividity without evidence of hypothermia, drug ingestion, or poisoning. In patients with rigor mortis or post-mortem lividity: • Attempt to open airway, assess for breathing for at least 30 seconds; assess pulse for 15 seconds • Rigor, if present, should be noted in jaw and/or upper extremities • If any doubt exists, place cardiac monitor to document asystole in 2 leads for 1 minute • Mass casualty situations Definition: Cardiac arrest with total absence of observers or witness information; or cardiac arrest in which witness information states arrest occurred greater than 15 minutes prior to arrival of prehospital personnel and no resuscitative measures have been done. Procedure: • BLS personnel—Follow Public Safety defibrillation guideline • ALS personnel—Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole in 2 leads for 1 minute Does not apply if hypothermia, drug ingestion or poisoning is suspected TRAUMATIC ARREST Definition: Blunt or penetrating traumatic arrest Procedure: • BLS personnel—Follow Public Safety defibrillation guideline • ALS personnel—Do not initiate CPR; Assess for presence of apnea, pulselessness (no heart tones/no carotid or femoral pulses), document asystole or wide-complex pulseless electrical activity (PEA) at rate of 40 or less 96§ Policy Summaries EMS POLICY 20 SUMMARY DNR AND POLST ORDERS VALID DNR ORDERS • A California EMSA/CMA Prehospital DNR Form • A California/EMSA POLST form in which Section A (Do Not Attempt Resuscitation/DNR) has been chosen • An Advanced Health Care Directive (includes living will or Durable Power of Attorney for Health Care) presented by an agent of the patient empowered to make health care decisions for the patient • An EMS-approved standard DNR medallion/bracelet e.g. Medi-Alert • A DNR order in the medical record of a licensed healthcare facility (e.g. acute care hospital, skilled nursing facility, hospice or intermediate care facility) signed by a physician. Electronic physician orders are considered signed and will be honored. • A verbal DNR order given by the patient’s physician who is present at the scene COMPLYING WITH AN HONORED DNR ORDER • Verify identity of patient • Perform no life-saving measures • Cancel the responding ambulance COMPLYING WITH A • Verify identity of patient. Review section B. • If “Full Treatment” marked, patient receives full care POLST ORDER (NOT • If “Limited Additional Interventions” or “Comfort IN ARREST) NO VALID DNR ORDER PRESENT AND REQUEST MADE FOR NO RESUSCITATION Measures Only” is marked, no advanced airway should be done • Section C does not apply to pre-hospital setting If the patient presents with advanced or terminal disease and incomplete forms or no forms are presented and an immediate family member, agent, or conservator requests no resuscitation, resuscitative measures may be withheld if there is complete agreement of family and providers on scene. Immediate family members include spouse, domestic partner, adult child(ren) or adult sibling(s) of the patient. No base contact is required. If any question of circumstances or disagreement of family or providers, proceed with resuscitation. §97 Policy Summaries EMS POLICY 23 SUMMARY ABUSE REPORTING RESPONSIBILITIES EMS personnel are mandated reporters. Report when there is reason to suspect abuse, which may be of a physical, sexual, or financial nature, or may involve neglect or domestic violence toward a child, elder, or dependent adult. BASIC ACTIONS CHILD ABUSE REPORTING ELDER ABUSE REPORTING (LONG-TERM CARE FACILITY) • Notify the appropriate law enforcement agency immediately if the scene is unsafe or it is suspected that a crime has been committed • Make reasonable efforts to transport the patient to a receiving hospital for evaluation, and advise the receiving hospital staff of abuse/neglect suspicions • Document observations and findings on the patient care report • Contact the appropriate reporting agency by telephoning immediately or as soon as reasonably possible to provide a verbal report • Call Children & Family Services Screening Unit: (all numbers are 24 hours/day) at 1-877-881-1116 • Complete a Suspected Child Abuse Report Form within 2 working days (SS 8572) (available online at http://www.ag.ca.gov/childabuse/pdf/ss_8572.pdf ) If the alleged abuse has occurred in a long-term care facility: • Call Ombudsman Services of Contra Costa (925) 685-2070 to make a verbal report • 24-Hour Crisis Line: 1-800-231-4024 • Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/ entres/forms/English/SOC341.pdf 98§ Policy Summaries EMS POLICY 23 SUMMARY ELDER ABUSE REPORTING – (ALL OTHER SITES) SEXUAL ASSAULT DOMESTIC VIOLENCE ABUSE REPORTING RESPONSIBILITIES (CON'T) If the alleged abuse has occurred anywhere else (not at a long-term care facility): • Call Adult Protective Services (925) 646-2854 or 1-877-839-4347 to make a verbal report • Complete a Suspected Dependent Adult/Elder Abuse Form within 2 working days (SOC 341). Available at: http://www.dss.cahwnet.gov/cdssweb/ entres/forms/English/SOC341.pdf Sexual assault shall be reported as above in situations involving elder, dependent adult, child, or domestic violence. • It is recommended to transport patients who have been sexually assaulted to Contra Costa Regional Medical Center for evaluation and evidentiary exam; however, the patient may be transported to the receiving hospital of choice or if medically unstable to the most appropriate facility for medical care • Discourage any activity that would compromise evidence collection prior to transport such as bathing, brushing teeth, brushing hair, urinating, defecating or changing clothes • Reporting responsibilities are fulfilled by notifying the local law enforcement agency, and by reporting suspicions and patient findings to receiving hospital staff (if transported) §99 Policy Summaries EMS POLICY 30 SUMMARY RESTRAINT TYPES RESTRAINT ISSUES RESTRAINTS • Leather or soft restraints may be used during transport • Handcuffs may only be used during transport if law enforcement accompanies the patient in the ambulance. Patients may not be handcuffed to the gurney • Chemical restraint • Patients shall be placed in Fowler’s or Semi-Fowler’s position • Patients shall not be restrained in hogtied or prone position • Method of restraint should allow for monitoring of vital signs and respiratory effort and should not restrict the patient or rescuer’s ability to protect the airway should vomiting occur • Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes LAW ENFORCEMENT • Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive ROLE TRANSPORT ISSUES patients • Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds • Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel • Patients under arrest must be accompanied by law enforcement personnel • If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient • If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation. 100§ Policy Summaries EMS POLICY 33C SUMMARY HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA ARE MET TIME CRITERIA CLINICAL CRITERIA USE AND CANCELLATION • Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally 20–25 minutes in most cases. • Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival • Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met • Trauma patients who meet activation criteria according to EMS trauma triage policy, except for: • Stable patients with isolated extremity trauma • Patients with mechanism but no significant physical exam findings • Trauma patients who do not meet activation criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport • Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric • Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway) The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. Considerations for IC: • Patient need • Estimated ground transport time versus air response and transport • Proximity of a helispot or need for a helicopter/ ambulance rendezvous site • ETA of the helicopter §101 Policy Summaries EMS POLICY 36 HAZARDOUS MATERIALS— SUMMARY EXPOSURE MANAGEMENT PRINCIPLES HAZMAT RECOGNITION WHILE RESPONDING HAZMAT RECOGNITION WHILE ON SCENE If alerted to a known or suspected hazmat exposure prior to scene arrival: • Request from dispatch the location and safe route to staging area or IC • If no staging area, determine location and safe route to report to IC • Do not enter contaminated areas or approach contaminated patients until cleared to do so by Incident Commander or designee • Decontaminate patient—Appropriately trained personnel shall perform decontamination in a designated area • Obtain clearance from IC prior to transport • Obtain MSDS for chemical if available • After patient decontamination, provide care as indicated per treatment guidelines • Provide early alert to hospital—repeat decontamination may be needed If EMS personnel become aware that a patient in their care may have been contaminated by a unknown or suspected hazardous material: • EMS personnel should consider themselves contaminated • Minimize exposure by evacuating to an uphill/ upwind safe location • If in cloud, travel crosswind until out of cloud • Notify fire/medical dispatch and IC of exposure • Request Hazardous Materials response team through Sheriff’s Dispatch • Request backup Fire/Transport as needed for affected EMS personnel and patients 102§ Policy Summaries EMS POLICY HAZARDOUS MATERIALS— 36 SUMMARY EXPOSURE MANAGEMENT PRINCIPLES HAZMAT RECOGNITION WHILE ON SCENE (CONTINUED) HAZMAT RECOGNITION WHILE TRANSPORTING • Remain in safe area until Incident Commander arrives and provides further instructions • Prepare to be decontaminated • Decontaminate EMS personnel and patient(s)— Appropriately trained personnel shall perform decontamination in a designated area. If EMS personnel become aware while transporting that a patient may have been contaminated by a known or suspected hazardous material: • EMS personnel should consider themselves contaminated • Determine if safe to drive (e.g. rescuers with or without symptoms) • If not safe to drive, immediate decontamination is needed. Stop transport, notify Fire/Medical Dispatch and request CCHS HazMat response. Request Fire/Transport backup as needed. Protect from further exposure and prepare to be decontaminated. • If safe to drive (decontamination is not immediately indicated), proceed to hospital decontamination staging area. Alert hospital early of the HazMat situation. Request staging site if not known. Prepare to be decontaminated. GENERAL • Provide prehospital medical care as soon as it is safe GUIDELINES FOR ALL • All precautions should be taken to prevent SITUATIONS contamination of hospital emergency department and personnel §103 Policy Summaries POLICY 39 SUMMARY 9-1-1 ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS Criteria for upgrade to advanced life support (ALS) for non-emergency transport providers DEFINITIONS • Unstable: A patient who has life- or limb-threatening condition requiring immediate and definitive care. An unstable patient may have respiratory distress, airway compromise, neurological changes from baseline, signs of actual or impending shock or may meet criteria for transport directly to a trauma center. • Non-emergency ambulance provider: An ambulance provider holding a valid Contra Costa non-emergency ambulance permit • 9-1-1 ambulance provider: An ambulance provider holding a valid Contra Costa emergency ambulance permit and/or contracting with the County to provide advanced life support ambulance response to 9-1-1 requests • Code 3: Responding to a location and/or transporting to a receiving facility using red lights and sirens UNSTABLE PATIENTS • A patient, determined to be unstable and/or needing Code 3 transportation to a hospital shall be transported by a 9-1-1 provider, whenever possible. • Non-emergency ambulance providers may transport an unstable patient to the closest/appropriate facility, if they can do so safely and the time from arrival on scene to arrival at the hospital is less than 10 minutes. In all other cases the nonemergency ambulance crew shall activate the 9-1-1 system and request an ALS response. • Any non-emergency ambulance provider transporting a patient that becomes unstable during transport should divert to the closest/ appropriate ED per the Patient Destination Determination Policy (Policy #9). Receiving facilities should receive notification as soon as possible of the need for diversion, patient status and the ETA to that facility. • All transports by non-emergency ambulance providers of unstable patients, and/or transports requiring Code 3 transportation are considered an unusual occurrence. For each such occurrence an EMS Event report must be completed and submitted to the EMS Agency within 24 hours of the call. 104§ Policy Summaries POLICY 39 SUMMARY ON-VIEWS 9-1-1 ACTIVATION FOR NON-EMERGENCY TRANSPORT PROVIDERS • In the event that a non-emergency ambulance provider arrives on the scene of a collision, illness or injury by coincidence, the crew shall provide appropriate care and immediately activate the 9-1-1 system §105 Policy Summaries 106§ table of contents—procedures and patient care 12-LEAD—MONITORING AND LEAD PLACEMENT............................................................. 109 12-LEAD—LOCALIZING SITE OF INFARCT.............................................................................. 110 12-LEAD—STEMI RECOGNITION AND DESTINATION........................................................111 12-LEAD—STEMI REPORT............................................................................................................ 112 12-LEAD—TRANSMISSION OF MONITOR DATA.................................................................. 113 BLS AIRWAY MANAGEMENT.............................................................................................114–115 INTRAOSSEOUS INFUSION IN ADULTS.........................................................................116–117 INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE................................................ 118 INTRAOSSEOUS INFUSION—PROXIMAL AND DISTAL TIBIA.......................................... 119 INTRAOSSEOUS INFUSION IN CHILDREN.............................................................................. 120 KEY PROCEDURES................................................................................................................ 121–126 NON-INVASIVE MONITORING OF END-TIDAL CO2.......................................................... 127 OXYGEN THERAPY......................................................................................................................... 128 OXYGEN TITRATION AND PULSE OXIMETRY MONITORING........................................... 129 PAIN ASSESSMENT AND MANAGEMENT.............................................................................. 130 PAIN ASSESSMENT TOOLS.......................................................................................................... 131 PEDIATRIC ASSESSMENT............................................................................................................. 132 PEDIATRIC VITAL SIGNS/GLASGOW COMA SCALE............................................................ 133 PEDIATRIC MEDICATION ADMINISTRATION........................................................................ 134 RULE OF NINES—BURN SURFACE AREA................................................................................ 135 SEPSIS SCREENING........................................................................................................................ 136 SPINAL INJURY ASSESSMENT.................................................................................................... 137 SPINAL MOTION RESTRICTION (SMR).................................................................................... 138 VASCULAR ACCESS........................................................................................................................ 139 VENTRICULAR ASSIST DEVICES (VAD).................................................................................... 140 §107 Procedures and Patient Care Reference 108§ Procedures and Patient Care Reference 12-LEAD MONITORING AND LEAD PLACEMENT sternal angle Limb Lead Placement: • Place limb leads on distal extremities if possible • Confirm correct lead placement for each limb • May be moved to proximal if needed (if motion artifact) Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2nd ribs are adjacent) then count down to 4th interspace (below 4th rib) V1—4th intercostal space at the right sternal border V2—4th intercostal space at the left sternal border V4—5th intercostal space at left midclavicular line Note: Place V4 lead first to aid in correct placement of V3 V3—Directly between V2 and V4 V5—Level of V4 at left anterior axillary line V6—Level of V4 at left mid-axillary line IMPORTANT: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG 12-lead monitoring should continue throughout call to assess for potential changes. §109 Procedures and Patient Care Reference LOCALIZING SITE OF INFARCT • Localization of an infarct pattern adds to the accuracy of ECG interpretation • A STEMI will have 1 mm or more ST-segment elevation in 2 or more contiguous leads (which means findings noted in the same anatomical location of the infarct) • Contiguous leads for inferior infarction include II, III, and aVF • Contiguous leads for anterior infarction include V1–V4 (V1–V2 elevation also called septal infarction) • Contiguous leads for lateral myocardial infarction include Leads I, aVL, V5, and V6 • Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or inferolateral) I–LATERAL aVR V1–SEPTAL or ANTERIOR V4–ANTERIOR (V4R–RVMI) II–INFERIOR aVL–LATERAL V2–SEPTAL or ANTERIOR V5–LATERAL III– INFERIOR aVF–INFERIOR V3–ANTERIOR V6–LATERAL 110§ Procedures and Patient Care Reference STEMI RECOGNITION AND DESTINATION STEMI RECOGNITION • Patients who have ECGs of acceptable quality with the following messages are candidates for transport to STEMI Receiving Centers: • ***Acute MI Suspected*** (LIFEPAK 12) • ***Meets ST-Elevation MI Criteria*** (LIFEPAK15) • The 12-lead ECG should be inspected prior to initiation of a STEMI Alert—a steady baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation • Causes of artifact include patient motion or tremor, poor lead contact, or electrical interference • Good skin preparation is essential for optimal lead contact and clear 12-lead tracings • If artifact is noted the ECG should be repeated • Paced rhythms may cause false readings—the pacemaker spike is not always detected by the computer algorithm. Inform facility if patient has a pacemaker during report. STEMI REPORT If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon as possible following completion of the ECG DESTINATION POLICY Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC) • Patients shall be transported to the closest SRC unless they request another facility • A SRC that is not the closest facility is an acceptable destination if estimated additional transport time does not exceed 15 minutes • Patients with cardiac arrest and return of spontaneous circulation shall be transported to the closest SRC regardless of 12-lead results. • Patients with unmanageable airway en route shall be transported to the closest available emergency department §111 Procedures and Patient Care Reference STEMI REPORT • A patient with a computer interpretation of ***Acute MI Suspected*** (LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center • Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have significant baseline artifact or other deficit before initiating a STEMI Alert SITUATION BACKGROUND ASSESSMENT RX – RECAP • Identify the call as a “STEMI Alert” • Estimated time of arrival (ETA) in minutes • Patient age and gender • Report ECG computer interpretation has a STEMI message (as listed above) • Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no ***Acute MI*** findings noted in tracings without significant artifact) • Verify that 12-lead ECG Transmission has been completed and received • Presenting chief complaint and symptoms • Pertinent past cardiac history • History of pacemaker (important—paced rhythms may give false ECG interpretations) • General assessment • Pertinent vitals (especially heart rate and BP) and physical exam • Cardiac rhythm • Pain level • Prehospital treatments given • Patient response to prehospital treatments 112§ Procedures and Patient Care Reference TRANSMISSION OF MONITOR DATA • 12-Lead ECG transmission is an enhancement to the STEMI system that allows facilities to interpret 12-lead data prior to patient arrival, appropriately prepare, and appropriately activate resources when indicated • Transmission of cardiac arrest monitor data and data related to treatment of dysrhythmias and patient intubations allows appropriate documentation and review of care provided in those situations 12-Lead ECG Tr ansmission 12-LEAD TRANSMISSION IDENTIFIERS HOSPITAL NOTIFICATION REVIEW • Any 12-Lead ECG that indicates that a patient is having a STEMI should be transmitted to the STEMI receiving center where the patient is being transported • For other patients who have 12-Lead ECGs done, at least one should be transmitted to the destination hospital or other monitor site identified by your provider agency At a minimum, 12-Lead ECG labeling should include initials of the first and last name of the patient. Provider agencies may require additional labeling Once a STEMI 12-Lead has been transmitted to a STEMI receiving facility, that facility should be notified as soon as possible following the transmission of the ECG to verify receipt and to complete STEMI alert Not all hospitals have ability to review transmitted ECGs and some may filter out normal or non-acute appearing ECGs. Hard copies of ECGs also must be left at all receiving facilities. Tr ansmission of Cardiac Arrest and Other Monitor Data INDICATIONS FOR TRANSMISSION TRANSMISSION REVIEW • Cardiac arrests • Any calls that involve the treatment of a cardiac dysrhythmia (medication, cardioversion or pacing) • Any call involving monitoring of intubated patients • Any other call in which the paramedic believes data review may add to PCR documentation of events • Transmit "ALL" data to the monitor site identified by your provider agency • This data is transmitted to the provider agency and to EMS for review but does not go to hospitals for immediate access. Code summaries should be printed and left at receiving facilities. Note: Optimally, a single monitor should be used to gather data, particularly with regard to cardiac arrest or continuous monitoring of intubated patients §113 Procedures and Patient Care Reference BLS AIRWAY MANAGEMENT GOALS The goal of airway management is to ensure adequate ventilation and oxygenation. Initial airway management should always begin with BLS Maneuvers VENTILATION RATES Avoid excessive ventilation. In non-arrest patients, AND DELIVERY ventilation rates: • Adults—10/minute • Children—20/minute • Infants—30/minute Deliver ventilations over one second to produce visible chest rise and to avoid distention of the stomach (do not squeeze hard or fast). Ventilation volumes will vary based on patient size. PREFERRED MANEUVERS Two-person technique is the preferred method to ventilate patients using bag-valve mask device Maneuvers—Use “JAWS” J—Jaw thrust maneuvers to open airway A—Airway—Use oral or nasal airway W—Work together—Ventilation using a bag-valve mask should include two rescuers—one to hold mask and other to deliver ventilations S—Slow and small ventilations to produce visible chest rise 114§ Procedures and Patient Care Reference BLS AIRWAY MANAGEMENT AIRWAY POSITIONING Position the patient to optimize airway opening and facilitate ventilations (see below) • Use the sniffing position with head extended (A) and neck flexed forward (B) unless suspected spinal injury • Position with head/shoulders elevated—anterior ear should be at the same horizontal level as the sternal notch (C). This is especially advantageous in larger or morbidly obese patients. C §115 Procedures and Patient Care Reference INTRAOSSEOUS INFUSION IN ADULTS INDICATIONS • Cardiac arrest • When IV access unsuccessful or after evaluation of potential sites it is determined that an IV attempt would not be successful in the setting of: • Shock or evolving shock, regardless of cause • Impending arrest or unstable dysrhythmia CONTRAINDICATIONS • Fracture of the targeted bone • IO within the past 48 hours in the targeted bone • Infection at the insertion site • Burns that disrupt actual bone integrity at insertion site • Inability to locate landmarks or excessive tissue over the insertion site • Previous orthopedic procedure near insertion site (prosthetic limb or joint) INSERTION SITE • Proximal humerus (preferred in patients with perfusing rhythm) • Proximal tibia • Distal tibia (if proximal humerus or tibia unavailable) PROCEDURE 1. Locate insertion site: • The proximal humerus site is the greater tubercle, identifiable as a prominence on the humerus when the arm is rotated inward and the patient’s hand is on the abdomen • The proximal tibia site is on the flat medial aspect of the tibia 2 finger-breadths below the lower edge of the patella and medial to the tibial tuberosity • The distal tibia site is 2 finger-breadths above the most prominent aspect of the medial malleolus (inside aspect of ankle) in the midline of the shaft of the tibia 2. Prep the insertion site with chlorhexidine and let air dry 3. Select and load the appropriately sized needle on the driver • For humeral access the 45 mm (yellow) needle is used except in adult patients less than 40 kg • For proximal and distal tibial access the amount of soft tissue should be gauged to determine if a 25mm (blue) or 45 mm (yellow) needle is appropriate 116§ Procedures and Patient Care Reference PROCEDURE INTRAOSSEOUS INFUSION IN ADULTS 4. Introduce the intraosseous needle through the skin as follows without pulling trigger of the power driver: • For humeral site, the direction of the needle should be placed perpendicular to the skin, directed at a downward angle of 45 degrees from the frontal plane, heading slightly downward toward the feet (see images); • For tibial sites, the direction of the needle should be at a 90 degree angle to the flat surfaces of the tibia (see images). 5. Once the needle has touched the bone surface, assess to see if the black line on the needle is visible. If it is not visible, either a larger needle is needed or (in the case of use of 45 mm needle) the soft tissue is too thick to allow use of the IO. 6. With firm pressure, insert needle using power driver. In most cases, the hub should be flush or touching the skin. Verify that needle is firmly seated in the bone (should not wobble). 7. Remove stylet and instill lidocaine if patient not in arrest: • For adult patients not in arrest, 40 mg (2 ml) of lidocaine 2% should be infused slowly over 1–2 minutes and allow one additional minute before starting flush. • For patients in arrest, no lidocaine is necessary initially but may be needed if patient regains consciousness. 8. Flush with 10 ml saline. In conscious patients, flush with 5 ml saline initially and repeat if necessary (may cause less patient discomfort). 9. Attach stabilizer to skin. 10. Attach IV tubing to intraosseous hub, and begin infusion using pressure bag on IV bag. 11. If painful, an additional 20 mg (1 ml) of lidocaine 2% can be infused over 30 seconds, and after another minute, infusion should be restarted. 12. Monitor site for swelling or signs of infiltration and monitor pulses distal to area of placement. 13. Place wristband included with IO set on patient. §117 Procedures and Patient Care Reference INTRAOSSEOUS INFUSION IN ADULTS—HUMERAL SITE 118§ Procedures and Patient Care Reference INTRAOSSEOUS INFUSION— PROXIMAL AND DISTAL TIBIA §119 Procedures and Patient Care Reference INTRAOSSEOUS INFUSION IN CHILDREN Indications and contraindications same as adult procedure. Use only proximal tibial site in children. PROCEDURE 1. Locate the insertion site—for pediatric patients the location of proximal tibial site is on the flat medial aspect of the tibia 2 finger-breadths below the lower edge of the patella and medial to the tibial tuberosity. 2. Prep the insertion site with chlorhexidine and let air dry. 3. Select and load the appropriately sized needle onto the driver: • The 15 mm (pink hub) needle is appropriate in infants or in small children with thin amounts of soft tissue in the proximal tibial site; 4. Introduce the intraosseous needle at a 90 degree angle to the flat surface of the tibia without pulling the trigger of the power driver. 5. Once the needle has touched the bone surface, assess to see if the black line on the needle is visible. If it is not visible, remove needle, switch to a longer needle set and reinsert (again without pulling the trigger of the power driver). 6. With mild to firm pressure, insert needle using power driver. For small children, once a “give” is sensed as the outer bony cortex is penetrated, remove finger from power driver trigger to stop insertion (do not withdraw driver when stopping). The IO hub may not be against the skin. 7. Remove stylet and instill lidocaine if patient not in arrest: • For pediatric patients not in arrest, 0.5 mg/kg of lidocaine 2% should be infused slowly over 1–2 minutes and allow one additional minute before starting flush. See pediatric drug chart for weight-based dose. • For patients in arrest, no lidocaine is necessary initially but may be needed if patient regains consciousness. 8. Flush with 5 ml saline 9. Attach stabilizer to skin 10. Attach IV tubing to intraosseous hub: • Utilize stopcock and syringe to administer appropriate fluid dose in smaller children • Pressure bag may be used in larger children (>50 kg). 11. Monitor site for swelling or signs of infiltration and monitor pulses distal to area of placement 12. Place wristband included with IO set on patient. 120§ Procedures and Patient Care Reference SKILL 12-Lead ECG KEY PROCEDURES INDICATIONS/CONTRAINDICATIONS/COMMENT INDICATIONS: • Chest pain or suspected Acute Coronary Syndrome (ACS) • Atypical ACS or anginal equivalents: • Symptoms include shortness of breath, diaphoresis, syncope, dizziness, weakness, and altered level of consciousness • Elderly patients, females and diabetics are more likely to present atypically • Dysrhythmias (both pre- and post-conversion) • Suspected cardiogenic shock • Cardiac arrest after return of spontaneous circulation CONTRAINDICATIONS: • Uncooperative patient • Any condition in which delay to obtain ECG would compromise immediately needed care (e.g. arrhythmia requiring immediate shock) AUTOPULSE (SRVFPD) INDICATIONS: • Cardiac Arrest in Adults CONTRAINDICATIONS: • Pediatric patients • Trauma patients • Patients too small or large for the compression band BLOOD GLUCOSE TESTING INDICATIONS: • Altered level of consciousness • Patients with signs and symptoms of hypoglycemia (may include diaphoresis, weakness, hunger, shakiness, anxiety) CONTRAINDICATIONS: • Patients not meeting any indication CO-OXIMETRY (CARBON MONOXIDE) INDICATIONS: • Suspected carbon monoxide poisoning CONTRAINDICATIONS: • None COMMENT: • May be unreliable with poor perfusion, excessive patient motion or excessive ambient light §121 Procedures and Patient Care Reference SKILL CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) ENDOTRACHEAL INTUBATION KEY PROCEDURES INDICATIONS/CONTRAINDICATIONS/COMMENT INDICATIONS: The patient is awake, able to maintain airway and follow commands and has 2 or more findings: • RR >25 • Pulse ox <94% • Use of accessory muscles CONTRAINDICATIONS: • Unconscious or unable to follow commands • Respiratory arrest / apnea • Pneumothorax • Vomiting • Major head, facial or chest trauma INDICATIONS: • Patient with decreased sensorium (GCS less than or equal to 8) and apneic (adults) • Patient with decreased sensorium (GCS less than or equal to 8) and ventilation unable to be maintained with BLS airway CONTRAINDICATIONS: • Pediatric patients under 40 kg • Suspected hypoglycemia or narcotic overdose • Maxillo-facial trauma with unrecognizable facial landmarks • Seizures • Patients with an active gag reflex COMMENT: • In non-arrest patients, allow no more than 2 interruptions of ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts • Monitor intubated patients continuously using end-tidal carbon dioxide waveform capnography (ETCO2) • Patients with perfusing pulses should be managed with BLS airways unless unable to successfully ventilate (e.g. trauma, respiratory insufficiency) 122§ Procedures and Patient Care Reference SKILL EXTERNAL CARDIAC PACING KEY PROCEDURES INDICATIONS/CONTRAINDICATIONS/COMMENT INDICATIONS: Symptomatic bradycardia CONTRAINDICATIONS: • Cardiac arrest • Hypothermia • Pediatric Patients COMMENT: Use careful titration with midazolam or fentanyl if required for relief of discomfort HELMET REMOVAL INDICATIONS: Helmet should be removed if: • Interferes with airway management or spinal motion restriction • Improper fit, allowing head to move within helmet • Patient in cardiac arrest CONTRAINDICATIONS: • Patient airway and spinal motion restriction can be addressed without helmet removal COMMENT: Face mask of sports helmets can be removed to facilitate easy airway access. If helmet removed, shoulder pads (if worn) must also be removed to maintain neutral spinal alignment IMPEDANCE THRESHOLD DEVICE (ITD)—ResQPOD (SRVFPD) INDICATIONS: Patients 9 years of age in cardiac arrest CONTRAINDICATIONS: • Age below 9 years • Perfusing pulse or spontaneously breathing • History of traumatic cardiac arrest due to blunt chest trauma • Flail chest COMMENT: • If secretions encountered, clear device by removing and shaking • Remove if patient resumes spontaneous breathing or regains perfusing pulse §123 Procedures and Patient Care Reference SKILL INTRANASAL NALOXONE KING AIRWAY LUCAS CHEST COMPRESSION SYSTEM KEY PROCEDURES INDICATIONS/CONTRAINDICATIONS/COMMENT INDICATIONS: • Patient with altered mental status, respiratory rate less than 12 and suspected opiate overdose CONTRAINDICATIONS: • Shock • Copious nasal secretions or bleeding • Patients with established vascular access COMMENT: May be less effective in patients with prior nasal mucosal damage INDICATIONS: • Cardiac arrest • Inability to ventilate non-arrest patient (with BLS airway maneuvers) in a setting in which endotracheal intubation is not successful or unable to be done CONTRAINDICATIONS: • Presence of gag reflex • Caustic ingestion • Known esophageal disease (e.g. cancer, varices, stricture) • Laryngectomy with stoma (place ET tube in stoma) • Height less than 4 feet INDICATIONS: Patients with medical cardiac arrest who properly fit device. CONTRAINDICATIONS: • Traumatic arrest • Pregnant Patients • Improper fit of device • Too small—suction cup pad does not touch chest when lowered as far as possible • Too large—support legs of LUCAS cannot be locked to back plate without compressing patient 124§ Procedures and Patient Care Reference SKILL NEEDLE THORACOSTOMY ORAL GLUCOSE STOMAL INTUBATION KEY PROCEDURES INDICATIONS/CONTRAINDICATIONS/COMMENT INDICATIONS: Signs and symptoms of tension pneumothorax: • Altered level of consciousness • Decreased BP • Increased pulse and respirations • Absent breath sounds, hyperresonance to percussion on affected side • Jugular venous distention • Difficulty ventilating • Tracheal shift CONTRAINDICATIONS: • Any condition without signs and symptoms of tension pneumothorax INDICATIONS: • Altered level of consciousness with known history of diabetes. Patient is conscious and should be able to sit in an upright position. CONTRAINDICATIONS: • Unconscious patient or unable to sit upright COMMENT: • Administer up to 30 grams in the patient’s mouth. Optimally the patient will self-administer. • If patient has difficulty swallowing, discontinue procedure and assure open airway INDICATIONS: Patients requiring intubation who have mature stoma and do not have a replacement tracheostomy tube available CONTRAINDICATIONS: Patients without mature stoma COMMENT: Pass tube until cuff is just past stoma. If inserted further, mainstem bronchus intubation may occur as carina is only around 10 cm from stoma. §125 Procedures and Patient Care Reference SKILL TOURNIQUET (COMBAT APPLICATION TOURNIQUET) KEY PROCEDURES INDICATIONS/CONTRAINDICATIONS/COMMENT INDICATIONS: • External hemorrhage from extremity that cannot be controlled with application of dressings with direct pressure • May be appropriate for use for hemorrhage control in multi-casualty settings CONTRAINDICATIONS: • Hemorrhage that can be controlled with pressure or dressings INDICATIONS: TRACHEOSTOMY TUBE REPLACEMENT • Dislodged tracheostomy tube (decannulation) • Tracheostomy tube obstruction not resolved by suction CONTRAINDICATIONS: • Recent tracheostomy surgery (less than 1 month) • Inadequately sized tract or stoma for insertion of new tube (use endotracheal tube instead) 126§ Procedures and Patient Care Reference NON-INVASIVE MONITORING OF END-TIDAL CO2 NON-INVASIVE ETCO2 MONITORING INDICATIONS FOR ETCO2 MONITORING ETCO2 FINDINGS • In patients without shock (normal perfusion), use of non-invasive end-tidal carbon dioxide measurement (ETCO2) can be valuable in monitoring respiratory rate and ventilation • ETCO2 measurements are an earlier indicator of respiratory depression than pulse oximetry • Patients at risk for inadequate ventilation may include: • Patients with borderline respiratory rates (8–12) from overdose or other cause (may help determine if naloxone appropriate) • Patients who have received medications such as fentanyl or midazolam that may depress respiratory rate. • Patients with chronic lung disease and chronic hypoxia—many patients have elevated ETCO2 levels to begin with and rapidly increasing levels may indicate that a patient has decreased respirations due to oxygen therapy (loss of hypoxic drive) • ETCO2 readings may be unreliable if there is shock or poor perfusion • Normal ETCO2 levels range from 32–36, but this may vary based on the patient’s underlying respiratory and metabolic status • ETCO2 levels that rise from a normal baseline to above 40 generally indicate hypoventilation is occurring • Patient stimulation, use of BVM, or use of naloxone may be appropriate based on the situation §127 Procedures and Patient Care Reference OXYGEN THERAPY OXYGEN SAFETY INITIAL INDICATIONS FOR OXYGEN BLS OXYGEN ADMINISTRATION OXYGEN DELIVERY • Oxygen has the potential to be harmful to patients —the general goal is to have normal oxygen levels (normoxemia)—high levels are not better than normal levels. When pulse oximetry can be used, an SpO2 of 94% is considered adequate. • Conditions in which high levels may be dangerous include stroke, patients who have return of circulation following cardiac arrest, and patients with severe chronic lung disease Supplemental oxygen is indicated in the following conditions: • Altered Level of Consciousness (e.g. overdose, seizure, stroke) • Cardiac Arrest • Chest Pain or other suspected cardiac problem (rapid or irregular pulse) • Respiratory Distress/Respiratory Depression or Apnea • Shock • Smoke or other chemical Inhalation • Suspected carbon monoxide exposure • Trauma (major) Follow specific treatment guidelines where applicable In general, patients in distress should receive high-flow oxygen initially • Chest pain and stroke patients without respiratory distress or shock should receive low-flow oxygen Low flow—Use nasal cannula with 4 L/min initial flow High-flow—Non-rebreather mask with 15 L/min flow Supplement with BVM if patient is apneic or has shallow respirations 128§ Procedures and Patient Care Reference OXYGEN TITRATION AND PULSE OXIMETRY MONITORING PULSE OXIMETRY PULSE OXIMETRY PITFALLS ALS OXYGEN TITRATION • Utilize pulse oximetry in all patients with oxygen therapy or suspected hypoxia • Pulse oximetry is a tool to measure oxygenation, but must be combined with other assessments and skills to determine best patient care • Pulse oximetry readings can be misleading with poor perfusion (shock) or cold extremities, hypothermia, anemia or in carbon monoxide poisoning. • Readings may be difficult to obtain or unreliable during with excessive patient movement (e.g.seizures) or if nail polish is present. • High flow oxygen should be maintained in patients with shock and in those with severe respiratory distress or profound hypoxia • In most conditions, titration of oxygen should occur to assure an SpO2 of at least 94% • Titration may involve decreasing the oxygen flow for either nasal cannula or non-rebreather masks, or switching from high to low flow devices • Stable patients without distress who have SpO2 readings of 94% or greater without therapy do not need supplemental oxygen • Some patients with chronic lung problems will not be able to attain an SpO2 of 94% and in fact may be at baseline with readings of 90% or less • The patient’s level of distress is an important finding in these cases—patients may be without distress at lower baseline levels and do not require high-flow oxygen §129 Procedures and Patient Care Reference PAIN ASSESSMENT AND MANAGEMENT Relief of pain and suffering is an important component of quality EMS field care. Pain assessment is the 5th vital sign and should be performed on each patient using an age appropriate pain scale. Pain is a subjective experience for the patient and should be treated following the appropriate pain treatment guideline. Patients in pain should be assessed before and after pain medication is administered. Appropriate efforts should be made to alleviate pain using both pharmacologic (e.g, Fentanyl, Nitroglycerin for cardiac cases) and nonpharmacologic (e.g., splinting, spinal motion restriction) measures. • Assess blood pressure, heart rate, respiratory rate and pain scale during initial assessment and 5 minutes after every medication administration • Assess pain using the same pain scale before and after pain administration and document • Dramatic drops in systolic blood pressure and respiratory rate can occur once pain is relieved. Administer medication cautiously and monitor patient. • Use narcotics cautiously in the elderly. Increased sensitivity to drugs and slowed drug metabolism can alter patient response. Allow 10 minutes to assess the full effect of the medication prior to additional narcotic administration. 130§ Procedures and Patient Care Reference FACES PAIN RATING SCALE (AGES 3 TO ADULT) 0–10 NUMERIC PAIN RATING SCALE (AGES > 9 YO) PAIN ASSESSMENT IN THE VERY YOUNG, NONVERBAL INFANT AND CHILD PAIN ASSESSMENT TOOLS See pain scale and English/Spanish chart on back cover of field manual • Point to each face using the words to describe the pain intensity • Ask the patient to choose the face that best describes how they are feeling. A person does not have to be crying to have the worst pain. Explain scale (0 means no pain and 10 is the most severe pain they have ever had). Ask patients what number on a scale of 0–10 they would give as the level of pain currently. Pain assessment in infants, non-verbal young children or developmentally delayed children is more complex and presents special challenges. Despite this, pain medication should be considered in cases where the infant or child is in severe pain. This includes evidence of painful mechanisms such as burns, limb fractures or other events. Using pain medication in these children requires judgment and caution. Signs and symptoms of pain in non-verbal young or developmentally delayed children include: • Inconsolable crying, screaming that cannot be distracted from by a caregiver • High pitched crying • Any pain face expression that is continual, such as grimace or quivering chin • Constant tense/stiff body tone and/or guarding “ Whatever is painful to adults, is painful to children until proven otherwise ” §131 Procedures and Patient Care Reference PEDIATRIC ASSESSMENT Begin interventions immediately and transport promptly if life-threatening conditions are identified in general visual assessment or primary assessment PEDIATRIC ASSESSMENT TRIANGLE—GENER AL VISUAL ASSESSMENT APPEARANCE WORK OF BREATHING CIRCULATION ASSESSMENT ABNORMAL Assess TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry Any abnormality Assess for skin color Abnormal skin color or external bleeding Assess effort Increased or decreased effort or abnormal sounds PREHOSPITAL PRIMARY ASSESSMENT ASSESSMENT SIGNS OF LIFETHREATENING CONDITION AIRWAY Assess patency Complete or severe airway obstruction CIRCULATION Assess heart rate, pulses, capillary refill, skin color and temperature, blood pressure Tachycardia, bradycardia, absence of detectable pulses, poor blood flow (increased capillary refill, pallor, mottling, or cyanosis), hypotension BREATHING DISABILITY EXPOSURE Assess respiratory rate and Apnea, slow respiratory rate, effort, air movement, airway and very fast respiratory rate or breath sounds, pulse oximetry significant work of breathing Assess AVPU response, pupil size and reaction to light, blood glucose Decreased response or abnormal motor response (posturing) to pain, unresponsiveness Assess skin for rash or trauma Hypothermia, rash (petichiae/purpura) consistent with septic shock, significant bleeding, abdominal distention 132§ Procedures and Patient Care Reference PEDIATRIC VITAL SIGNS/GLASGOW COMA SCALE AGE NORMAL RR NORMAL HR TERM NEONATE INFANT (<1 YR) TODDLER (1–3 YR) PRESCHOOLER (4–5 YR) SCHOOL AGE (6–12 YR) ADOLESCENT (13–18 YR) 30–60 100–205 30–60 100–190 24–40 90–150 22–34 80–140 18–30 70–120 12–20 60–100 HYPOTENSION BY SYSTOLIC BP Neonate: Less than 60 mmHg or weak pulses Infant: Less than 70 mmHg or weak pulses 1–10 yrs: Less than 70 mmHg + (age in yrs x 2) Over 10: Less than 90 mmHg PEDIATRIC GCS INFANT MOTOR RESPONSE Spontaneous movements Withdraws to touch Withdraws to pain Flexion Extension No response SCORE 6 5 4 3 2 1 CHILD SCORE Obeys commands Localizes Withdraws Flexion Extension No response 6 5 4 3 2 1 5 4 3 2 1 VERBAL RESPONSE Coos and babbles 5 4 3 2 1 Oriented Confused Inappropriate Incomprehensible No response EYE RESPONSE 4 3 2 1 Opens spontaneously 4 Opens to speech 3 Opens to pain 2 Irritable cry Cries to pain Moans to pain No response Opens spontaneously Opens to speech Opens to pain No response No response 1 §133 Procedures and Patient Care Reference PEDIATRIC MEDICATION ADMINISTRATION Patient safety in medication administration is paramount. Accurate administration of pediatric medications requires multiple steps. Follow each of these steps in every case. Remember the 6 Rights—Right patient, right drug (and ASSESS PATIENT indication), right dose, right route of administration, right timing and frequency, right documentation OBTAIN WEIGHT ESTIMATE IN KG DETERMINE VOLUME ON DRUG CHART DRAW UP MEDICATION DOUBLE CHECK TO CONFIRM VOLUME ADMINISTER MEDICATION DOCUMENTATION • Use Broselow tape in every child of appropriate height to determine color range of weight • Broselow applies to patients less than 147 cm tall (4 feet 10 inches) • If taller than Broselow tape, estimate weight by patient/parent history or paramedic estimate and ALWAYS convert to kg using conversion table • Consult drug chart based on medication name to determine volume in ml • If 50 kg or greater, utilize adult dosages • Verify drug being administered • Utilize smallest syringe for volume (e.g. 1 ml or less, use tuberculin syringe) • When giving IM or intranasal medication, load syringe only with amount to be administered • Double-check volume and dose with drug chart in hand—verbalize name of medication, volume, dosage and route to another paramedic or EMT on scene • Administer by appropriate route • Observe patient for any signs of adverse reaction • Always document drug dosages in chart by mg (most drugs), grams (Dextrose), or mcg (Fentanyl) • Document response to medication and any observed adverse reaction 134§ Procedures and Patient Care Reference RULE OF NINES—BURN SURFACE AREA §135 Procedures and Patient Care Reference SEPSIS SCREENING • Sepsis is a life-threatening condition that can occur when a systemic reaction known as Systemic Inflammatory Response Syndrome (SIRS) develops and is related to an infection • The inflammatory response may be the result of exposure to infectious agents in the blood, urine, lungs, skin, or other organs RISK FACTORS INDICATIONS FOR SCREENING ASSESSMENT CRITERIA FOR POSITIVE SCREEN HOSPITAL REPORTING Common risk factors for sepsis include elderly age, diabetes, and immunocompromised states. Other risk factors include cancer, renal disease, alcoholism, injection drug use, malnutrition, hypothermia, or recent surgery or invasive procedure. Sepsis screening should be done in adults in the setting of suspected infection. Examples: • Fever; • Respiratory symptoms such as tachypnea, shortness of breath, cough, sputum production; • Abdominal symptoms such as vomiting, diarrhea, or abdominal pain; • Urinary symptoms such as flank pain or painful/frequent urination; • Skin infections (cellulitis or abscess); • General weakness, altered level of consciousness or lethargy, especially in the elderly Sepsis screening includes assessment of pulse rate, respiratory rate and temperature. It is important to note that an elevated temperature may not be seen in sepsis, particularly in elderly patients or advanced stages. A positive sepsis screen in adults occurs in the setting of suspected infection when two of the three following conditions are met: • Heart rate/pulse greater than 90; • Respiratory rate greater than 20; • Temperature above 100.4 or below 96. If a positive sepsis screen is encountered, the receiving facility should be notified as part of the report from the field. Report the finding as a “positive sepsis screen.” Not all patients with a positive screen will have sepsis but alerting the facility may assist in calling attention to time-sensitive steps in evaluation and care that are needed to be taken upon hospital arrival. 136§ Procedures and Patient Care Reference SPINAL INJURY ASSESSMENT ASSESSMENT PRINCIPLES • Careful motor/sensory and spine exams • Consider reliability of patient • Consider factors that elevate risk PATIENT RELIABILITY Unreliable assessments if: • Coma or altered level of consciousness (including significant impairment by drugs or alcohol) • Communication barrier • Significant distracting injury EXAMINATION AND KEY FINDINGS Examination should include: • Wrist or finger extension of both hands • Plantarflexion and dorsiflexion of both feet • Gross sensation in all extremities • Check for abnormal sensations to extremities (paresthesias) • Palpate vertebral column thoroughly Key findings on examination include: • Midline spinal tenderness on palpation • Obvious deformity of spine • Neurologic deficit of extremities • Weakness, paralysis, sensory findings or subjective sensory complaints (numbness or tingling) • Presence of priapism or spinal shock RISK ASSESSMENT • History of high-velocity blunt injury increases risk • Axial load injury to the head (e.g. diving) increases risk • Low-velocity injuries such as falls from standing or lower-velocity motor vehicle accidents have increased risk in older patients (65 and older) §137 Procedures and Patient Care Reference SPINAL MOTION RESTRICTION (SMR) • The purpose of full spinal motion restriction is to protect patients from potential further injury when an unstable spinal fracture exists. • Full spinal motion restriction may cause airway or respiratory compromise, lead to skin breakdown (decubiti) and may cause significant pain. • Routine use of full spinal motion restriction should be avoided and should be reserved for patients with confirmatory physical findings or high suspicion of spinal fracture. SPINAL MOTION RESTRICTION IN BLUNT TR AUMA • Cervical collar, head bed, concave or padded board, straps FULL SPINAL MOTION RESTRICTION METHODS • Cervical collar with full-length vacuum splint INDICATIONS FOR FULL SPINAL MOTION RESTRICTION (BLUNT TRAUMA): • Major blunt trauma meeting criteria for trauma center activation • Presence of neurologic deficit (paralysis, weakness, numbness or tingling), priapism or suspected spinal shock • Obvious anatomic deformity of spine • Significant tenderness on palpation of vertebral column • Significant blunt trauma mechanism when patient evaluation is unreliable • Cervical collar only MODIFIED SPINAL MOTION RESTRICTION • Cervical collar with padding to limit movement • Cervical collar with KED or half-length vacuum splint METHODS • Blunt trauma not meeting above criteria but with pain complaints INDICATIONS FOR or concerns based on mechanism or patient risk MODIFIED SPINAL MOTION RESTRICTION • Examples of patients may include those ambulatory after self-extrication, low-velocity mechanisms, and those with no (BLUNT TRAUMA) neurologic findings. SPINAL MOTION RESTRICTION IN PENETR ATING TR AUMA INDICATIONS FOR FULL SPINAL MOTION RESTRICTION • Spinal motion restriction should only be employed in penetrating trauma if there is a neurologic deficit or an obvious deformity of the spine • Patients who have both penetrating injury and a significant blunt injury should be evaluated using blunt trauma criteria • Altered level of consciousness or presence of an entry/exit wound in proximity of the spine are no longer indications for SMR 138§ Procedures and Patient Care Reference VASCULAR ACCESS SKILL SALINE LOCK ARM IV ANTECUBITAL IV INDICATION/COMMENT When medication alone is being given or a potential for medication is anticipated No anticipated need for prehospital medication or fluid When fluids or medications needed and patient not in shock or arrest. Antecubital site not ideal unless no other vein available. No anticipated need for prehospital medication or fluid • Shock • Adenosine (rapid IV bolus) • Cardiac arrest if easily accessible • Other peripheral sites not available and medications or fluids indicated No anticipated need for prehospital medication or fluid INTRAOSSEOUS • Cardiac arrest • Profound shock or unstable ACCESS (IO) EXTERNAL JUGULAR IV CONTRAINDICATION dysrhythmia when rapid IV access or suitable vein cannot be rapidly located • Use lidocaine for pain control in non-arrest patients PRIOR to IO flush, fluid or medication (Infusion is painful!) • If no medication or fluid is being administered (do not use for prophylactic vascular access) • If patient stable • When other routes for medications available (IM, IN) Unstable patient needs • Contraindicated in cardiac emergent IV medication or arrest unless IO and fluids AND no peripheral site is antecubital IV cannot be available AND IO not appropriate started (interrupts CPR) (e.g. very alert patient) • When other routes for medications available (IM, IN)—e.g. naloxone or use of glucagon instead of dextrose §139 Procedures and Patient Care Reference VENTRICULAR ASSIST DEVICES (VAD) BACKGROUND INFOR MATION • A Ventricular Assist Device (VAD) is an implanted device used to partially or completely replace the pumping function of a failing heart. VADs are used both as a bridge device while patients are awaiting heart transplant, and now increasingly are used permanently in patients who are not transplant candidates (referred to as destination therapy). • VAD patients and their families/caretakers have been given training for their devices and they should be capable of basic troubleshooting of the device. Hospitals that implant VADs have 24-hour on-call coverage (VAD Coordinators) for families or responders to contact in case of any issues. The contact phone number should be present on the patient’s equipment and this person may be able to help the family or responding personnel in assessing the device. ASSESSMENT • Depending on the type of VAD, a patient may or may not present with a palpable pulse, and blood pressure may not be detected, particularly with automatic measurements. Most newer VADs work without generating a pulse. The pulse, if present, may not correspond to the patient’s heart rate on the monitor. • In the absence the ability to detect pulse and blood pressure, patient evaluation of skin signs, level of consciousness, oxygen saturation, non-invasive end-tidal carbon-dioxide, and general appearance may give the best clues as to the patient’s clinical status. TREATMENT • Patients may be cardioverted or defibrillated if symptomatic, but asymptomatic dysrhythmias do not require treatment • VAD devices may become dislodged with chest compressions and this may lead to massive hemorrhage. Do not perform chest compressions on patients with VADs, even if the patient is unconscious. • Treatment should otherwise follow appropriate treatment guidelines. Medical direction is provided by the base hospital (VAD coordinators cannot provide medical direction). DESTINATION and DISPOSITION • In most circumstances, when transport is indicated the appropriate destination for the patient is the hospital where the VAD was implanted and the patient is managed. • For very minor conditions (e.g. small laceration repair) local transport may be appropriate. • Contact the base hospital if there are questions concerning destination. • If possible, the patient’s family member or caregiver should accompany the patient in the ambulance, and all related VAD equipment (e.g. spare batteries) should also be transported with the patient. • In arrest situations, determine if DNR/POLST or advance directives are available. Many VAD patients have made end-of-life care decisions. 140§ Procedures and Patient Care Reference table of contents—operational reference RADIO COMMUNICATIONS....................................................................................................... 142 SBAR REPORTING........................................................................................................................... 143 EMT SCOPE OF PRACTICE.................................................................................................144–145 PARAMEDIC SCOPE OF PRACTICE..................................................................................146–147 PARAMEDIC SCOPE OF PRACTICE—LOCAL OPTIONAL SCOPE...................................... 148 BURN CENTERS............................................................................................................................... 149 CONTRA COSTA COUNTY HOSPITALS.......................................................................... 150–151 OUT-OF-COUNTY SPECIALTY CENTERS................................................................................. 152 §141 Operational and Regulatory Reference RADIO COMMUNICATIONS Four radio channels are designated for communications with hospitals in Contra Costa County. Receiving hospital communications are done via XCC EMS 2, whereas paramedic base hospital communications may occur via XCC EMS 2 or XCC EMS 3, depending on location XCC EMS 1 (formerly L9) XCC EMS 2 (formerly L19) T: 491.4375 R: 488.4375 T: 491.9125 R: 488.9125 Use for Sheriff’s Dispatch-toambulance communication XCC EMS 3 T: 491.6125 R: 488.6125 XCC EMS 4 T: 491.6625 R: 488.6625 Primary channel for base contact for paramedic units operating south of Ygnacio Valley Road and west of I– 680 along Highway 24 Primary channel for base contact for West County paramedic units. Also used county-wide for BLS and helicopter radio traffic Primary channel for base contact for paramedic units operating in East County and Central County north of Ygnacio Valley Road Whenever possible, paramedic personnel should use the XCC EMS channel assigned to the area in which they are responding, for ambulance-to-base hospital communications. XCC EMS 2 is the county-wide backup ALS channel and should be used if XCC EMS 3 or XCC EMS 4 is not available. Ambulance and helicopter personnel are to contact Sheriff’s Dispatch on XCC EMS 1 to request the use of XCC EMS 2 prior to utilizing the channel. The dispatcher shall be given unit identification and a description of current traffic (Code 2, Code 3 or trauma destination decision). No request for use is necessary for XCC EMS 3 or XCC EMS 4. However, each unit must monitor the channel prior to use to ensure that other units are not already using the channel. Radio identification procedures must be strictly followed, as more than one call may be occurring at the same time. If traffic is in progress on a XCC EMS channel, other ambulance personnel may either wait until current traffic is finished or find an alternate means of contacting the desired hospital. Any unit may, in cases such as trauma destination decisions, request that Sheriff’s Dispatch break into current traffic on XCC EMS 2 to request temporary use of the channel. Units using XCC EMS 3 or XCC EMS 4 may request use of the channel from a unit that is currently on that channel. When making base contact for trauma destination only, the initial transmission should make the purpose of the call clear. Cellular phones may also be used as a means of communication. 142§ Operational and Regulatory Reference SBAR REPORTING SBAR is a tool that is recommended to assure timely, effective communication during all patient-related communications between all health care providers. SBAR assures that urgent issues and immediate needs get addressed up front. SBAR is compatible with the trauma MIVT reporting. Routine use during base contact and patient handoff supports safe and effective patient care. SITUATION KEY INFORMATION SBAR REPORT EXAMPLE • Identify yourself • What is the situation? • State urgent issues and immediate needs up front! This is Unit 123 with a STEMI alert. Patient is a 45 yo male with 12 lead positive for ST elevation RR 28 labored B/P 160/98 Diaphoretic, Pain 9 out 10, 12 lead ***Acute MI*** no significant artifact seen. No significant change with treatment. Airway stable. BACKGROUND • What has happened up to this point? • What past history would be important to know for further patient treatment? (e.g. high risk medications, past medical history) Patient started having chest pain off and on the last 2 hours. Family called 911. Patient has no history of heart problems and takes Lipitor and metformin. ASSESSMENT • How is the patient now? • Improved or worse since on scene? • Patient stable or unstable? Rx Recap • What field care given? • Was it effective? • Concerns? ASA and oxygen 4L nasal cannula STEMI alert §143 Operational and Regulatory Reference EMT SCOPE OF PRACTICE "Emergency Medical Technician" or "EMT" means a person who has successfully completed an EMT course which meets the requirements of this Chapter, has passed all required tests, and who has been certified by the EMT certifying authority. 100063. Scope of Practice of Emergency Medical Technician (EMT) a. During training, while at the scene of an emergency, during transport of the sick or injured, or during interfacility transfer, a certified EMT or supervised EMT student is authorized to do any of the following: 1. Evaluate the ill and injured. 2. Render basic life support, rescue and emergency medical care to patients. 3. Obtain diagnostic signs to include, but not be limited to the assessment of temperature, blood pressure, pulse and respiration rates, level of consciousness, and pupil status. 4. Perform cardiopulmonary resuscitation (CPR), including the use of mechanical adjuncts to basic cardiopulmonary resuscitation. 5. Administer oxygen. 6. Use the following adjunctive airway breathing aids: A. B. C. D. Oropharyngeal airway; Nasopharyngeal airway; Suction devices; Basic oxygen delivery devices for supplemental oxygen therapy including, but not limited to, humidifiers, partial rebreathers, and venturi masks; and E. Manual and mechanical ventilating devices designed for prehospital use including continuous positive airway pressure. 7. Use various types of stretchers and body immobilization devices. 8. Provide initial prehospital emergency care of trauma, including, but not limited to A. B. C. D. E. F. Bleeding control through the application of tourniquets; Use of hemostatic dressings from a list approved by the Authority; Spinal immobilization; Seated spinal immobilization; Extremity splinting; and Traction splinting. 144§ Operational and Regulatory Reference EMT SCOPE OF PRACTICE 9. Administer over the counter medications when approved by the medical director of the LEMSA, including, but not limited to: A. Oral glucose or sugar solutions; and B.Aspirin (not currently allowed in Contra Costa County). 10. Extricate entrapped persons. 11. Perform field triage. 12. Transport patients. 13. Mechanical patient restraint. 14. Set up for ALS procedures, under the direction of an Advanced EMT or Paramedic. 15. Perform automated external defibrillation. 16. Assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and selfadministered emergency medications, including epinephrine devices. 17. In addition to the activities authorized by subdivision (a) of this section, the medical director of the local EMS agency may also establish policies and procedures to allow a certified EMT or a supervised EMT student in the prehospital setting and/or during interfacility transport to: A. Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions including Ringer’s lactate for volume replacement; B. Monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn off the flow of intravenous fluid; and C. Transfer a patient who is deemed appropriate for transfer by the transferring physician, and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines; D. Monitor preexisting vascular access devices and peripheral lines delivering intravenous fluids with additional medications pre-approved by the Director of the Authority (not currently allowed in Contra Costa County). §145 Operational and Regulatory Reference PARAMEDIC SCOPE OF PRACTICE California Code of Regulations, Title 22, Division 9, Chapter 4: 100145. Scope of Practice of Paramedic. a. A paramedic may perform any activity identified in the scope of practice of an EMT in Chapter 2 of the Division, or any activity identified in the scope of practice of an Advanced EMT (AEMT) in Chapter 3 of this Division. b. A paramedic shall be affiliated with an approved paramedic service provider in order to perform the scope of practice specified in this Chapter. c. A paramedic student or a licensed paramedic, as part of an organized EMS system, while caring for patients in a hospital as part of his/her training or continuing education under the 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, or while working in a small and rural hospital pursuant to section 1797.195 of the Health and Safety Code, may perform the following procedures or administer the following medications when such are approved by the medical director of the local EMS agency and are included in the written policies and procedures of the LEMSA. 1. Basic Scope of Practice: A. Utilize electrocardiographic devices and monitor electrocardiograms, including 12lead electrocardiograms. B. Perform defibrillation, synchronized cardioversion, and external cardiac pacing. C. Visualize the airway by use of the laryngoscope and remove foreign body(ies) with forceps. D. Perform pulmonary ventilation by use of lower airway multi-lumen adjuncts, the esophageal airway, perilaryngeal airways, stomal intubation, and adult oral endotracheal intubation. E. Utilize mechanical ventilation devices for continuous positive airway pressure (CPAP), bi-level positive airway pressure (BPAP) and positive end expiratory pressure (PEEP) in the spontaneously breathing patient. F. Institute intravenous (IV) catheters, saline locks, needles, or other cannulae (IV lines), in peripheral veins; and monitor and administer medications through preexisting vascular access. G. Institute intraosseous (IO) needles or catheters. H. Administer intravenous glucose solutions or isotonic balanced salt solutions, including Ringer’s lactate solution. 146§ Operational and Regulatory Reference I. J. K. L. M. N. O. P. Q. R. PARAMEDIC SCOPE OF PRACTICE Obtain venous blood samples. Use laboratory devices, including point of care testing, for pre-hospital screening use to measure lab values including, but not limited to: glucose, capnometry, capnography, and carbon monoxide when appropriate authorization is obtained from State and Federal agencies, including from the Centers for Medicare and Medicaid Services pursuant to the Clinical Laboratory Improvement Amendments (CLIA). Utilize Valsalva maneuver. Perform needle cricothyroidotomy. (not currently used in Contra Costa County) Perform needle thoracostomy. Perform nasogastric and orogastric tube insertion and suction. (not currently used in Contra Costa County) Monitor thoracostomy tubes. Monitor and adjust IV solutions containing potassium, equal to or less than 40 mEq/L. Administer approved medications by the following routes: IV, IO, intramuscular, subcutaneous, inhalation, transcutaneous, rectal, sublingual, endotracheal, oral or topical. Administer, using prepackaged products when available, the following medications: (1) 10%, 25% and 50% dextrose; (25%, 50% not currently used in Contra Costa County) (2) activated charcoal; (not currently used in Contra Costa County) (3) adenosine; (4) aerosolized or nebulized beta–2 specific bronchodilators; (5) amiodarone; (6) aspirin; (7) atropine sulfate; (8) pralidoxime chloride; (9) calcium chloride; (10) diazepam; (not currently used in Contra Costa County) (11) diphenhydramine hydrochloride; (12) dopamine hydrochloride; (not currently used in Contra Costa County) (13) epinephrine; (14) fentanyl; §147 Operational and Regulatory Reference PARAMEDIC SCOPE OF PRACTICE (15) glucagon; (16) ipratropium bromide (not currently used in Contra Costa County) (17) lorazepam; (not currently used in Contra Costa County) (18) midazolam (19) lidocaine hydrochloride; (20) magnesium sulfate; (not currently used in Contra Costa County) (21) morphine sulfate; (not currently used in Contra Costa County) (22) naloxone hydrochloride; (23) nitroglycerin preparations, except IV, unless permitted under (c)(2)(A) of this section; (24) ondansetron (25) sodium bicarbonate 2. Local Optional Scope of Practice: A. Perform or monitor other procedure(s) or administer any other medication(s) determined to be appropriate for paramedic use, in the professional judgment of the medical director of the local EMS agency, that have been approved by the Director of the Emergency Medical Services Authority when the paramedic has been trained and tested to demonstrate competence in performing the additional procedures and administering the additional medications. CONTR A COSTA LOCAL OPTIONAL SCOPE • Impedance Threshold Device (ResQPOD) • Pediatric Endotracheal Intubation (limited to patients > 40 kg) CONTR A COSTA LOCAL OPTIONAL SCOPE ITEMS ITEMS LIMITED TO CRITICAL CARE TR ANSPORT PAR AMEDICS ONLY • Blood/Blood Product Infusion • Glycoprotein IIb/IIIa Receptor Inhibitor Infusion • Heparin Infusion • KCL Infusion • Lidocaine Infusion • Midazolam Infusion • Morphine Sulfate Infusion • Nitroglycerin Infusion • Sodium Bicarbonate Infusion • Total Parenteral Nutrition (TPN) Infusion 148§ Operational and Regulatory Reference HOSPITAL BURN CENTERS SERVICES PHONE Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose CA Adult and Pediatric Burn Center (408) 885-6666 UC Davis Medical Center Regional Burn Center 2315 Stockton Blvd. Sacramento CA Adult and Pediatric Burn Center (916) 734-3636 St. Francis Burn Center Adult and Pediatric Burn Center (No Helipad available) (415) 353-6255 900 Hyde Street San Francisco CA §149 Operational and Regulatory Reference CONTRA COSTA COUNTY HOSPITALS Base Hospital HOSPITAL BASE PHONE ED PHONE Taped: (925) 939-5804 Receiving Facility Notification: (925) 947-3379 ED: (925) 939-5800 14524 SERVICES ED PHONE Contra Costa Regional Medical Center 2500 Alhambra Avenue Martinez CA 94553 Basic ED OB/Neonatal (925) 370-5971 XCC EMS 2 ALERT CODE 14574 Doctors Medical Center— San Pablo 2000 Vale Road San Pablo CA 94806 Basic ED STEMI Center Stroke Center (510) 234-6010 13613 John Muir Health— Concord Campus 2540 East Street Concord CA 94520 Basic ED STEMI Center Stroke Center (925) 689-0553 14214 John Muir Health— Walnut Creek Campus 1601 Ygnacio Valley Rd Walnut Creek CA 94598 Basic ED OB/Neonatal Trauma Center STEMI Center Stroke Center Receiving Facility Notification: (925) 947-3379 ED: (925) 939-5800 14524 John Muir Health— Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA 94598 XCC EMS 2 ALERT CODE Receiving Facilities HOSPITAL 150§ Operational and Regulatory Reference CONTRA COSTA COUNTY HOSPITALS HOSPITAL SERVICES ED PHONE XCC EMS 2 ALERT CODE Kaiser Medical Center — Antioch 5001 Deer Valley Road Antioch CA 94531 Basic ED OB/Neonatal Stroke Center (925) 813-6099 14564 Kaiser Medical Center — Richmond 901 Nevin Avenue Richmond CA 94504 Basic ED Stroke Center (510) 307-1758 13653 Kaiser Medical Center — Walnut Creek 1425 South Main Street Walnut Creek CA 94596 Basic ED OB/Neonatal STEMI Center Stroke Center (925) 939-1788 14284 San Ramon Regional Medical Center 6001 Norris Canyon Road San Ramon CA 94583 Basic ED OB/Neonatal STEMI Center Stroke Center (925) 275-8338 13623 Sutter Delta Medical Center Basic ED 3901 Lone Tree Way OB/Neonatal Antioch CA 94509 STEMI Center (925) 779-7273 14294 §151 Operational and Regulatory Reference OUT-OF-COUNTY SPECIALTY CENTERS HOSPITAL TYPE ED PHONE Alameda County Medical Center— Oakland (Highland) Trauma (510) 535-6000 Alta Bates Medical Center —Berkeley Stroke (510) 204-2500 Children’s Hospital— Oakland Trauma (510) 428-3240 Eden Medical Center— Castro Valley Trauma Stroke (510) 889-5015 Kaiser Oakland Stroke (510) 752-7667 Kaiser South Sacramento Trauma (916) 688-6964 Marin General Hospital Trauma (415) 925-7203 San Francisco General Hospital Trauma (415) 647-4747 Summit Campus— Alta Bates Medical Center —Oakland STEMI Stroke (510) 869-8797 UC Davis Medical Center— Sacramento Trauma (916) 734-3892 (916) 734-5669 Valley Care— Pleasanton STEMI (925) 416-6518 152§ Operational and Regulatory Reference table of contents—drug reference ADULT DRUG REFERENCE.................................................................................................155–161 PEDIATRIC DRUG REFERENCE..........................................................................................162–164 PEDIATRIC WEIGHT-BASED DOSING CHARTS...........................................................165–180 Adenosine................................................................................................................................ 165 Amiodarone............................................................................................................................. 166 Atropine.................................................................................................................................... 167 Defibrillation............................................................................................................................168 Dextrose 10%..........................................................................................................................169 Diphenhydramine................................................................................................................ 170 Epinephrine 1:10,000...........................................................................................................171 Epinephrine 1:1000............................................................................................................. 172 Intranasal Fentanyl.............................................................................................................. 173 Fentanyl IV/IM........................................................................................................................ 174 Fluid Bolus............................................................................................................................... 175 Glucagon................................................................................................................................. 176 Lidocaine................................................................................................................................. 177 Midazolam.............................................................................................................................. 178 Naloxone................................................................................................................................. 179 Weight Conversion.............................................................................................................. 180 §153 Operational and Regulatory Reference 154§ ADULT DRUG REFERENCE DRUG INDICATION ADENOSINE Paroxysmal SVT ALBUTEROL Bronchospasm 5 mg in 6 ml NS nebulized Crush Injury— Hyperkalemia 5 mg in 6 ml NS nebulized continuously Ventricular Fibrillation or Pulseless VT 300 mg IV or IO bolus, repeat 150 mg bolus if rhythm persists Stable Ventricular Tachycardia 150 mg IV infusion or slow IV push over 10 minutes (15 mg/ minute) AMIODARONE ADULT DOSAGE PRECAUTIONS/ COMMENTS May cause transient heart block or asystole. Side effects include chest pressure/pain, 2nd Dose—12 mg palpitations, hypotension, rapid IV push dyspnea, or feeling of impending doom. Use Follow each dose with rapid bolus of caution when patient is taking carmbamazepine, 20 ml NS dipyramidole, or methylxanthines. Do not administer if acute asthma exacerbation. 1st Dose—6 mg rapid IV Repeat as needed for bronchospasm Use with caution in patients taking MAO inhibitors (antidepressants Nardil and Parnate) In patient with pulses, may cause hypotension. Do not administer if patient hypotensive. When creating infusion, careful mixing needed to avoid foaming of medication (do not use filter needle). §155 Drug Reference ADULT DRUG REFERENCE DRUG INDICATION ASPIRIN Chest Pain— Suspected ACS ATROPINE ADULT DOSAGE PRECAUTIONS/ COMMENTS 4–81 mg tabs— chewed Contraindicated in aspirin or salicylate allergy. Coumadin or Plavix use is not a contraindication Symptomatic Bradycardia (not to be used in wide QRS 2nd and 3rd degree blocks) 0.5 mg IV or IO every 3–5 minutes up to max. 3 mg Atropine can dilate pupils, aggravate glaucoma, cause urinary retention, confusion, and dysrhythmias, including V-tach and Vfib. Doses less than 0.5 mg can cause paradoxical bradycardia. Increases myocardial oxygen consumption. Organophosphate poisoning 1–2 mg IV or IO— repeat every 3-5 min. as needed to decrease symptoms Remove clothing of victim of organophosphate poisonings, and flush skin to remove traces of poison 156§ Drug Reference ADULT DRUG REFERENCE DRUG INDICATION CALCIUM CHLORIDE Hyperkalemia— Arrest ADULT DOSAGE PRECAUTIONS/ COMMENTS 500 mg IV or IO slowly May repeat in 5–10 minutes Hyperkalemia— Crush Injury 1 gm IV or IO slowly over 60 seconds Hydrofluoric Acid Toxicity 500 mg IV or IO slowly Use cautiously or not at all in patients on digitalis. Avoid extravasation Rapid administration can cause dysrhythmias or arrest DEXTROSE 10% Hypoglycemia 10 g initially (100 ml). If glucose remains 60 or below, give additional 15 g (150 ml) Recheck glucose after administration DIPHENHYDRAMINE 25–50 mg IV or IM For allergy, consider lower dose if patient has already taken po dose in past two hours for symptoms Cardiac Arrest 1 mg IV or IO every 3–5 minutes Anaphylactic Shock 0.1 mg increments IV or IO up to 0.5 mg IV total dose Alpha & beta sympathomimetic. May cause serious dysrhythmias and exacerbate angina. Allergy—Hives/ Itching Dystonic Reaction EPINEPHRINE 1:10,000 Use only if IM treatment ineffective §157 Drug Reference ADULT DRUG REFERENCE DRUG INDICATION EPINEPHRINE 1:1000 Allergy/ Anaphylactic Shock Asthma FENTANYL ADULT DOSAGE PRECAUTIONS/ COMMENTS 0.3–0.5 mg IM Use lower dose in smaller, older patients 0.3 mg subcutaneously 0.3 mg IM if respiratory arrest from asthma or bronchospasm Pain Control 50–200 mcg IV (25-50 mcg increments) 100 mcg Intranasally 50–100 mcg IM Sedation— Pacing 25–100 mcg IV in 25–50 mcg increments Never administer intravenously! Do not use in asthma patients with a history of hypertension or coronary artery disease. May cause serious dysrhythmias and exacerbate angina. Can cause hypotension and respiratory depression. Recheck VS between each dose. Hypotension more common in patients with low cardiac output or volume depletion. Respiratory depression reversible with naloxone. Additional IV doses (titration) can be given every 5 minutes. IM and intranasal doses can be repeated once in 15 minutes. 158§ Drug Reference ADULT DRUG REFERENCE DRUG INDICATION GLUCAGON Hypoglycemia LIDOCAINE MIDAZOLAM ADULT DOSAGE PRECAUTIONS/ COMMENTS 1 mg IM Effect may be delayed 5–20 min IO Anesthesia 40 mg IO Repeat dose 20 mg Administer slowly over 1 minute Not needed in arrest situations Seizure Titrate 1–5 mg IV in 1–2 mg increments With IV dosing, begin with 1 mg dose. IV increments should not exceed 2 mg. 0.1 mg/kg IM (max. dose 5 mg IM) Sedation for pacing or cardioversion Titrate 1–5 mg IV in 1–2 mg increments Sedation— transfer of intubated patient Titrate 2–5 mg IV in up to 2 mg increments Behavioral Emergency 5 mg IM Observe respiratory status Use with caution in patients over age 60 1–3 mg IV in 1 mg increments if IV available §159 Drug Reference ADULT DRUG REFERENCE DRUG INDICATION ADULT DOSAGE PRECAUTIONS/ COMMENTS NALOXONE Respiratory Depression (Respiratory rate less than 12) or Apnea Intranasal administration preferred unless patient in shock or has copious secretion/blood in nares. 1–2 mg IV or IM Shorter duration of action than that of For careful most narcotics. Abrupt titration in withdrawal symptoms chronic pain or terminal patients, and combative behavior may occur. dilute 1:10 and give 0.1 mg increments NITROGLYCERIN Chest Pain— Suspected ACS 0.4 mg sl or spray up to 3 doses Pulmonary Edema 0.4 mg sl or spray if systolic BP 90–149 2 mg intranasally (IN) 0.8 mg sl or spray if systolic BP 150 or over Max.dose 4.8 mg ONDANSETRON Vomiting and Severe Nausea 4 mg IV, IM or po (ODT) May repeat q 10 min X 2 Can cause hypotension and headache. Do not give if BP less than 90 systolic or heart rate below 50. Perform 12-lead ECG before administration. Do not give if STEMI detected. Do not give if Viagra, Levitra, Staxyn or Stendra taken within 24 hours or if Cialis taken within 36 hours. Give IV over 1 minute— may cause syncope if administered too rapidly 160§ Drug Reference ADULT DRUG REFERENCE DRUG INDICATION SODIUM BICARBONATE Cardiac arrest ADULT DOSAGE PRECAUTIONS/ COMMENTS 1 mEq/kg IV or IO Assure adequate ventilation. Can precipitate or inactivate other drugs. In cardiac arrest, indicated for treatment of suspected pre-existing acidosis (e.g. kidney failure), hyperkalemia or arrest due to tricyclic antidepressant overdose Tricyclic Antidepressant OD 1 mEq/kg IV Use only if lifethreatening, hemodynamically significant dysrhythmias Crush injury 1 mEq/kg IV For crush injury, consider additional 1 mEq/ kg added to 1L NS using second IV line §161 Drug Reference PEDIATRIC DRUG REFERENCE DRUG INDICATION ADENOSINE Paroxysmal SVT PEDIATRIC DOSAGE 1st Dose—0.1 mg/kg rapid IV (max. 6 mg) 2nd Dose—0.2 mg/kg rapid IV (max 12 mg) Follow each dose with rapid 10–20 ml NS bolus ALBUTEROL Bronchospasm AMIODARONE 5 mg in 6 ml NS nebulized Ventricular Fibrillation or Pulseless VT ATROPINE 5 mg/kg IV or IO bolus Maximum dose 300 mg Symptomatic Bradycardia 0.02 mg/kg IV or IO Minimum dose 0.1 mg Maximum dose 0.5 mg DEXTROSE 10% Hypoglycemia 0.5 g/kg IV (5 ml/kg) DIPHENHYDRAMINE Allergy—Hives/ Itching 1 mg/kg IV or IM Maximum dose 50 mg PRECAUTIONS/ COMMENTS Base Order Required: May cause transient heart block or asystole. Side effects include chest pressure/ pain, palpitations, hypotension, dyspnea, or feeling of impending doom. Do not administer if acute exacerbation of asthma. Repeat as needed Bradycardia in pediatric patients primarily related to respiratory issue—assure adequate ventilation first Recheck glucose after Maximum 250 ml administration Consider lower dose (0.5 mg/kg) if patient has already taken po dose in the past two hours for symptoms 162§ Drug Reference PEDIATRIC DRUG REFERENCE DRUG INDICATION EPINEPHRINE 1:10,000 Cardiac Arrest EPINEPHRINE 1:1000 PEDIATRIC DOSAGE 0.01 mg/kg IV or IO every 3–5 minutes Max. dose 1 mg Anaphylactic Shock Titrate in up to 0.1 mg increments slow IV or IO to a max. of 0.01 mg/kg Allergy/ Anaphylactic Shock 0.01 mg/kg IM Asthma 0.01 mg/kg subcutaneously Max single dose 0.3 mg Maximum dose 0.3 mg PRECAUTIONS/ COMMENTS In anaphylactic shock, IM epinephrine 1:1000 should be administered first and epinephrine 1:10,000 IV should only be used if IM is ineffective Never administer intravenously! If respiratory arrest from asthma or bronchospasm, administer IM FENTANYL Pain Control GLUCAGON See drug chart Can cause hypotension for exact dosage. and respiratory 1 mcg/kg IV or IM depression. Hypotension is more common in 1.5 mcg/kg patients with volume Intranasal depletion. Nausea may occur. Hypoglycemia Weight less than 24 kg: 0.5 mg IM Weight 24 kg or more: 1 mg IM Effect may be delayed 5–20 minutes—if patient responds, give po sugar §163 Drug Reference PEDIATRIC DRUG REFERENCE DRUG INDICATION PEDIATRIC DOSAGE LIDOCAINE IO Pain MIDAZOLAM Seizure Titrate in up to 1 Observe respiratory mg increments IV status carefully up to 0.1 mg/kg Maximum IV dose dependent on patient 0.1 mg/kg IM Maximum dose 5 weight (e.g. for 20 kg patient, maximum dose mg IM 2 mg). For patients 50 kg and above, maximum IV dose 5 mg Sedation for Cardioversion 0.1 mg/kg IV or IO titrated in 1 mg increments 0.5 mg/kg IO. Maximum dose 20 mg PRECAUTIONS/ COMMENTS Give slowly over one minute. Not needed in arrest situations Sedation and cardioversion only with base hospital order only. Maximum dose dependent on patient weight (see above). NALOXONE Respiratory Depression or Apnea Use IM route initially unless shock present. Shorter duration of action than that of most narcotics. ONDANSETRON 0.1 mg/kg IM or IV Maximum dose 2 mg May repeat as needed Vomiting and Severe Nausea 4 mg IV, IM, or po (ODT) In patients 40 kg and over, may repeat q 10 min X2 For use in patients 4 years and up. Administer IV over 1 minute. Rapid administration may cause syncope. 164§ Drug Reference ADENOSINE INDICATION: SUPRAVENTRICULAR TACHYCARDIA Concentration = 3 mg/ml 1st Dose = 0.1 mg/kg IV 2nd Dose = 0.2 mg/kg IV Base Order Only COLOR Gray (3-5 kg) Pink (6-7 kg) Red (8-9 kg) Purple (10-11 kg) Yellow (12-14 kg) White (15-18 kg) Blue (19-23 kg) Orange (24-29 kg) Green (30-36 kg) 40 kg 45 kg DOSES (mg) 0.45 mg 0.9 mg 0.66 mg 1.35 mg 0.9 mg 1.8 mg 1 mg 2 mg 1.35 mg 2.7 mg 1.7 mg 3.4 mg 2.1 mg 4.2 mg 2.7 mg 5.4 mg 3.3 mg 6.6 mg 4 mg 8 mg 4.5 mg 9 mg GIVE (ml) 1 - 0.15 ml 2nd - 0.3 ml 1st - 0.22 ml 2nd - 0.45 ml 1st - 0.3 ml 2nd - 0.6 ml 1st - 0.33 ml 2nd - 0.67 ml 1st - 0.45 ml 2nd - 0.9 ml 1st - 0.6 ml 2nd - 1.2 ml 1st - 0.7 ml 2nd - 1.4 ml 1st - 0.9 ml 2nd - 1.8 ml 1st - 1.1 ml 2nd - 2.2 ml 1st - 1.3 ml 2nd - 2.7 ml 1st - 1.5 ml 2nd - 3 ml st Note: Follow with rapid bolus 10-20 ml NS §165 Drug Reference AMIODARONE INDICATION – VENTRICULAR FIBRILLATION Concentration = 50 mg/ml Dose = 5 mg/kg IV COLOR DOSE (mg) GIVE (ml) Not given Gray (3-5 kg) Pink (6-7 kg) 35 mg 0.7 ml Red (8-9 kg) 45 mg 0.9 ml Purple (10-11 kg) 50 mg 1 ml Yellow (12-14 kg) 65 mg 1.3 ml White (15-18 kg) 80 mg 1.6 ml Blue (19-23 kg) 100 mg 2 ml Orange (24-29 kg) 130 mg 2.6 ml Green (30-36 kg) 170 mg 3.4 ml 40 kg 200 mg 4 ml 45 kg 225 mg 4.5 ml 166§ Drug Reference ATROPINE INDICATION – SYMPTOMATIC BRADYCARDIA Concentration = 0.1 mg/ml Dose = 0.02 mg/kg IV Minimum Dose – 0.1 mg IV Maximum Dose – 0.5 mg IV COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) 0.1 mg 1 ml Pink (6-7 kg) 0.13 mg 1.3 ml Red (8-9 kg) 0.17 mg 1.7 ml Purple (10-11 kg) 0.2 mg 2 ml Yellow (12-14 kg) 0.25 mg 2.5 ml White (15-18 kg) 0.35 mg 3.5 ml Blue (19-23 kg) 0.42 mg 4.2 ml Orange (24-29 kg) 0.5 mg 5 ml Green (30-36 kg) 0.5 mg 5 ml 40 kg 0.5 mg 5 ml 45 kg 0.5 mg 5 ml Assure adequate ventilation before considering atropine Not indicated for asystole §167 Drug Reference DEFIBRILLATION Energy Selection PHYSIO-CONTROL LP-12 and LP-15 COLOR First Second Maximum Gray (3-5 kg) 8J 15 J 30 J Pink (6-7 kg) 15 J 30 J 50 J Red (8-9 kg) 15 J 30 J 70 J Purple (10-11 kg) 20 J 30 J 100 J Yellow (12-14 kg) 30 J 50 J 125 J White (15-18 kg) 30 J 70 J 175 J Blue (19-23 kg) 30 J 70 J 200 J Orange (24-29 kg) 50 J 100 J 250 J Green (30-36 kg) 70 J 125 J 300 J 40 kg 70 J 150 J 360 J 45 kg 100 J 175 J 360 J Note: Cardioversion energy dosages are equal to first and second energy levels. Cardioversion in pediatric patients requires base hospital direction. 168§ Drug Reference DEXTROSE 10% INDICATION – HYPOGLYCEMIA Concentration = 0.1 g/ml Dose = 0.5 g/kg IV up to 10g initially COLOR DOSE (g) GIVE (ml) Gray (3-5 kg) 2g 20 ml Pink (6-7 kg) 3.5 g 35 ml Red (8-9 kg) 4.5 g 45 ml Purple (10-11 kg) 5.5 g 55 ml Yellow (12-14 kg) 6.5 g 65 ml White (15-18 kg) 8.5 g 85 ml Blue (19-23 kg) 10 g 100 ml* Orange (24-29 kg) 10 g 100 ml* Green (30-36 kg) 10 g 100 ml* 40 kg 10 g 100 ml* 45 kg 10 g 100 ml* * Additional dosage of up to 150 ml (15g) may be required based on repeat blood glucose determination. Administer in 50 ml (5g) increments. §169 Drug Reference DIPHENHYDRAMINE INDICATION: ALLERGIC REACTION (URTICARIAL RASH or ITCHING) Concentration = 50 mg/ml Dose = 1 mg/kg – Give IV or IM COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) 5 mg 0.1 ml Pink (6-7 kg) 6.5 mg 0.13 ml Red (8-9 kg) 8.5 mg 0.17 ml Purple (10-11 kg) 10 mg 0.2 ml Yellow (12-14 kg) 12.5 mg 0.25 ml White (15-18 kg) 17.5 mg 0.35 ml Blue (19-23 kg) 20 mg 0.4 ml Orange (24-29 kg) 25 mg 0.5 ml Green (30-36 kg) 35 mg 0.7 ml 40 kg 40 mg 0.8 ml 45 kg 45 mg 0.9 ml Utilize epinephrine 1:1000 IM first if serious systemic reaction (anaphylaxis) Consider giving one-half dosage diphenhydramine if patient has taken/been given full dose within 1 hour 170§ Drug Reference EPINEPHRINE 1:10,000 FOR CARDIAC ARREST Concentration = 0.1 mg/ml Dose = 0.01 mg/kg IV COLOR Gray (3-5 kg) DOSE (mg) GIVE (ml) 0.04 mg 0.4 ml ** Pink (6-7 kg) 0.06 mg 0.6 ml ** Red (8-9 kg) 0.08 mg 0.8 ml ** Purple (10-11 kg) 0.1 mg 1 ml Yellow (12-14 kg) 0.13 mg 1.3 ml White (15-18 kg) 0.17 mg 1.7 ml Blue (19-23 kg) 0.21 mg 2.1 ml Orange (24-29 kg) 0.27 mg 2.7 ml Green (30-36 kg) 0.33 mg 3.3 ml 40 kg 0.4 mg 4 ml 45 kg 0.45 mg 4.5 ml Epinephrine 1:10,000 IV is also used in anaphylactic shock if IM treatment ineffective ** In anaphylactic shock: • Patients under 10 kg receive smaller increments (same as single dose for cardiac arrest) • For patients 10 kg and up, give 0.1 mg increments (1 ml) §171 Drug Reference EPINEPHRINE 1:1000 Anaphylaxis – use IM Route Asthma – use Subcutaneous (SC) Route NEVER GIVE EPINEPHRINE 1:1000 VIA IV ROUTE Concentration = 1 mg/ml Dose = 0.01 mg/kg IM or SC Maximum Dose 0.3 mg IM / SC COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) 0.04 mg 0.04 ml IM / SC Pink (6-7 kg) 0.06 mg 0.06 ml IM / SC Red (8-9 kg) 0.08 mg 0.08 ml IM / SC Purple (10-11 kg) 0.1 mg 0.1 ml IM / SC Yellow (12-14 kg) 0.13 mg 0.13 ml IM / SC White (15-18 kg) 0.17 mg 0.17 ml IM / SC Blue (19-23 kg) 0.21 mg 0.21 ml IM / SC Orange (24-29 kg) 0.27 mg 0.27 ml IM / SC Green (30-36 kg) 0.3 mg 0.3 ml IM / SC 40 kg 0.3 mg 0.3 ml IM / SC 45 kg 0.3 mg 0.3 ml IM / SC 172§ Drug Reference INTRANASAL FENTANYL (IN) INDICATION – PAIN MANAGEMENT Concentration = 50 mcg/ml Dose = 1.5 mcg/kg INTRANASAL (IN) Intranasal dosing is single dose only – base contact required for repeat doses COLOR DOSE (mcg) GIVE (ml) Gray (3-5 kg) Not given Pink (6-7 kg) 9 mcg 0.18 ml Red (8-9 kg) 12.5 mcg 0.25 ml Purple (10-11 kg) 15 mcg 0.3 ml Yellow (12-14 kg) 20 mcg 0.4 ml White (15-18 kg) 25 mcg 0.5 ml Blue (19-23 kg) 30 mcg 0.6 ml Orange (24-29 kg) 40 mcg 0.8 ml Green (30-36 kg) 50 mcg 1 ml 40 kg 60 mcg 1.2 ml* 50 kg 75 mcg 1.5 ml* 60 kg 90 mcg 1.8 ml* 70 kg or over 100 mcg 2 ml* * DIVIDE DOSAGE OVER 1 ML BETWEEN BOTH NARES §173 Drug Reference FENTANYL IV / IM INDICATION – PAIN MANAGEMENT Concentration = 50 mcg/ml Dose = 1 mcg/kg IV or IM Single dose only – base contact required for repeat doses COLOR DOSE (mcg) GIVE (ml) Gray (3-5 kg) Not given Pink (6-7 kg) 6 mcg 0.12 ml Red (8-9 kg) 8 mcg 0.16 ml Purple (10-11 kg) 10 mcg 0.2 ml Yellow (12-14 kg) 12.5 mcg 0.25 ml White (15-18 kg) 15 mcg 0.3 ml Blue (19-23 kg) 20 mcg 0.4 ml Orange (24-29 kg) 25 mcg 0.5 ml Green (30-36 kg) 35 mcg 0.7 ml* 40 kg 40 mcg 0.8 ml* 45 kg 45 mcg 0.9 ml* *IV doses above 25 mcg can be titrated to effect beginning with 25 mcg increment. 174§ Drug Reference FLUID BOLUS INDICATION – SHOCK / HYPOTENSION NORMAL SALINE BOLUS = 20 ml/kg IV Maximum single bolus = 500 ml COLOR GIVE (ml) Gray (3-5 kg) 80 ml Pink (6-7 kg) 130 ml Red (8-9 kg) 170 ml Purple (10-11 kg) 210 ml Yellow (12-14 kg) 260 ml White (15-18 kg) 340 ml Blue (19-23 kg) 420 ml Orange (24-29 kg) 500 ml Green (30-36 kg) 500 ml 40 kg 500 ml 45 kg 500 ml §175 Drug Reference GLUCAGON INDICATION – HYPOGLYCEMIA Concentration = 1 mg/ml Dose = 0.5 – 1 mg/ml IM COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) 0.5 mg 0.5 ml Pink (6-7 kg) 0.5 mg 0.5 ml Red (8-9 kg) 0.5 mg 0.5 ml Purple (10-11 kg) 0.5 mg 0.5 ml Yellow (12-14 kg) 0.5 mg 0.5 ml White (15-18 kg) 0.5 mg 0.5 ml Blue (19-23 kg) 0.5 mg 0.5 ml Orange (24-29 kg) 1 mg 1 ml Green (30-36 kg) 1 mg 1 ml 40 kg 1 mg 1 ml 45 kg 1 mg 1 ml 176§ Drug Reference LIDOCAINE INDICATION – PAIN MANAGEMENT FOR IO (PATIENTS NOT IN ARREST) Concentration = 2% (100 mg / 5 ml) Dose = 0.5 mg/kg IO – 20 mg max COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) Not given Pink (6-7 kg) 3 mg 0.15 ml Red (8-9 kg) 4 mg 0.2 ml Purple (10-11 kg) 5 mg 0.25 ml Yellow (12-14 kg) 7 mg 0.35 ml White (15-18 kg) 9 mg 0.45 ml Blue (19-23 kg) 10 mg 0.5 ml Orange (24-29 kg) 14 mg 0.7 ml Green (30-36 kg) 16 mg 0.8 ml 40 kg 20 mg 1 ml 45 kg 20 mg 1 ml §177 Drug Reference MIDAZOLAM INDICATION – SEIZURE Concentration = 5 mg/ml Dose = 0.1 mg/kg IV or IM Titrate IV dosage in 0.5-1 mg (0.1-0.2 ml) increments to desired effect (seizure cessation) or maximum dose listed IM administration - single dose only COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) 0.5 mg 0.1 ml Pink (6-7 kg) 0.75 mg 0.15 ml Red (8-9 kg) 0.85 mg 0.17 ml Purple (10-11 kg) 1 mg 0.2 ml Yellow (12-14 kg) 1.25 mg 0.25 ml White (15-18 kg) 1.75 mg 0.35 ml Blue (19-23 kg) 2 mg 0.4 ml Orange (24-29 kg) 2.75 mg 0.55 ml Green (30-36 kg) 3.25 mg 0.65 ml 40 kg 4 mg 0.8 ml 45 kg 4.5 mg 0.9 ml 178§ Drug Reference NALOXONE INDICATION – RESPIRATORY DEPRESSION Concentration = 1 mg/ml Dose = 0.1 mg/kg IV or IM Maximum single dose = 2 mg (may be repeated) Naloxone is available in other concentrations This chart is correct for 1 mg/ml concentration COLOR DOSE (mg) GIVE (ml) Gray (3-5 kg) 0.4 mg 0.4 ml Pink (6-7 kg) 0.7 mg 0.7 ml Red (8-9 kg) 0.9 mg 0.9 ml Purple (10-11 kg) 1 mg 1 ml Yellow (12-14 kg) 1.3 mg 1.3 ml White (15-18 kg) 1.7 mg 1.7 ml Blue (19-23 kg) 2 mg 2 ml Orange (24-29 kg) 2 mg 2 ml Green (30-36 kg) 2 mg 2 ml 40 kg 2 mg 2 ml 45 kg 2 mg 2 ml §179 Drug Reference WEIGHT CONVERSION Always Document Weight in kg COLOR Kg Pounds Gray 3-5 kg 6-11 lbs Pink 6-7 kg 13-15 lbs Red 8-9 kg 17-20 lbs Purple 10-11 kg 22-25 lbs Yellow 12-14 kg 27-32 lbs White 15-18 kg 34-41 lbs Blue 19-23 kg 42-52 lbs Orange 24-29 kg 54-65 lbs Green 30-36 kg 67-80 lbs 40 kg 40 kg 90 lbs 45 kg 45 kg 101 lbs 180§ Drug Reference §181 Drug Reference contra costa county emergency medical services agency 1340 arnold drive, ste. 126 martinez ca 94553 925-646-4690 phone 925-646-4379 fax www.cccems.org 182§ MULTICASUALTY INCIDENTS (MCI) TIER DEFINITIONS and EXAMPLES TIER ZERO • Official notification of an incident that has the potential to result in activation of the MCI plan at a higher tier, even when the number of known victims is zero • Activation at this tier is required for a Community Warning System Level II or Level III incident or any receiving hospital Emergency Department closure or evacuation (not diversion or trauma bypass) • Other examples of this might include active shooter where number of victims unknown or cannot be confirmed, emergency landing at airport, actual or potential significant hazmat incident, including transportation incidents TIER ONE • An incident involving 6–10 patients when the scene is contained and the number of patients is not expected to rise significantly • Examples include a multi-vehicle traffic collision, multiple known shooting victims and no ongoing active shooter threat TIER TWO • An incident involving more than 10 patients OR an incident involving less than 10 patients when there is a substantial chance that the number of patients may rise • EMS Transportation Resource Ordering will be processed by EMS Operational Area Communications Center (Sheriff’s Dispatch) • Examples include a petrochemical incident with a dispersal cloud moving over a populated area, passenger train derailment, or an active shooter with an uncontained scene TIER THREE • Any incident involving more than 50 patients, mass casualties, or a reasonable expectation of mass casualties • EMS Transportation Resource Ordering will be processed by EMS Operational Area Communications Center (Sheriff’s Dispatch) • Examples include a significant explosion around occupied commercial or multi-resident structure, or in a heavily populated area, or a large-scale evacuation of a hospital or skilled nursing facility PAIN RATING SCALE 0 1–2 MILD 3–4 5–6 MODERATE 7–8 9–10 SEVERE ESCALA DE VALORACIÓN DE DOLOR 0 1–2 LEVE 3–4 5–6 MODERADO 7–8 9–10 SEVERO
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