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Item D03 D3 BOARD OF COUNTY COMMISSIONERS COUNTY of MONROE Mayor Craig Cates,District 1 The Florida Keys Mayor Pro Tern Holly Merrill Raschein,District 5 Michelle Lincoln,District 2 James K.Scholl,District 3 David Rice,District 4 Board of County Commissioners Meeting July 19, 2023 Agenda Item Number: D3 2023-1171 BULK ITEM: Yes DEPARTMENT: Fire Rescue TIME APPROXIMATE: STAFF CONTACT: Chief Callahan N/A AGENDA ITEM WORDING: Issuance (renewal) of a Class A Certificate of Public Convenience and Necessity(COPCN) to National Health Transport, Inc., for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2023 through August 16, 2025. National Health Transport, Inc. is not permitted to perform 911 emergency response work in Monroe County. ITEM BACKGROUND: On July 21, 2017 a Class A COPCN was renewed for National Health Transport, Inc. to operate an ALS inter-facility transport ambulance service in all geographical locations of Monroe County, Florida. This certificate will be expiring on August 16, 2023. In view of the foregoing National Health Transport, Inc. is applying to renew this COPCN which would become effective August 17, 2023 and expire August 16, 2025. PREVIOUS RELEVANT BOCC ACTION: 7/15/15: MCBOCC approved the issuance (renewal) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2015 through August 16, 2017. 7/19/17: MCBOCC approved the issuance (renewal) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2017 through August 16, 2019. 7/17/19: MCBOCC approved the issuance(renewal)(C.10) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2019 through August 16, 2021. 7/21/21: MCBOCC approved the issuance(renewal)(C.13) of a Class A COPCN to National Health Transport, Inc. for the operation of an ALS inter-facility transport ambulance service for the period August 17, 2021 through August 16, 2023. CONTRACT/AGREEMENT CHANGES: N/A 371 STAFF RECOMMENDATION: Approval DOCUMENTATION: National Health Transport Class A COPCN Application 2023—Redacted.pdf National Health Certificate.pdf FINANCIAL IMPACT: Effective Date: 08/17/23 Expiration Date: 08/16/25 Total Dollar Value of Contract: N/A Total Cost to County: N/A Current Year Portion: N/A Budgeted: N/A Source of Funds: N/A CPI: N/A Indirect Costs: N/A Estimated Ongoing Costs Not Included in above dollar amounts: N/A Revenue Producing: N/A If yes, amount: N/A Grant: N/A County Match: N/A Insurance Required: Yes, per Statutory Requirements 372 MONROE COUNTY, FLORIDA APPLICATION FOR CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY(COPCN) CLASS A EMERGENCY MEDICAL SERVICE wa uiuu� m . MIN uwa � mwwwuuur (PRINT OR TYPE) ❑ INITIAL APPLICATION-$950.00 J11 RENEWAL APPLICATION-$475.00 IF RENEWAL,PLEASE LIST NUMBER OF PREVIOUS CERTIFICATE:# y` . I. NAME OF SERVICE NATIONAL HEALTH TRANSPORT INC. 2290 NW 110TH AVENUE SWEET BUSINESS MAILING ADDRESS 1111111111 _WATER, FL 33172 BUSINESS PHONE NUMBER 305-636-5509 EMERGENCY PHONE NUMBER 3 ... 05-479-3471 2. TYPE OF OWNERSHIP i.e.,Sole Proprietor,Partnership,Corporation,etc. S-C RP DATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 01/15/2010 3. LIST ALL OFFICERS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necessary): NAME AGE ADDRESS F365 PHONE# POSITION/TITLE RAUL RODRIGUEZ 44 215 SW125TH AVE,MIAMI,FL 3318479-3471 CEO 4. LEVEL OF CARE TO BE PROVIDED: ❑BLS or N ALS IF ALS:❑TRANSPORT or❑NON TRANSPORT 5. DESCRIBE THE ZONES(S)THAT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if necessary): MONROE COUNTY INTERFACILITY TRANSPORTS IN ALLGEOGRAPHICAL LOCATIONS WITHIN MONROE COUNTY, FLORIDA. 6. LIST THE ADDRESS AND/OR DESCRIBE THE LOCATION OF YOUR BASE STATION AND ALL SUB- STATIONS(Use separate sheet if necessary): BASE STATION 19970 OVERSEAS HWY, SUGARLOAF KEY, FL 33040 SUB-STATION Page 1 of 6 373 7. DESCRIBE YOUR COMMUNICATION SYSTEM(Attach copy of all FCC licenses): � UE. ......__ - .......... F NCIES CALL NUMBERS #OF MOBILES #OF PORTABLES RADIO ATTACHED 8. LIST THE NAMES AND ADDRESSES OF THREE(3)U.S.CITIZENS WHO WILL ACT AS REFERENCES FOR YOUR SERVICE: �.._....�_ .......... _ �_. .. .. NAME ADDRESS TERESITA FERNANDEZ 481 W 40TH PL, HIALEAH, FL 33012 ALEXIS MANTECON 3267 RIVIERA DR, CORAL GABLE 33143 �S, FL DANIE..L...ESPINO _..�..1 ,,- n�_.. D-eY �I .s� � ��` r tl 9. ATTACH A SCHEDULE OF RATES WHICH YOUR SERVICE WILL CHARGE DURING THE COPCN PERIOD. 10. PROVIDE VERIFICATION OF ADEQUATE INSURANCE COVERAGE DURING THE COPCN PERIOD. 11. ATTACH A COPY OF YOUR SERVICE'S CONTRACT WITH A MEDICAL DIRECTOR. 12. ATTACH A COPY OF ALL STANDING ORDERS AS ISSUED BY YOUR MEDICAL DIRECTOR. 13. ATTACH A CHECK OR MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE TO THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. I,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,DO HEREBY ATTEST MY SERVICE MEETS ALL OF THE REQUIREMENTS FOR OPERATION OF AN EMERGENCY MEDICAL SERVICE IN MONROE COUNTY AND THE STATE OF FLORIDA. I FURTHER ATTEST THAT ALL THE INFORMATION CONTAINED IN THIS APPLICATION,TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT, SIGNATURE OF PLICAN /AU ti *T'11ZED ES'111'TENTATIVE NOTARY SE LI -..., ALISSAD.GARCiIA MY COMMISSION#HH 151116 a - 'FaP woe 8wd d ru NN0"Public rWe Undervrtite►s n o`= EXPIREY DATE Page 2 of 6 374 All EMT-STATE Certifications On Record in District 100 Abad, Edel A EMT 566251 12/1/2024 Abreu, Crystal EMT579882 12/1/2024 Alonso,Jorge A EMT576547 12/1/2024 Amaro, Aramis EMT576926 12/1/2024 Artica, Bryan A EMT580631 12/1/2024 Artimez,Alberto EMT562425 12/1/2024 Banos,Angel EMT571770 12/1/2024 Borja, Hector A EMT560746 12/1/2024 Brown, Randolph EMT 578416 12/1/2024 Brown,Stephen M EMT 546579 12/1/2024 Cabrero,Juan Carlos EMT576256 12/1/2024 Cano,Jonathan EMT544248 12/1/2024 Carbonell, Mario EMT579584 12/1/2024 Carias,Sean G EMT 580899 12/1/2024 Carrion,Jacob EMT 579455 12/1/2024 Carvajal, Matthew L EMT579620 12/1/2024 Castano,Zachary EMT574733 12/1/2024 Delima, Miguel A EMT581417 12/1/2024 Diaz, Darian EMT570566 12/1/2024 Diaz,Jeremy J EMT 562571 12/1/2024 Diaz Piazza,Santiago EMT582674 12/1/2024 Egued,Victoria EMT574702 12/1/2024 Escobar, Summer L EMT 581369 12/1/2024 Fernandez,Yudelis EMT567234 12/1/2024 Gabriel-Mitchell,Christopher EMT308603 12/1/2024 Genty, Kendley EMT579997 12/1/2024 Gonzalez,Carlos A EMT535586 12/1/2024 Gonzalez,Justin EMT563984 12/1/2024 Gonzalez, Rafael EMT559862 12/1/2024 Guitian, Eric C EMT547288 12/1/2024 Hernandez, Eduardo D EMT560213 12/1/2024 Ibanga, Idara E EMT579879 12/1/2024 Was,Jancar I EMT565355 12/1/2024 Jewett, Nicholas A EMT556948 12/1/2024 375 Jones,Jonathan X EMT567659 12/1/2024 Loctar,Joshua EMT569940 12/1/2024 Martin, Blake E EMT560303 12/1/2024 Martin, Kyle M EMT579655 12/1/2024 Mckenna,Tiffany L EMT530729 12/1/2024 Mederos,Jonathan EMT576335 12/1/2024 Montes,Anaisie G EMT573747 12/1/2024 Moss, Keirandra EMT573529 12/1/2024 Nunez,Joe M EMT 555285 12/1/2024 Otero, Ryan A EMT581264 12/1/2024 Peng,Jennifer M EMT 581570 12/1/2024 Perez, Arturo EMT 563364 12/1/2024 Perez,Jonathan T EMT576047 12/1/2024 Perez,Yoelvis EMT560568 12/1/2024 Perez Rojas, Dianelis EMT576255 12/1/2024 Plasencia,Jorge A EMT580207 12/1/2024 Prentice, Byron R EMT571752 12/1/2024 Pulido, Luciano EMT574671 12/1/2024 Rodriguez,James EMT 570724 12/1/2024 Roldan, Claudio EMT582692 12/1/2024 Romero, Brian A EMT559070 12/1/2024 Ruiz,Adrian A EMT580588 12/1/2024 Ruiz,Jaslyn EMT576569 12/1/2024 Santa,Jose A EMT577170 12/1/2024 Silva,Joshua EMT576735 12/1/2024 Siqueira, Christopher C EMT 580727 12/1/2024 Solano, Manuel A EMT558479 12/1/2024 Sparkman, Dorothy M EMT 580318 12/1/2024 Tellez,Jorge EMT576970 12/1/2024 TERRY, ZACHARY EMT582456 12/1/2024 Torres, Karina W EMT573992 12/1/2024 Vandelanotte,Tristan EMT575259 12/1/2024 Veintemilla Ratto, CarlosJavier EMT578568 12/1/2024 Verdi, Daniella S EMT581186 12/1/2024 Victoria, Mark EMT572968 12/1/2024 Yousif, Michael K EMT582274 12/1/2024 376 All PARAMEDIC-STATE Certifications On Record in District 100 Alexandre,James PMD522923 12/1/2024 Alonso,Jorge A PMD542014 12/1/2024 Arellana, Brandy PMD542465 12/1/2024 Cano,Jonathan PMD530851 12/1/2024 Fernandez, Steven A PMD532947 12/1/2024 Fernandez, Yudelis PMD542757 12/1/2024 Gonzalez,Justin PMD539713 12/1/2024 Henry, Hayley PMD542261 12/1/2024 Hernandez, Eduardo PMD535591 12/1/2024 D Marti,Sergio PMD522969 12/1/2024 Meana, Felix H PMD541964 12/1/2024 Pierre, Geraldine PMD521233 12/1/2024 Rodriguez,James PMD542359 12/1/2024 Silva,Joshua PMD542683 12/1/2024 Silveira, Benet J PMD542698 12/1/2024 Solano, Manuel A PMD539305 12/1/2024 Tellez,Jorge PMD542675 12/1/2024 377 /-%1 v 1 U U 1-M NCE License HRS ALS or Transport or TYPE MODEL YEAR MILEAGE Chassis# Tag Vehicle# BLS Non II FORD 2016 214601 1 FDYR2CM4GKA54513 MIP09L 5008 BLS Transport II FORD 2016 171585 1 FDYR2CM3GKA69018 MIV25E 5009 BLS Transport II FORD 2016 199750 1 FDYR2CM5GKA50812 MIP12L 5017 BLS Transport II FORD 2017 156466 1FDWE3FS3HDC34249 MIS12Z 5924 BLS Transport II FORD 2016 183790 1 FDYR2CM2GKA50816 MIP11A 5013 BLS Transport II FORD 2016 201254 1FDYR2CM1GKA66053 MIP07L 5016 BLS Transport II FORD 2016 192475 1 FDYR2CMXGKA66052 MIP14A 5015 BLS Transport II FORD 2016 179482 1 FDYR2CMOGKA66044 MIP10L 5012 BLS Transport II FORD 2016 183760 1 FDYR2CMXGKA54516 MIP12A 5011 BLS Transport II CHEV 2009 422841 1GBJG316291183546 MIS90E 6095 BLS Transport II Ram 2019 125492 3C6TRVDG5KE563084 MIS86E 22965 ALS Transport II Ram 2019 97625 3C6TRVDG7KE563071 MIS83E 22966 ALS Transport II FORD 2009 218042 1FDSS34P99DA84414 NZV109 23059 ALS Transport II CHEV 2009 344358 1GBHG396791117612 MIV89P 23060 ALS Transport II CHEV 2009 274163 1GBHG396691182970 MIV90P 23061 ALS Transport II Ram 2019 85872 3C6TRVDGXKE536933 MIU761 23062 ALS Transport II Ram 2019 95698 3C6TRVDGOKE536942 MIU751 23063 ALS Transport II FORD 2018 197476 1 FDYR2CM5JKA07157 PJZD26 23152 ALS Transport II Ram 2019 77342 3C6TRVDG4KE559768 MIU841 23231 ALS Transport II Ram 2019 69009 3C6TRVDG1KE559775 MIU821 23232 ALS Transport II Ram 2019 63904 3C6TRVDG2KE559767 MIU831 23233 ALS Transport 11 Ram 2019 84311 3C6TRVDGOKE559766 MIU871 23280 ALS Transport II Ram 2019 87841 3C6TRVDG6KE559772 MIU861 6215 BLS Transport II Ram 2019 90863 3C6TRVDG2KE559770 MIU881 23282 ALS Transport II Ram 2021 73520 3C6ERVDG3ME502263 MIV16E 23362 ALS Transport II Ram 2021 130708 3C6ERVDG6ME502256 MIV18E 23364 ALS Transport II Ram IT 2022 23169 3C6LRVDG9NE124989 MIV02Q 6885 BLS Transport II Ram 2022 10670 3C6LRVDG2NE125000 MIV03Q 6886 BLS Transport II FORD 2018 168498 1 FDYR2CM3JKA00059 MIV05Q 6916 BLS Transport II RAM 2022 26277 3C6LRVDG3NE140864 MIV09Q 6915 BLS Transport II RAM 2022 1236 3C6LRVDG3NE142050 MIV10Q 6932 BLS Transport II RAM 2023 3926 3C6LRVDG2PE519213 MI 112Q 6946 BLS Transport II RAM 2023 3534 3C6LRVDG8PE519183 MIV13Q 6947 BLS Transport III FORD 2019 105652 1 FDXE4FS7KDC41500� NYS149 23057 ALS Transport III GMC 2020 72966 7GZ67VCGXLN005986 ftPGKU61 23153 ALS Transport III CHEV 2013 332264 1GB3G3CL3D1146610 EV67 20660 ALS Transport III FORD_ 2008 338342 1GBJG316981139817 91P 18290 ALS Transport 378 6L£ _....... .... .............._. ,.....__..........m m..._...... .......... w w A N co O M CD CDw z ° p O N 0 0 0 0 [� O N 0�0 T r M m 00 W 8 ems.. ... .. ...-........N.ii .... LL LL LL LL LL LL LL s ri4 �w.m .. ..._ ....., 't i W v w a � a w A A A W e+ � w c3 � z o � > r i Q 3U 1 ------- - . ......... ............ N ww O o � a wH A N _ > J xx a A N _O Ca (u E A F U O = O W (u LL N Q = Q m F d vi ) O 'Z N F. •F CDrl C w Q V L a) cm CU y LL C� a wW F xa AV NATIONAL rRANSPORT EMS RATES SCHEDULE ADVANCED LIFE SUPPORT Base Rate $800.00 Mileage (per transported mile) $10.85 Oxygen $32.55 Waiting Time (per 1/ hour) $300.00 Special Handling $86.80 BASIC LIFE SUPPORT Base Rate $550.00 Mileage (per transported mile) $10.85 Oxygen $32.55 Waiting time (per % hour) $220.00 Special Handling $43.40 19970 Overseas Highway,Sugarloaf Key FL 33040 1 OFFICE: 305-636-5555 1 FAX:305-636-5503 WWW.NATIONALHEALTHTRANSPORT.COM 380 _._�... ............ �® CERTIFICATE OF LIABILITY INSURANCE DATE`MMIDD"YYY) 05/3012023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT': If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER A MARSH USA,LLC. NAME: - PHONE FAX .... .. 1221 Brickell Avenue,Suite 1550 WC,No,Ex* talc,No): Miami,FL 33131 E-MAIL ADDRESS: INSURERIS)AFFORDING COVERAGE _ NAIC# CN110033400-WAGP-23-24 INSURER A:Old Republic Insurance Co 24147 INSURED R INSURE B:Covers Speclal6 Insurance Company 15686 National Health Transport,Inc. - k' i � 2290 NW 11 OTH Ave INSURER C: Sweetwater,FL 33172-1923 INSURER D INSURER E: INSURER F: �rvry -- ......... .... COVERAGES CERTIFICATE NUMBER: ATL-005439277-06 REVISION NUMBER: 2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LSI TYPE OF INSURANCE ... "1ADDLAUBR' POLICY EFF POLICY EXP ..... ........ ..._... INSR POLICY NUMBER MM1DDfM"M"yYp gMMIDD/YYYY LIMITS B �_ �.� �. X COMMERCIAL GENERAL LIABILITY 005FL000036286 06/23/2022 06/23/2023 EACH OCCURRENCE $ 1,OOQ000 DAMAGE TO ❑ SESCLAIMS-MADE X OCCUR (Ea occurrence� -- -. .... MED EIXP(Any one person) I $ 55000 PERSONAL&ADV INJURY 1$ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES LOC I' PRODUOTS-COM AT $ 3,000,000 GGREGATE X POLICY AGG I$ .....3,000,000.. . OTHER: '',. .... is .... ......... A AUTOMOBILE LIABILITY_..... .. MWTB 313612 23....._..._. 06101/2023 06I01/2024 E MBINED SINGLE LIMIT $ 1,000,000 Y g BODILY INJURY a accident X .ANY AUTO "Auto Physical Damage" URY(Per person) $ OWNED SCHEDULED "Comprehensive Ded:$1,000" BODILY INJURY P AUTOS ONLY _ 1 AUTOS (Per accident) $ X 1HIRED X NON-OWNED "Collision Ded:$1,000" PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ 1 1 UMBRELLA LIAR IOCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ A WORKERS COMPENSATION MWC 313611 23 _mm ��1 17"1,� 06/01/20_�4 1 X PER__ OTH- $ __M AND EMPLOYERS'LIABILITY Y/N ,...._. STATUTIE ER ANYPROPRIETOR/PARTNERIEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000' OFFICER/MEMBEREXCLUE N NIA --. ,.. ..... (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 yes, O under D E.L.DISEASE-POLICY LIMIT $ DESCRIPTION N OF OPERATIONS below 1,000,000 B Professional Liability 005FL000036286 06/2312022 06/23/2023 Limit Per Claim l 1,000,000 Aggregate 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLE S(ACORD 101,Additional Remarks Schedule,may be attached it more space is � _ _._.........._-�®IT ..--_....... ..........- y � required) ........ -.. ..... ..............—_ ._... ,........ .._..-.._,........_ CERTIFICATE HOLDER CANCELLATION Monroe County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1100 Simonton Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Key West,FL 33040 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 381 AGREEMIENT This constitutes the agreement between National Health Transport(Corporation)and Z Medical, LLC(ZMED) effective August 1, 2023. A) RECITALS WHEREAS, the Corporation, in accordance with Florida Statutes operates an Emergency Medical Services System which include advanced life support. WHEREAS, ZMED has authority to contract Michael J. Zappay MD(Physician)who is duly licensed to practice medicine and is qualified to be the Medical Director of any advanced life support provider in accordance with Florida Statutes. WHEREAS, the Corporation desires Physician to serve as its Medical Director of Emergency Medical Services, both parties agree to the following: B) RIGHTS AND RESPONSIBILITI[ES OF PHYSICIAN 1. Physician shall be the sole Medical Director of Emergency Medical Services for the Corporation. Physician may designate another qualified director(as per Florida Statutes)to serve as acting Medical Director in periods of his absence. Corporation will be notified in advance of such periods. 2. Physician or his designee will be available for 24 hours a day by telecommunications. 3. Physician shall comply with all state and HRS regulations regarding medical direction and advanced life support services. 4. Physician solely maintains the right to set all standards and protocols regarding patient care including,but not limited to, determination of any employee's eligibility to perform patient care. 5. Physician shall oversee and provide medical direction for the paramedics and EMT's working for the Corporation, 6. Physician shall develop and review standing orders and protocols. 7. Physician shall review transport policies(including trauma)to assure patients are optimally triaged. 8. Physician shall assist with the continuing medical education of personnel under his supervision. 9, Physician will help in the development and implementation of a patient care quality assurance system. 10. Physician will ride in the EMS system minimum of 10 (ten)hours annually. Q1.RIGHTS AND RESPONSIBILTEES OF CORPORATION Corporation shall employ appropriate personnel and have and maintain appropriate equipment to provide optimal Emergency Medical Services as dictated by the to of Florida and the Physician. 2. Corporation shall appoint a paramedic to assist Physician in implementation of quality assurance system. 3.. Corporation shall provide clerical, administrative, and material support to to Physician to carry out duties outlined in this document. CI) LIABILITY 1. Corporation shall maintain liability insurance covering the acts and omissions of its employees to include without limitation all paramedics, emergency medical technicians, ambulance drivers, attendants, etc. 2. Corporation shall include Physician on its liability insurance policy to cover all his duties as Medical Director in an amount not less than one million dollars. 3 Corporation agrees to indemnify and hold ha lessthe Physician from any and all claims, actions, liability, loss, expenses, or damages whatsoever including attorney's fees arising out of acts or omissions by the Corporation's employees or contractors. CH) COMIPENSATION 1, Z Medical ,LLC shall be regarded as an independent contractor and will be paid two thousand five hundred dollars per month for Services of Physician, payable by the 51 of each month following the on of service. CHI) TERM 1. The to of this agreement shall be from August 1, 2023 through July 31, 2024. Z This agreement may be terminated immediately for breach of any oft e covenants contained herein. 383 3. All notices hereunder shall be in writing and delivered in person, by telecopy, or by certified ail, tot efollowing-, For thePhysician: Michael J. Zappa,M.D. Medical, LC 12374 SW Sand Dollar Way Port St. Lucie,FL 34987 For the Corporation: National Health Transport 2290 NW 110'avenue Miami,FL 3317 ZMED/PHYSICIAN CORPORATION .. w, , Mid"��el �pp� ,M.D. National HeaA Transport Date: Date: 5/12/23 r, 384 �0 M Federal Communications Commission W Z Public Safety and Homeland Security Bureau �sa RADIO STATION AUTHORIZATION LICENSEE: NATIONAL HEALTH TRANSPORT INC Call Sign File Number WQYV' 0007636303 Radio Service ATTN:RAUL RODRIGUEZ PW-Public Safety Pool,Conventional NATIONAL HEALTH TRANSPORT INC 2950 NW 7TH AVE MIAMI,FL 33127 Regulatory Status PMRS Frequency Coordination Number FCC Registration Number(FRN): 0026,157818 PS20170200025 Grant Date Effec#ve1w4i Expiration Date Print Date 02-06-2017 02-06-2017 " ^ 02-06-2027 02-07-2017 STATION TECHNICAL SPECIFICATIONS Fixed Location Address or.Mobile Area of Operations Loc.1 Area of operation _ Countywide:BROWARD,FL Antennas Loc Ant Frequencies Sta. No. No. Emission Output ERP Ant. Ant. Construct No. No. (MHz) Cls. Units Pagers Designator Power (watts) Ht./Tp AAT Deadline (watts) meters meters Date 1 1 000463.00000000 MO 20 11K2F3E 100.600 100.000 02-06-2018 1 1 000463.18750000 MO 20 IMME /100.000, 100.000 02-06-2018 1 1 000468.00000000 MO 20 I MME ',100'000, 100.000 02-06-2018 1 1 000463.02500000 MO 20 I MME 100.000 160.090 02-06-2018 1 1 000468.02500000 MO 20 11K2173E 1'00.006 _100.0010 02-06-2018 1 1 000463.05000000 MO 20 11K2F3E 100.000 100.006 02-06-2018 Conditions: Pursuant to§309(h)of the Communications Act of 1934,as amended,47 U.S.C. §309(h),this license is subject to the following conditions: This license shall not vest in the licensee any right to operate the station nor any right in the use of the frequencies designated in the license beyond the term thereof nor in any other manner than authorized herein. Neither the license no!the right granted thereunder shall be assigned or otherwise transferred in violation of the Communications Act of 1934,as amended. See 47 U.S.C.§310(d). This license is subject in terms to the right of use or control conferred by§706 of the Communications Act of 1934,as amended. See 47 U.S.C. §606. FCC 601-ULSHSI Pagel of 4 August 2007 385 Licensee Name: NATIONAL HEALTH TRANSPORT INC Call Sign:WQYV706 File Number: 0007636303 Print Date:02-07-2017 Antennas Loc Ant Frequencies Sta. No. No. Emission Output ERP Ant. Ant. Construct No. No. (MHz) Cls. Units Pagers Designator Power (watts) HtJTp AAT Deadline (watts) meters meters Date 1 1 000468.05000000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.0750000Q MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.07500000`, MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.10000000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.10000000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.12500000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.12500000 MQ ?0 I MME 100.000 100.000 02-06-2018 1 1 000463.15000000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.18750000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.01250000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.01250000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.03750000 MO 20 1IK2F3E 100.000 100.000 02-06-2018 1 1 000468.03750000 MO 20 11OME 100:900 100.000 02-06-2018 1 1 000463.06250000 MO 20 11 k2F3E 100.000 100.000 02-06-2018 1 1 000468.06250000 MO 20 11K2F3E 1WOW 100.000 02-06-2018 1 1 000463.08750000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.08750000 MO 20 11K2F3E 100.000 100.600 02-06-2018 1 1 000463.11250000 MO 20 11K2F3E 1100.000 190'000 02-06-2018 1 1 000468.11250000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.13750000 MO 20 11K2F3E 100.000 1.00.600 02-06-2018 FCC 601-ULSHSI Page 2 of 4 August 2007 386 Licensee Name: NATIONAL HEALTH TRANSPORT INC Call Sign:WQYV706 File Number: 0007636303 Print Date:02-07-2017 Antennas Loc Ant Frequencies Sta. No. No. Emission Output ERP Ant. Ant. Construct No. No. (MHz) Cls. Units Pagers Designator Power (watts) Ht./Tp AAT Deadline (watts) meters meters Date 1 1 000462.98750000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000467.98750000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.13750000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.16250000 MO 20 11 K2173E 100.000 100.000 02-06-2018 1 1 000468.16250000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000462.95000000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000467.95000000 mo '2(N HUME 100.000 100.000 02-06-2018 1 1 000462.96250000 N10 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000467.96250000 MO 2,0 11K2F3E 100.000 100.000 02-06-2018 1 1 000462.97500000 MO 201 11K2F3E 100.000 100.000 02-06-2018 1 1 000467.97500000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000468.15000000 MO 20 11K2F3E 100.000 100.000 02-06-2018 1 1 000463.17500000 MO 20 11K2F3E 1K000 100.000 02-06-2018 1 1 000468.17500000 MO 20 11k2F3E 100.0,00 100.000 02-06-2018 Control Points Control Pt.No. 1 Address:2950 NW 7th Ave City:Miami County: MIAMI-DADE State:FL Telephone Number:(305)636-5510 Associated Call Signs <NA> FCC 601-ULSHSI Page 3 of 4 August 2007 387 Licensee Name: NATIONAL HEALTH TRANSPORT INC Call Sign:WQYV706 File Number: 0007636303 Print Date: 02-07-2017 Waivers/Conditions: NONE FCC 601-ULSHSI Page 4 of 4 August 2007 388 �� BOARD OF COUNTY COMMISSIONERS County of Monroe ' 'IP t Mayor Craig Cates,District 1 The Florida Keys 1 Mayor Pro Tem Holly Merrill Raschein,District 5 f Michelle Lincoln,District 2 James K.Scholl,District 3 - ��.�'' David Rice,District 4 Monroe County Fire Rescue 490 63Td Street Ocean Marathon,FL 33050 Phone(305)289-6004 �" MEMORANDUM TO: Nicole Lyons FROM: Cara Johnson SUBJECT: Check for Deposit- COPCN DATE: June 14, 2023 ...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Attached please find Check_and_ dated June 12, 2023 in the amount of$475.00 per check to be deposited in revenue account 141-342000-RC 00345.These checks have been issued for the renewal application of a Class A and Class B Certificate of Public Convenience for National Health Transport Inc. Thank you, Ca4r, ;'6� Cara Johnson 389 Yls,�":u%;".�'=�m,�,„,�Rm,.+ ,.:u�rw.,rv,.�i5.✓.��'�.,, r�.�"✓*.,:',-.1 '��Y!�'9�V„�$Y�„,w�1,�,''i '"F11�i,�ri�n.'�w�".w$"w71w.�iAa�%ip„.� ;„;��'C�`iatwww..^°'"uV�Wtiw"�'"'�'m`u7.w"c�lie' rT°wimdurh+w, dµ%�tv'udm". rMM,�Hn�Wero�'.w� r7R'�"tl�'�a;'�4 (" 81=275/829 _ NATIONAL HEALTH TRANSPORT INC. VARIABLE ACCOUNT 2950 NON 7TH AVENUE baTE MIAMI,FLORIDA 33127 PAY TOT 42E' ORUEROF P � s $ DOLLARS w.. i 0,1011 err. r o my=bank.eom Iv � 11 t i f t r ( l 0 7 k { a s d 390 �M an j , r r 2023 EMS Procedures, and Policies 391 PP,r>-Mr> The following document is designed to enhance the delivery of state of the art emergency care to all those we serve. It reflects the latest in pre-hospital research as well as guidelines promulgated by local, state and national organizations, including the American Heart Association. The protocols define provider roles. The Paramedic action(s) are identified by P. The EMT-B action(s) are identified by E. When Medical Control is required, this will be clearly defined within the algorithm of each protocol. Any medications found in this protocol that are not routinely carried by NHT will be clearly identified in the protocol by IIR;Xw. The protocols are written to represent the common range of medications used to treat conditions affecting patients that are being transported. It is expected that you will continue the administration of such medications during transport when they have been initiated by the referring facility. Please follow the dosage guidelines in the protocol in the absence of a direct order from the discharging physician. Field personnel are reminded that "patients do not know protocols." More precisely, patients often present with an injury or illness which dictates the use of multiple protocols at one time. Each patient should be evaluated thoroughly to assure the most prudent use of the appropriate protocol(s). Key information during the initial physical evaluation, medical questioning, and the scene survey are all-important components of a patient care plan. Areas of concern regarding the patient's surroundings, questionable history and/or other "red flags" should always be reported to the receiving hospital personnel. I hereby authorize use of these protocols by EMT's and Paramedics working for National Health Transport. Medical Director March 2023 392 Table of Contents Section 1 - EMS Protocols 1. Universal Patient Care 2. Adult Airway 3. Adult, Failed Airway 4. Airway, Drug Assisted Airway 5. Behavioral 6. Pain Control: Adult 7. Adult Asystole/ PEA 8. Bradycardia: Pulse Present 9. Cardiac Arrest: Adult 10. Cardiac Arrest:Traumatic 11. Chest Pain: Cardiac and STEMI 12. CHF/ Pulmonary Edema 13. Adult Tachycardia/ Narrow Complex 14. Adult Tachycardia/Wide Complex 15. Ventricular Fibrillation / PulselessVentricular Tachycardia 16. Persistent V-Fib/ Pulseless Ventricular Tachycardia 17. Post Resuscitation 18. Abdominal Pain 19. Allergic Reaction /Anaphylaxis 20. Altered Mental Status 21. Adult COPD/Asthma 22. Diabetic: Adult 23. Dialysis/ Renal Failure 24. Hypertension 25. Hypotension/Shock 26. Overdose/Toxic Ingestion 27. Seizure 28. Suspected Stroke 29. Suspected Sepsis 30. Syncope 31. Vomiting and Diarrhea 32. Childbirth/ Labor 33. Newly Born 34. Obstetrical Emergency 35. Adult Thermal Burn 36. Head Trauma 37. Multiple Trauma 38. Pediatric Airway 39. Pediatric Failed Airway 40. Pediatric Pain Control 41. Pediatric Asystole/ PEA 42. Pediatric Bradycardia 43. Pediatric Pulmonary Edema/CHF 44. Pediatric Pulseless Arrest 393 45. Pediatric Tachycardia 46. Pediatric Ventricular Fibrillation/Pulseless V-Tac 47. Pediatric Post Resuscitation 48. Pediatric Allergic Reaction 49. Pediatric Altered Mental Status 50. Pediatric Diabetic 51. Pediatric Hypotension/Shock 52. Pediatric Overdose/Toxic Ingestion 53. Pediatric Respiratory Distress 54. Pediatric Seizure 55. Pediatric Vomiting/Diarrhea 56. Pediatric Head Trauma 57. Pediatric Multiple Trauma 58. Pediatric Thermal Burn 59. START/JumpStart Triage 60. Fever/ Infection Control 61. Police Custody 62. Emergencies Involving Indwelling Central Lines 63. Respiratory Distress with aTracheostomy Tube 64. Emergencies Involving Ventilators 65. Bites and Envenomations 66. Carbon Monoxide/Cyanide 67. Drowning/Submersion Injury 68. Hyperthermia 69. Hypothermia/ Frostbite 70. Blast Injury/ Incident 71. Chemical and Electrical Burn 72. Crush Syndrome Trauma 73. Extremity Trauma 74. Selective Spinal Immobilization 75. Unsafe Provider Environment Destination Facilities Miami-Dade Broward Treasure-Coast Central Florida 394 LO M z N 4(} Cr) N Ow O O (p Lo O (n 0N Lo r (Nn ` ON: Or Lo Lo 6 O co Lo O O Sry N 't M N N r �y CP C JLo r l0 00 M (b V ui O ' r am r (Y3 4Y3 O to d O hN O 7 °' (!5 O N O 0 " �w I(L (!Y O Lo Id1' N ct N M Lo CM, to O O O N 00 V 0` c0 M 00 Lo '.1' c0 N Lo O 4(7 frl J F' (A (p (!3 (!3 (A UJ U) (13.,. (D (D (D W w w w w w w w w w w w w W U) w Gal } 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 IwIo�'J Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' Iwo�' r m m m m 2 m m 2 m m 1: m m 2 1 2 m m m oz W (J) ( w w w ( w w.. w w w ( rA rA w Ir �rN';ni -Q wz ww wwww ww wwww w w w w a Y.w w U U 0 c3 U 0 0 0 0 C3 0 U U U 43 U U C5 43 U U � `N a U) U) P P ( P P U) U) P P V) V) V) f ( ( U) U) U) V) "` > w U C? CL CL Cf CG CG 0 AU CL CG U U U 0L a. a. t3 [L U U N O N N C O L U (6 N m E (6 N >N }- w w w w w w w w w w w w w w w w w w w .. m z m z m z m z z m z _ p z z w z Z w z z w z z z z z z z (p w w (9wwC7w w (9w w w w w w w a) v U' c9 0 1 1 c9 U C7 C3" U a� O � C o W U) (n (n W (n (n v� cn cn (n (n W (n W co � 3 Q .o CO LU J a 7w ?w ?w ' ?w ?w ?w }w } }w co a o .� c c — J Lu! W oc � U w (n (n co co co co ( cn v3 cn W U) w U) U) U) ( U) U) (n u3 a�i > u� u� a� m — � 7w ?w ?w ?w ?w ' ?w ?w ?w ?w ?w ,, V 7w o Y N N cn m s QI a- 0 0 Y N -O 00H. LL pl E � 'O .Q C c � 8 m m Z ui o O m � C: a) cq N � U ° '-u co a� m m . 0 U) ° d' n an � U m o V a m m LL Q U c 0 m U m - a� m m o N � N C O O L o o 0 Yo U) s H Y `6 o II W— >a� U'- Q m u� a x m :� m E 'm 5 - U E c fQ� O w a' } (� o ff c c C) 4 _ z a in a 00 U CD = m J H m o5 4�5 0 -o - ° c 05 ro c II II II I Q v- J in in in U' CJ '' m �? Z (f} m o5 Rf (� m Z Q o c: > m o `o o `o o c U Z I I I I U Z w s - — — �3m ° I Z I o s s E 3 4 0 > E E E N — o z a � o `m o 0 0 0 .� o 05 0 v o 0 0 . o a — (n (n W U (n Q W I— LL a> m m c � c, = z Y X z � z z a to z > CO. � m m 0 IL O _ _ Broward Facilities Cil-11 Pulislhed :3/I l2I IIII III""' sinm�� UPdoled 3/15/2022 -prob,dedb V 8towa tclC'oun®vRelllona:E MSCoauuno (1,2022) CATEGORIZATIONHOSPITAL HOSPITAL NAME PEDIATRIC I1SYOBSTETRICS ADMISSION ' STROKE FAOLI'TY CNI1 II_V�4If:7 ADMISSION ATU�LdSSION 0EN'I'EllZ aNTSR t.o��ard Nlc�illh C'o��il�>pliii�a N y y N Primary y IN � rdl t Illilia}� Io l l" i_I N N IN NOVLT Primary y N �Il d 11li I ;, cr y y ADIL 1,1 Comprehensive y IN II fIlhrorth N N N Comprehensive v N Oevellarnd Clinic Hospital IN N N IN Thromhe ctom r Capable y y Florida Merl ieal Center N N N ADULT 'Ihrombectomy Capable y N 11CA Florida Plantation freestanding Ell II IN N N N N N ffI('A ll lcrriclaUniversitx,ff3c„tIl N Y N N IN II 11CA Florida Westside llos pital III Tl N N Thromhectomv Capable y N lKA.florido Woodnnont I lospit t N IN N AO JUI 'EO N N N Holy Cross tiospital N N N N Qhrombectom� Capable v N Me nonill Mcrncr al It1os rLrl Miramar rrl1ol r:; �W N N N p IN v� N Primary N N modal llospial South IN N IN N N Memorial Hospital West IN IN IN Thromhectomy Capable y N \Ii.morlal Ile io nal Hospital y y ADIJU1 PED Comprehensive y y North, est Medical Cente, N N y N Primary v N West Boca fi eestanc nnaR LN R oeonwt Creek) IN y y kmm I6r1orr Rcc I Io.pJ 1.] N N y N o tnnptcherns lvt v N 11 1% LI j I.ti•i ( c u 'Irauma Only N y Comprehensive y N c.I of "did _t._ i[ilrr IN y y N ti; N m � , Kendall Regional Medical Center I I(Ail o t id 40rcY SPIltall LIIN t Nw Mum Ave,M ami 6 L I'i fl 1IJ ..._., VniverSityofMnaml'T.ichonMemorialR'IrnCenler St.Mary's Medi calCenter (c)014`yth Ifee1, e5tPa1fo0 ach FL )J � Jg!! Lw wo r S�q"u��VdtPdw B,K R 0 ) 3;, prl 12 I a II d ICIbFI l lI v �q „ ° (fl l )lrtnS e I&e u Cc� a wI ... N2II II o id o . 1 \ 396 Section 2 - Procedures 1. 12 Lead ECG 2. Airway: BIAD King 3. BIAD Removal 4. Airway: CPAP 5. Airway: Cricothyrotomy-Surgical 6. Airway: Endotracheal Tube Introducer(Bougie) 7. Airway: Foreign Body Obstruction 8. Airway Intubation Confirmation- End Tidal CO2 Detector 9. Airway: Intubation Nasotracheal 10. Airway: Intubation OralTracheal 11. Airway: Nebulizer Inhalation Therapy 12. Airway: Respirator Operation 13. Airway:Suction ing-Advanced 14. Airway: Suctioning-Basic 15. Airway:Tracheostomy Tube Change 16. Airway: Ventilator Operation 17. Arterial Line Maintenance: Line Maintenance 18. Assessment: Adult 19. Pain Assessment and Documentation 20. Assessment: Pediatric 21. Blood Glucose Analysis 22. Capnography 23. Cardiac: External Pacing 24. Cardiopulmonary Resuscitation 25. Cardioversion 26. Chest Decompression 27. Childbirth 28. CNS Catheter: Epidural Catheter Maintenance 29. Decontamination 30. Defibrillation: Automated 31. Defibrillation: Manual 32. Double Sequential External Defibrillation 33. Gastric Tube Insertion 34. Injections: Subcutaneous and Intramuscular 35. Orthostatic Blood Pressure Measurement 36. Pulse Oximetry 37. Restraints: Physical 38. Spinal Immobilization 39. Selective Spinal Immobilization 40. Splinting 41. Stroke Screen: MEND 42. Temperature Measurement 43. Venous Access: Central Line Maintenance 44. Venous Access: Existing Catheters 397 45. Venous Access: External Jugular Access 46. Venous Access: Extremity 47. Venous Access: Intraosseous 48. Wound Care-General 49. Wound Care-Hemostatic Agent 50. Wound Care-Tourniquet 51. Rapid Sequence Intubation 52. Medication Administration:Epi 1:1,000 53. Medication Administration: Naloxone 398 Section 3 — EMS Policies 1. Criteria for Death/Withholding Resuscitation 2. Discontinuation of Prehospital Resuscitation 3. Do Not Resuscitate 4. EMS Documentation and Data Quality 5. Documentation of vital signs 6. Domestic Violence ( Partner and/or Elder Abuse ) 7. Patient Without a Protocol 8. State Poison Center 9. Transport 10. Patient Defined 11. Medical Control 12. Unknown Medication 399 Section 4 — Drug List Acetaminophen Adenosine Albuterol Amiodarone Aspirin Atropine Calcium Chloride Dextrose Diltiazem (Cardizem) Diphenhydramine (Benadryl) Dopamine Epinephrine 1:1,000 Epinephrine 1:10,000 Fentanyl Glucagon Haloperidol (Haldol) Ipratropium (Atrovent) Ketorolac (Toradol) Labetalol Levophed Magnesium Sulfate Methylprednisolone (Solu-Medrol) Midazolam (Versed) Morphine Sulfate Naloxone (Narcan) Normal Saline Nitroglycerin Ondansetron (Zofran) 400 Oxygen Oxymetazoline (Afrin or Otrivin) Pralidoxime (2-PAM) Sodium Bicarbonate ;f 4 e ; 401 Revised 03/01/2023 Universal Patient Care Scene ient YES Bring all necessary Demonstrate professionalism geand cnt to ourtesy Required VS Safe Mass assembly consider WMD Blood pressure NO Palpated pulse rate Utilize appropriate PPE Respiratory rate Pulse ox if available Consider Airborne or Droplet Isolation if indicated If Indicated: Initial assessment Glucose BLS maneuvers 12 Lead ECG Initiate oxygen if indicated Temperature Pain scale Adult Assessment Procedure CO Monitoring Pediatric Assessment Procedure Use Broselow-Luten tape Trauma Medical Patient Patient Evaluate Mechanism of Injury (MOI) Mental Status Consider Spinal Immobilization Exam If indicated Unresponsive Responsive Significant MOI No Significant MOI Primary and Chief Complaint secondary Obtain Primary and Primaryand assessment SAMPLE Secondary Secondary trauma trauma assessment assessment Obtain history of Primary and Focused assessment present illness from Secondary on specific injury available sources/ assessment Obtain VS scene survey Focused assessment Obtain SAMPLE on specific complaint Obtain SAMPLE Obtain VS Repeat assessment while preparing for transport Exit to Continue on-going assessment Exit to Appropriate Protocol Repeat initial VS Appropriate Protocol 111111110 Evaluate interventions/procedures 111111[flim Transfer Patient hand-off includes patient information, personal property and summary of care and Patient does not Patient does not fit specific response to care fit specific protocol protocol Notify Destination or Contact Medical Control N rwww I 0 01 MUM 1 402 Revised 03/01/2023 Universal Patient Care • Initial Assessment of all patients must be completed by the highest credentialed person on scene. Pearls ccouimuuimucu,,mdcd Il,,xai ur Ill liiiifliumui4m exai .uii liif not noted oin i14mc slpecliifliic Il wmoi.ocomll� sligins iu ieiimlaml sl.al.Us li11!lm GCS, aind IllocalJoin of uiu1JU111my oul"coiumuip1 lamlint • Any patient contact which does not result in an EMS transport must have a completed refusal form. • A pediatric patient is defined by fitting on the Broselow-Luten tape,Age <_ 15,weight<_49 kg. Pediatric Airway Protocols are defined by patients <_ 11 years of age. • Timing of transport should be based on patient's clinical condition and the transport policy. Never hesitate to contact medical control for patients who refuses transport. • Blood Pressure is defined as a Systolic/Diastolic reading. A palpated Systolic reading may be necessary at times. • SAMPLE: Signs/Symptoms; Allergies; Medications; PMH; Last oral intake; Events leading to illness/injury Protocol 403 Revised Adult Airway 03/01/2023 Supplemental oxygen Protocols 1, 2 and 3 should be Assess Respiratory Rate, Effort, Goal oxygen saturation Oxygenation utilized together(even if �90% agency is not using RSI) as Cls Airway/Breathing Adequate? YES they contain very useful information for airway NO Exit to management. Appropriate Protocol Basic Maneuvers First -open airway chin lift/jaw thrust -nasal or oral airway -Bag-valve mask(BVM) Adult/Pediatric Respiratory Distress With Spinal Immobilization Procedure a Tracheostomy Tube if indicated Protocol if indicated I1111HII Consider AMS Protocol Airway Foreign Body Obstruction Procedure NO Airway Patent? Direct Laryngoscopy YES Complete Obstruction? NO Breathing/Oxygenation YES E Supplemental oxygen Support needed? BVM Consider Airway YES NO CPAP Procedure � Monitor/Reassess Supplemental Oxygen Airway Cricothyrotomy if indicated Surgical Procedure Exit to appropriate protocol Unable to Ventilate and Oxygenate>_90% during or after one(1) or more unsuccessful E Airway BIAD Procedure NO BVM/CPA intubation attempts . Effective? Oral/Nasotracheal Anatomy inconsistent Intubation Procedure with continued YES Consider RSI Protocol attempts. P if available Two(2) unsuccessful attempts by most Consider Sedation experienced EMT-P/I. If BIAD or ETT in place p Midazolam 2.5-5.0 mg IV/10/IN *or* Exit to Ketamine 1-2mg/kg IV/IQ Adult Failed Airway Protocol Notify Destination or Contact Medical Control 404 Revised Adult Airway 03/01/2023 Always weigh the risks and benefits of endotracheal intubation in the field against transport.All prehospital endotracheal intubations are to be considered high risk. Ifventilation/oxygenations is adequate rapid transport may be the best option.The most important airway device and the most difficult to use correctly and effectively is the Bag Valve Mask(not the laryngoscope). Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques. Please refer to'Protocol &4 for additional information, Difficult Airway Assessment Difficult 8VM Ventilation: MOANS:Difficult Mask seal due to facial hair,anatomy,blood or secretions/trauma;Obese or late pregnancy;Age>55;No teeth(roll gauze and place between gums and cheeks to improve;seal);Stiff or increased airway pressures(Asthma,COPD,Obese,Pregnant). Difficult Laryngoscopy; LEMON:Look externally for anatomical distortions(small mandible,short neck,large tongue);Evaluate 3-3-2 Rule(Mouth open should accommodate 3 patient fingers;mandible to neck junction should accommodate 3 patient fingers,chin-neck junction to thyroid prominence' should accommodate 2 patient'fingers);;Mallampati(difficult to assess in the field);Obstruction/Obese or late pregnancy;Neck mobility. Difficult BIAD: RODS:Restricted mouth opening;Obstruction/Obese or late pregnancy;Distorted or disrupted airway;Stiff or increased airway pressures (Asthma,COPD,Obese Pregnant); Difficult Cricothyrotomy/Surgical Airway: SHORT:Surgery or distortion of airway;Hematoa over lying neck;Obese or late pregnant;Radiation treatment skin changes;Tumor overlying neck. Trauma:Utilize in-line cervical stabilization during intubation,BIRD or BVM use,During intubotion or BIAD the cervical collar front should be open or removed to facilitate translation of the mandible,/mouth;opening. Nasotracheal intubation:Orotrocheol intubation is the preferred choice. Procedure requires patient have spontaneous breathing. Contraindicated in combative patients,anatomically disrupted or distorted airways,increased intracranial pressure,;severe facial trauma,basal skull fracture,head injury.Not a rapid procedure and exposes patient to risk of desaturation. e Ks Ilr�rot in:o lio on0y For ouzo uuu II r�atuents w'rtlh ani Age w2 or II r�atuents Il:wuger ilrani tllrc, IGlltiroocflov II urta�n II allac Capurnolne%tury(Collor) or calrrurnograpby Ili II"nanda'toury W di a ll)' abbe% prods of ntWiaflon. Docuruhhc*Iln't Ilre%sWl'ts. CoV"nfli nuuouus cal nogllrap by (l''tCO2) Ifs otllrourngly Ilrh1%ooininc1% ndh*d'foll"'tll e% VnoVrnlltoi1 ng of alll "aafle%i n'ts VnuVtlli a P:3lAl3 on" c1%ndo1uraollrc*all r turllrh*. ri y ut rr ua�::u u tr;::a u:.i!l Ilrly IIIfA A w utlr �� n:�Mh u i u u u o u::ru.0 Il�u a ll se�M iu�a urru��^try urh,�uiu.,u: s�Mt' !�90, ui uo a�un i�:epri:��u4�e to e Ilf earn a.ff: �� iu�rn.uuuhw u' li� Ilr�:.uuul cournfunuue%Wdi Ibaouo aliury ay a°rho%aoururaro uurnste%ad of uusuurng a Il3 Al43 or Iluroturlllratliourn. e I our fllie% Ilauurllrose%s of tllruo Il urot000ll, a secuuure%airway ay uo Whe%urn die% Il of e% nt us urecc*uouurog all ll urolpi1ate% o yge% naWuourn and ve% nfullatuourn. e An Ilurntuullrafuourn Atte%inpt us de%fuurne%d as Ilaaaouurng fll e% Ilaryurngoscolpe% Ilrllade%our c1%ndoturaollha*all to ie% (l ast die tee%dlr ou"uurnseirte%d uinto fll e% urnasM Ilaassagh*. e Acl%nfllVatory iratc*olhhoWd Ilr(1%8..10 Il e%ir ithhorhurte% to uhhauuataun a IG:ACO2 of 35 45.Aooud Ilryll a�*irou�*uhtullatuouu. • An Airway Evaluation Form will be completed with any BIAD or Intubation procedure. • Advanced EMTs and Paramedics should use a BIAD if orotracheal intubation is unsuccessful • Maintain C-spine immobilization for patients with suspected spinal injury. • Do not assume hyperventilation is psychogenic—use oxygen, not a paper bag. • Cricoid pressure maneuver may be used to assist with difficult intubations. It may worsen view in some cases. • Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO2 of 30-35. • Gastric tube placement should be considered in all intubated patients if available or time allows. • Manual stabilization of endotracheal tube should be used during all patient moves/transfers. Consider C-Collar • Video laryngoscopy should be considered on first orotracheal intubation attempts if available. 405 Revised Adult,03/01/2023 Failed Airway Unable to Ventilate and Oxygenate>_90%during or after one(1)or more unsuccessful intubation attempts . Protocols 1, 2 and 3 should be Anatomy inconsistent with continued attempts. utilized together(even if agency is not using RSI) as Two(2) unsuccessful attempts by they contain very useful most experienced EMT-P/I. information for airway management. Each attempt should include change in approach or equipment NO MORE THAN TWO (2)ATTEMPTS TOTAL Failed Airway Call for additional resources if available BVM Adjunctive Airway YES Maintains Sp02 >_90 % Continue BVM Supplemental Oxygen NO n Exit to Appropriate Protocol Airway Cricothyrotomy Significant Facial PI Surgical Procedure YES— Trauma/Swelling/ Distortion Continue Ventilation/ NO Oxygenation Maintain Sp02>_90% E Airway BIAD Procedure IF 000' ENO BIAD Successful > Y S Continue Ventilation/Oxygenation Maintain Sp02 >_90% EtCO2 35—45 Ventilate 8—10 breaths/minute Notify Destination or Contact Medical Control 406 Revised Adult,03/01/2023 Failed Airway Afailed airway occurs when a provider begins a course of airway management by endotracheal intubation and identifies that intubation by that means will not succeed. Conditions which define a Failed Airway: 1. Failure to maintain adequate oxygen;saturation 90%or greater after 2 or more failed intubation attempts. 2.Two(2)failed intubation attempts by the most experienced pre-hospital provider on scene even when adequate oxygen saturation 90%or greater can be maintained. 3.Unable to maintain adequate oxygen saturation 90%or greater with BVM techniques and insufficient time to attempt alternative maneuvers.A patient near death or dying. The most important way to avoid a failed airway is to identify patients with expected difficult airway,difficult BVM ventilation,difficult BIAD,difficult laryngoscopy and/or difficult cricothyrotomy. Please refer to Protocol 1,Adult Airway page 2 for Information in show to identify the patient with potential difficult airway. Position of patient; In the field,setting improper position of the patient and rescuer are responsible for many failed and difficult intubations.often this is dictated by uncontrolled conditions present at the scene and we must adapt.However,many times the rescuer does not optimize patient and rescuer position.The sniffing position or the head simply extended upon the neck are probably the best positions.The goal is to align the ear canal with the suprasternal notch in a straight line. In the obese or late pregnancy patient,elevating the torso by placing blankets,pillows or towels will optimize the position.This can be facilitated by raising the head of the cot..... Use of cot in optimal patient/rescuer position: The cat can be elevated and lowered to facilitate intubation.With the patient on the cot,raise until the patient's noise is at the level of your umbilicus which will place you at the optimal position. Trauma:Utilize in-line cervical stabilization during intubation,BIAD or BUM use.During intubation or BIAD insertion,;the cervical collar front should be opened or removed to facilitate translation of the mandible/mouth opening, Cricothyrotomy/Surgical Airway Procedure: Use in patients 12 years of age and greater only.Percutaneous transtracheal jet ventilation]is used,in younger patients. Relative contraindications include: Pre-existing laryngeal or tracheal tumors,infections or an abscess overlying the cricoid area. Hematoma or anatomical landmark destruction/injury. • If first intubation attempt fails, make an adjustment and then consider: • Different laryngoscope blade/Video or other optical laryngoscopy devices • Gum Elastic Bougie • Different ETT size • Change cricoid pressure. Cricoid pressure no longer routinely recommended and may worsen view. • Change head positioning • Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. • Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways. • Significant facial trauma exists, consider Cricothyrotomy prior to 2 failed intubation attempts. • Video laryngospy should be considered on first orotracheal intubation attempts if available. • Notify Illvle6cail Coii l.r6o AS EARLY AS POSSIBLE about the patient's difficult/failed airway. 407 Revised 03/01/2023 Airway, Drug Assisted Airway n6cstoons to yg u�II'�CII Preox enate 100% 02 sullura* to Il rote%ct uie%airw ay P IV Procedure (preferably 2 site 10 Procedure dussllialla* to o a*usstu* Protocols 1, 2 and 3 should be 2g Assemble Airway Equipment utilized together(even if Suction equipment agency is not using RSI) as U.Uinslli kl% to ve% ntullsta* Alternative Airway Device they contain very useful uuullsu*uroduusg slirvss2 information for airway coil npurouuuase management. "tnt w w /II ��,':'��.uuultlr , Iltr0sopm':M .. u.uten II apc: Hypoxia and/or Hypotension/Shock Present Dangerously Combative Ketsuuuuuse 1 .. 2 u°rugtllrg IIA t IIC �(X IlAouuundste 0.3 irnghkg ''Or IA t IIC Or ddd urug IIII'd For Il:ta nga*urouusll2 Colluull afly* eta1%1ainhnc1% 1 .. 2 1nghkg IW I IIC P 3afl % nts urntWliate% trsclhea 112y30UNIsu01111SllIo6lr Il3uro loco lls Or As unducste%d a II All::t I3Ilsceiiuua*III t Aa*u atoa*d Contuunuuou.us Cslp nogursllsllhy Exit to onsl69 i long 'le rr iDsusl lk« Adult Airway Au*cu.uuronuuuuru 10 urug (0.1 a°rugtllrg) II At IIC Protocol 01, ,Uu II1ocu.uuo III uuuuru I urug t Ilrg IIAt IIC cif Consider Restraints Physical Procedure Paralytics: Consider Gastric Tube Insertion Procedure Procedure will remove patient's protective airway reflexes and ability to ventilate. Awakening or Moving YOU are responsible for after intubation Oxygenation and Ventilation IRX Morphine 4 mg IV/10 Repeat 2 mg every 5 minute as needed Maximum 10 mg CAR P Fent'anyl lmcg/kg IV/10/IN 11e%d I'e%xt Repeat 25 mcg every 5 minutes as needed are the key performance Maximum 200 mcg indicators used to evaluate Midazolam 2.5—5.0 mg IV/10/IN protocol compliance. Repeat every 3-5 minutes as needed Maximum 10 mg An Airway Evaluation Form must be completed on every patient who receives a Drug Assisted Notify Destination or Airway. Contact Medical Control 408 Revised 03/01/2023 Airway, Drug Assisted Airway Hiah Risk Patients: Brain illness or injury;Underlying respiratory disease;Underlying cardiac disease;Aortic disease;Obese patients;Pregnant patients;and Patients age>55.All pre-hospital Rapid Sequence Intubations are to be considered HIGH-RISK Patients with anticipated difficult airway who can be managed by basic maneuvers/BVM/CPAP with'adequate oxygenation and ventilation may; require rapid transport only. Refer to Adult Airway,and Adult Failed Airway protocols. Specifically make sure you assess the difficulty in using a Bag Valve Mask,Laryngoscopy,BIRD,and Cricothyrotomy with each patient. Preparation: Assemble and test equipment.Oxygen,BVM,Suction,Laryngoscope,Gum iElastic Bougie,BIAD,Syringes,Medications,King Vision,and Cricothyrotomy device. Assure large bore IV with 2 sites preferable. Pre-Oxuaenate: Pre-Oxygenation should optimally occur during initial assessment. Provide at least 3 minutes of high flow oxygen before RSI CPAP is an effective means to provide adequate pre-oxygenation. S 'i Give Ketamine first,then follow the protocol.Manage the airway appropriately. Align external auditory canal with sternal notch.May need to elevate head/torso(pillows or stretcher)in the obese or pregnant patient.If difficulty is anticipated use your stretcher to place the patient's nose in line with your umbilicus. Trauma:Utilize in-line cervical stabilization during intubation,BIAD or BVM use.During intubation or BIAD the cervical collar front should be open or removed to facilitate translation of the mandible/mouth opening. Place endotracheal tube or BIAD: Cricoid pressure may worsen your view and may increase risk of aspiration in some patients. Use if it improves;your view. Bimanual laryngoscopy:Use your right hand to externally manipulate the thyroid cartilage and/or head to give you the best glottic view. Confirm placement of endotracheal tube into glottis by:Direct visualization;Chest rise and fall;increasing oxygen saturation;ETCO2 Device. Maintain continuous waveform capnography/capnometry at all times to assure endotracheal tube does not become dislodged. Post intubation manaaement: Give Versed as needed to maintain sedation while maintaining a systolic blood pressure greater than 90. Expect transient hypotension immediately following RSI/[drug assisted intubation, Use Vecuronium only after adequate sedation if excessive patient movement is noted.Repeated doses of paralytics are discouraged. Protect the airway with a combination of physical restraints,versed and vecuronium as needed. Intranasal Versed Dosing: Mix 5mg of Versed in 1ml of NS 0.2mg/kg IN(if>26 kg`give 5mg) Split dose between each nostril Contact Medical Control for repeat dose Agencies uruuust ueuaalinitaura as sell)„awnate 11'1ew Lrwwueuaance Ilurullncwweivent 11'"rograaueu sll,ae ific tc; II'')u uug Ass listed Ai14waaay. e 11ew foneu INem cdogiin„all exaaueu Law screen Lrww n;rwnh alindicaltions. 11 his Ilsrr;;tocw u4 is r;:wu"III, for uu°,e!!il l Iln,wtuu;rots uMh,l:uaw Agi,:, t!T or lln,ath:,lilts lkxigrtdu,rthan this:!I13u0,4,u1l0ime 11 uuten 111"nall:ae to uug Assisted A14waaay is allowed uua I11mtlenits walla M on the II'IIBu awsellowa..11 uulten"'11"'aallae waiith II'')1111r11.C"'11 0IN111 III411 IIg111'II11l)IICA11..011:111l)1illik. Ltysiteueu Ildediic all IltuwecU!n rww`Assisit aunt Ildedic all 11't4ecitca(s)ueuuust give this II)1111 111::C 11",0IN11 INIllIId11.11'')ICAll 01111I1t11I111t. e t onitlinuuouus W awetrwwaii Caa11:)ngwgraa11:a1fay and 11'"uullse duxilivetly and aawe a ertuu4ed Lrww uintuull:miti n wee ilfic apron and ongariivag I11mitlient uvionlitcaiirag. 111hiis is in:wt valludnated and uruaay Il:awawwe iiillll:x:wssullmlle iira uaeon ataall Ilaawllauullaatiirwua wewiitiin:;naltlon 12 odhew ueuenans its wecoilluueuendedl II BeLrwNe aaduruuuausltew ling any laaaw„ally'Liic dw g screen Lrww`n:onito„auuadiic ations waiith na th wwcmglh uaeuuwa;dogic exaaueu. '... IL uuLplliziing Ilyeltaueuiine „assess trww 11°N 111"'Id and t an:hyc wdiiaa iiran:ll udiirag Il:au:L„a aagoiniisits. Kol airuno can ho clsod Mill[,i aru'illoW r.I7r.rr.lyflc In conjtinc ilon Milli ondolicac,ho al Inicil allon of 1&IAI::) <olcunino can tisoci Io rac ili,alo I0c-,cl,cilcflon dill i saiilcwcay lnculcsaric>irul,rcr Kol airuno n=,o in danrlu locisly aril alod Ipcalloilcl call ho givoin IIVII P:rnl IV/lO sac,cc,,,s'llotild ho os'l alrlislloc�i sa,wolic cr,I7c,,,ilrlc> • Drug Assisted Airway medications can be repeated for a second dose only. • Paralytics can be dangerous if given when oxygen saturations are<90%. • If First intubation attempt fails,make and adjustment and try again: '.. Different laryngoscope blade Different ETT size '.. Change head positioning Continuous pulse oximetry should be utilized in all patients. '.. Consider BURP Maneuver Change cricoid pressure,No longer routinely recommended and may worsen yourview. 409 Revised Behavioral 03/01/2023 + Situational crisis • Anxiety, agitation, confusion + Altered Mental Status differential • Psychiatric illness/medications 0 Affect change, hallucinations • Alcohol Intoxication Injury to self or threats to others + Delusional thoughts, bizarre 0 Toxin/Substance abuse • Medic alert tag behavior a Medication effect/overdose • Substance abuse/overdose + Combative violent • Withdrawal syndromes Diabetes + Expression of suicidal/homicidal 0 Depression thoughts a Bipolar(manic-depressive) + Schizophrenia + Anxiety disorders iP,lluuuuuuuu boo 00 00 lui^ Call for help/additional resources Stage until scene safe Blood Glucose Analysis Procedure Patients are to be secured If indicated on the stretcher with all appropriate straps secured Exit to Appropriate Protocol If indicated before transport begins Altered Mental Status Protocol Overdose/Toxic Ingestion Protocol ult, Head Trauma Protocol Assume patient has Medical cause of behavioral change Excited Delirium Syndrome Paranoia, disorientation, hyper-aggression, IV Procedure hallucination,tachycardia, increased strength, YES Preferably 2 large bore hyperthermia Normal Saline Bolus 1 L then 150 mL/hr May repeati500 mL bolus as needed ggressive, io en , Restraint Physical Procedure Maximum 2 Liters Agitation Monitor per restraint procedure Threat to Self or others ES E if indicated Setting of Psychosis Ketamine 4UU mg IM Monitor and Reassess See Pearls Consents to Crisis Midaz°lam' Intervention IV Procedure p 2.5—5.0 mg IV/10/lN/IM iz X-Haloperidol 5 mg IV/IM Age>_65 Age�:65 2.5 mg IV/IM 1-2.5 mg IV/[O/IN/IM Proceed to the Crisis May repeat once Repeat every 2-3 minutes as Intervention protocol for 14ot for suspectpd substarice needed. abuse or DI disposition �,� Cardiac Monitor Midazolam 2.Smg-5.0 mg IV/IU/ IN/IM External Cooling Measures NO Age*a 65 0.5 mg-2.5 mg IV/IU/IN/ E Restraint Physical IM Procedure Repeat every 2-3 minutes as needed. Monitor and Reassess Notify Destination or Contact Medical Control 410 Revised B e h av i o ral 03/01/2023 How to De-escalate a Crisis Situation The first impression is most critical when starting the de-escalation process.Just as you,the medical provider,are assessing the situation upon arrival,the patient is also assessing you.Your first impression can determine how the encounter proceeds.There are seven steps in the de- escalation process. 1. INTRODUCE YOURSELF-start to create a relationship(make a good genuine first impression) Z LISTEN-actively listen more than talking-relay back what you have heard-assess the situation as you listen-encourage the patient to talk more so than asking questions. 3. MINIMAL ENCOURAGERS-nod your head-say"okay"or"I see'. Demonstrate to the patient that you are listening and paying attention to him/her.Do this early in the encounter. 4. REFLECTING/MIRRORING-repeat what has been said to you.Usually the last 3-4 words that were said.DO NOT INTERUPTI! 5. RE-STATING/PARAPHASING-Demonstrate that you understand what is being said to you by putting into your words.Should be done with a calm voice and avoid a mocking tone. & EMOTIONAL LABELLING-Help the patient put their feelings into words-active listening will help with this. 7. "1"STATEMENTS-Begin your statements with 1.DO NOT PUT THE PATIENT ON THE DEFENSIVE."I"statements help communicate that you are listening to the patient. If other steps have been successful,this stem sets the stage for a transition to a resolution Transition to the THREE STEP ASSERTIVE INTERVENTION: 1.Empathy Statement-reinforce that the patient is being heard 2.Conflict Statement-address the situation at hand.Provider can present their view. 3.Action Statement-a specific request from the provider to the patient. Zecciiniineinded II:::xaiim IlCeintM Status, S11(ilin, 11, eart, 11 UlIgS, IlyeWrC Ciirew I uresllmindeirs safety!is the uaalin i�)irlcirlty. Ainy ';mtleint who!is IhalldCUtted eu iresturalined 11!�,)y 11 aw ::::infcirceiineint aind tirainslp;mrted 11!�,)y ::1MS inUSt 11!�,)e accciinlp;minled 11!�,)y Ilaw einfoirceiineint liin the aiinl!)Ulaince. Consider HaIdol for patients with history of psychosis*OR*a benzodiazepine for patients with presumed substance abuse. All patients who receive either physical and chemical restraint must be continuously observed by ALS personnel on scene or • immediately upon their arrival. Be sure to consider all possible medical/trauma causes for behavior(hypoglycemia, overdose,substance abuse,hypoxia,head injury, • etc.) Do not irritate the patient with a prolonged exam. Do not overlook the possibility of associated domestic violence or child abuse. If patient is suspected of suffering from agitated delirium and suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early. Do not position or transport any restrained patient in such a way that could impact the patient's respiratory or circulatory status. Excited Delirium Syndrome: Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations,speech disturbances,disorientation, violent/bizarre behavior,insensitivity to pain,hyperthermia and increased strength. Potentially life-threatening and associated with use of physical control measures,including physical restraints and Tasers. Most commonly seen in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar agents.Alcohol withdrawal or head trauma may also contribute to the condition. Do NOT administer Haloperidol to a patients with symptoms of Excited Delirium Syndrome. Extrapyramidal reactions: Condition causing involuntary muscle movements or spasms typically of the face,neck and upper extremities. May present with contorted neck and trunk with difficult motor movements.Typically an adverse reaction to antipsychotic drugs like Haloperidol and may occur with your administration.When recognized give Diphenhydramine 50 mg IV/10/IM/PO in adults or 1 mg/kg IV 10 IM/PO in pediatrics. 11 atleints that iirecelive Il etaiinline AWST11have a 114C Il etaiinline ::vaWaficin II:::ciriin cciinll Meted and attached Wth the chairt. Ketamine may be given to patients who no longer fit on a length based resuscitation tape Ketamine Dissociation Syndrome: • Treatment includes benzodiazepines. May require repeat dosing. • Treatment also includes decreasing ambient stimulus such as sounds,lighting,or activity • Ketamine may cause hypotension,hypertension,vomiting, respiratory depression, or laryngospams • Laryngospasms respond to BVM 411 evised 0301/2023 Pain Control : Adult Age + Severity (pain scale; Wong-Baker . Per the specific protocol Location Faces) + Musculoskeletal Duration • Quality (sharp, dull, etc.) . Visceral (abdominal) Severity (1 - 10) 0 Radiation 0 Cardiac If child use Wong-Baker faces 0 Relation to movement, respiration . Pleural/Respiratory Past medical history . Increases with palpation to the area 0 Neurogenic • Medications + Renal (colic) Drug allergies Utilize Protocol based on Specific Complaint Assess Pain Severity Use combination of Pain Scale, Circumstances, MCI, Injury or Illness severity Mild Moderate to Severe IV Procedure 1 10 Procedure Toradol.15mg IV/10 P I°iI,(-Acetaminophen 15 mg/ 30mg IM kg PO(Up to 650 mg) Consider IV Procedure Cardiac Monitor Fentanyl 1 mcg/kg IV/10/IN (50-100 mcg typical adult); Repeat 25 mcg every 5 minutes as needed Maximum 200 mcg OR Pain Relief? No Ketamine 0.2mg/kg IV/10' Yes Maximum 20mg Mix in 50-250 ml of NS and Infuse over 10 minutes May repeat in 30 minutes as needed Monitor and Reassess Monitor and Reassess Every 10 minutes following sedative Monitor and Reassess Notify Destination or Contact Medical Control 412 03/R01/2023 evised Pain Control : Adult Wong-Baker VACES Pain aating Scale 1 2 4 5 140 HURT HURTS HURTS "0044n HURTS HURTS LITTLE BIT LITTLE MORE EVEN MORE %#~LE IOT WORST 0-10 Ntimeric Pain Intensity Scale: 0 1 2 3 4 7 No Mild Pain Moderate :were Worst Pain Pain Pain Possible This protocol is designed to treat the acute onset of pain vs. chronic pain. i.e. A patient in Moderate Pain: a combination of oral medication and parenteral can be utilized if no contraindications are present. �Rcicoinine%nded xaim II'Acln[M Status,Area of Il3ahn, IINcluiro �3aun seve%iruty (0 10) us a vutM sugn to be% re%coirde%d be%foire%and afteir '30, IIV, IIO our HIA nc'%6caflon deflHveNry aiiid at Ilaafle%ilt Ihaild %off. 10011IRoir E� �3 6os(fly as sc:daflvc: and Ilaaun contir6 agc:ints nay causc: hypotc%lisioll.: Both arms of the algorithm may be used in concert. Vital signs should be obtained before, 10 minutes after,and at patient hand off with all pain medication administered. All patients who receive IM or IV medications must be observed 15 minutes for drug reaction in the event no transport occurs. Do not administer any PO medications for patients who may need surgical intervention such as open fractures or fracture with deformities, headaches, or abdominal pain. Ketorolac(Toradol)and Ibuprofen should not be used in patients with known renal disease or renal transplant, in those with known drug allergies to NSAID's(non-steroidal anti-inflammatory medications),with active bleeding, headaches, abdominal pain,stomach ulcers or in patients who may need surgical intervention such as open fractures or fracture with deformities. Do not administer Acetaminophen to patients with a history of liver disease. Burn patients may require higher than usual opioid doses to effect adequate pain control. Do not go above 0.3mg/kg of Ketamine, between 0.3mg/kg and 1 mg/kg the danger for re-emergence syndrome is a possibility. The range above 1 mg/kg is reserved for airway management and induction. 413 ... Revised Adult Assto''e' . 03/01/2023 Pulseless Electrical Activity ........................................................................ ......................................................................................................................... 11 fistoiry Siigins and Symllptolrns IE iffeireintiiall • Past medical history • Pulseless • Hypovolemia (Trauma,AAA, other) • Medications • Apneic • Cardiac tamponade • Events leading to arrest • No electrical activity on ECG • Hypothermia • End stage renal disease • No heart tones on auscultation 0 Drug overdose(Tricyclic, Digitalis, Beta • Estimated downtime blockers, Calcium channel blockers) • Suspected hypothermia 0 Massive myocardial infarction • Suspected overdose • Hypoxia • Tricyclic • Tension pneumothorax • Digitalis • Pulmonary embolus • Beta blockers • Acidosis • Calcium channel blockers 0 Hyperkalemia • DNR, MOST, or Living Will Decomposition Rigor mortis "M"A Cardiac Arrest Protocol Dependent lividity Blunt force trauma Injury incompatible with Return of life Criteria for Death/No Spontaneous Extended downtime with YES Resuscitation asystole Review DNR/MOST Form Circulation NO Do not begin ®b1b110 resuscitation Go to Follow algorithm for CPR compressions listed in Post Resuscitation the Cardiac Arrest Protocol Protocol For one,two and three providers. Cardiac Monitor Reversible Causes Follow Hypovolemia Rhythm Appropriate rYES Shockable Rhythm Hypoxia Protocol Hydrogen ion (acidosis) �111111[fim NO Hypothermia Search for Reversible Causes Hypo/Hyperkalemia „ Hypoglycemia IV Procedure 10 Procedure . Tension pneumothorax Dialysis/ Consider Normal Saline 500 mL IV/10 Tamponade; cardiac IIIIIII Renal Failure Toxins 1116, Epinephrine 1:10 000 1 m IV/10 � Protocol ) 9 Thrombosis; pulmonary if indicated One dose only (PE) Thrombosis; coronary (MI) Consider Chest Decompression Procedure Discontinue Resuscitation Criteria for Discontinuation:> --*YES Follow Deceased Subjects Policy NO Notify Destination or Contact Medical Control 414 Revised Ad�ult Asystolel 03/01/2023 Pulsele s Electrical /©►ctiVit i/ i i Ilf�eaui°Ils ffouimi.s II!mo mllld Ilfc direcfcd at Illmliigllrm IgL4llliiig aind coil mi.lii III WoUs coium.uill uiressliio ill:ms liii.11lm IlluI1111u11iIled aind eaiillly dsfliillfuimliillllll mi.liioum Wiiein VIin6cai.sd::: CoinsuIdeir eaii Illy II'0 IP Illaceixicint oir iiif OffiiiU llli V access is aiimfiiiciiilpated::: i0 II140 i 11III..: ""i If no advaincsd amiirway III ill': i,,: II i i"" 111111 Il lllace) coium°uipirsssliioins afire coiimi.liiu1mrmorms WI11d°1om.mi vsumi.liilllafliiou,:m Lmiimfiiilll ain advaincsd auiuimway is Il lllaccd Ihfadva1iced aiiiiuimway its liiu,:1 Il lllacc, vcu,:miJIilllale 5 fd Iloreai.11lms eir uimuliium mi.c wvIliim cou,mi111111 moms, Lmu,:mliiuimfcuimuimLmll fed coiumuipressuioins::: Iio not iiumiouimuimmmlpt coiumuipiressuIoins i.o Il lllacc eindolra6llmcalll i.mmllfc CoinsVIdcui 14;iill': i flirsf i.o IlliIixiJt * Breathing/Airway management after 2 rounds of compressions (2 minutes each round.) * Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. * If no IV/ 10, drugs that can be given down ET tube should have the dose doubled then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IWO is the preferred route when available. * Consider each possible cause listed in the differential: Survival is based on identifying and correcting the cause. * Potential association of PEA with hypoxia so placing definitive airway with oxygenation early may provide benefit. * PEA caused by sepsis or severe volume loss may benefit from higher volume of normal saline administration. * Return of spontaneous circulation after Asystole/PEA requires continued search for underlying cause of cardiac arrest. * Treatment of hypoxia and hypotension are important after resuscitation from Asystole/PEA. * Asystole is commonly an end-stage rhythm following prolonged VF or PEA with a poor prognosis. * Consider Sodium Bicarb in the dialysis/renal patient, known hyperkalemia or tricyclic overdose at 50 mEq total IV/ 10. * Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options. * Potential protocols used during resuscitation include Overdose/Toxic Ingestion, Diabetic and Dialysis/Renal Failure. * Studies have shown that administration of Dextrose in cardiac arrest may worsen acidosis. Sodium Bicarbonate may be more effective in the patient with hypoglycemia, until ROSC where the patient may then benefit from Dextrose 415 X Revised 03//01/2023 �Bradycardia ; Pulse Presen History Signs and Symptoms Differential + Past medical history • HR< 60/min associated with: • Acute myocardial infarction + Medications • Hypotension + Hypoxia • Beta-Blockers . Chest pain + Pacemaker failure • Calcium channel blockers . Respiratory distress • Hypothermia • Clonidine • Hypotension or Shock • Sinus bradycardia • Digoxin • Altered mental status 0 Athletes • Pacemaker • Syncope 0 Head injury (elevated ICP)or Stroke • Spinal cord lesion • Sick sinus syndrome • AV blocks(1°, 2°, or Y) + Overdose Exit to Heart Rate <60/minute and Appropriate Symptomatic Protocol rN0 Hypotension,Acute AMS, Chest Pain, Acute CHF, Seizures, Syncope, or Shock •i1- secondary to bradycardia YES Dyspnea/Increased Appropriate Airway Work of Breathing YES and/especially with hypoxia Respiratory Distress Protocol NO Suspected Beta Blocker E 12 Lead ECG Procedure or Calcium Channel P Cardiac Monitor Blocker IV Procedure IO Procedure Follow Normal Saline Bolus 500 mL IV/IQ Overdose/ May repeat as needed Toxic Ingestion Maximum 2 Liters Protocol Atropine 0.5 mg IV/iQ Repeat every 3--5 minutes Maximum mg Consider Sedation Midazolam 2.5 mg to 5.0 Transcutaneous Pacing mg IV/ID If not responsive to Atropine May repeat as needed Consider earlier in 2"d or 3rd AVB) Maximum dose 5 mg Consider Dopamine 10'-20 mcg/kg/min IV/Ip If no clinical response Notify Destination or Contact Medical Control U& Sal' 416 4`A X Revised 03//01/2023 Bradycardia ; Pulse �Presen ........... ......... ........................ Dopamine Calculation Chart When using 800 main 500 mL.the concentration will remain 1.600 mcg/ml o iml Dopominile50, mit a 1#6 �01 woU)'tal rm11cP,llkq, Palienl*% We' , l,1111 Ire h11 91 wlik's ollimiste 25l S IQ 20 10 111 fop 60 10 8,01 fed 1001 -( 1 2' 1 6 h 11i 13 15 1� 1 1 10,, nr: i 1 2 1 8 11 15 19 V 2,16 joi 1314 '115 inc i 1 3 6 111 17 23 '28 341 J9 45 51 56 1 11 11I 3 1 10 145 53 60 1 (A h a So drop per art drip sefthis I thie r,jobw elnrirl er nlllhr, Observe for extravoisabloin-��;=1 1111iaig, 18,111 r, pain, aft, st N Site,� Pearls ccouimuuimucu,,mdcd Il;x in, III' cuf all SIMUS, IINeclllk II', leant,, Ill...,Uumgs IINeU111m0 grim dycaiimd'ia caUS� iiumg syui ,111pl.oill'is uis tyll iiicalllllly , dd/uimiulii111MIR IIIFUYf.11lmxii xllrmoL llld Il e liiintciimll iimct.cd liiin lilie cointext of syin'liploin'lis aind II III°m uimuimu colllogliic 111 trealin'lleint gliivein oufllly Wliein syuimiull fouimivalf.uic, of.11lneiim iisc in'loiluiif.oiim aind ureassess ldeint.liifyiiing sliigiims aind syui 'llipl.oill'is of Il ooui Il cuimfUSsIiou,,m caUscd by Il radycaiir6a aiimc Il auirainiuoU Ili,It. Atropine: Caution in setting of acute MI. The use of Atropine may worsen heart damage. Do not delay Transcutaneous Pacing with poor perfusion. Ineffective in cardiac transplantation. • Utilize transcutaneous pacing early if no response to atropine. If time allows transport to specialty center as transcutaneous pacing is a temporizing measure and patient will likely require transvenous pacemaker. • Wide complex, bizarre appearance of complex with slow rhythm consider hyperkalemia. • Consider treatable causes for bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, etc.) • Hypoxemia is a common cause of bradycardia be sure to oxygenate the patient and support respiratory effort. Protocol i 417 ------------- Revised 03//01/2023 Cardiac Arrest; Adult History Signs and Symptoms Differential Events leading to arrest + Unresponsive • Medical vs. Trauma • Estimated downtime • Apneic 0 VF vs. Pulseless VT * Past medical history . Pulseless + Asystole • Medications . PEA • Existence of terminal illness 0 Primary Cardiac event vs. Respiratory arrest or Drug Overdose Decomposition Rigor mortis Criteria for Death/No Resuscitation EYES Dependent lividity Review DNR/MOST Form Blunt force trauma Return of Injury incompatible with life NO Spontaneous Extended downtime with Circulation asystole Begin Continuous CPR Compressions Push Hard(2 inches) Push Fast(100-120/min) resuscitation not begin Change Compressors every 2 minutes re (Limit changes/pulses checks<_10 seconds) Go to Place a NRB with 15LPM of 02 on the patient Post Resuscitation Protocol 2t I I II\FIIII 2 Initiate Compressions Only CPR Initiate Automated Defibrillation Procedure If available Call for additional resources arum uu"n2...II.j.II .. .II ....IL. �.`.2.IP 2.!I"deIII Assume Compressions or Initiate Automated Defibrillation Procedures Consider BIAD DO NOT interrupt Compressions If BIAD placed ventilate at 6-8 breaths per minute AIB"LS.0 o....IL..J`.2.i'229f.!k" BLS gun ALS ALS - Shockable Rhythm P Cardiac Monitor YES NO Shock Delivery Shockable Rhythm Continue CPR E 2 Minutes Continue CPR NO YES Repeat and reassess E 2 Minutes Repeat and reassess Airway Protocol(s) ""'V Airway Protocol(s) Follow ®im6: Follow Asystole/PEA VF/Pulseless VT Airway Airway Protocol(s) Protocol(s) as indicated as indicated Notify Destination or lillu m Contact Medical Control •l(191 418 Revised 03//01/2023 Cardiac Arrest; Adult • When these are less than two providers of any level on scene,there should be continuous compressions without airway intervention.A Non- Rebreather Mask should be placed with a flow rate of at least 15 liters per minute. • Placement of the Non-Rebreather Mask with high volumes of Oxygen will provide adequate oxygenation to the patient.Compressions provide only a fraction of the capacity that an operating heart does and is imperative that compressions continue.By utilizing a NRB and the body's normal mode of negative pressure ventilation,the compressions will promote adequate air movement in and out of the chest and adequately ventilate the patient until an advanced airway can be placed. • Once a second provider has arrived...,and placement of an advanced airway is considered,compressions must not be interrupted Pearls ffoliml.s SIIPmoL llld be Oirecicd at Illmliigllrm q,L4llliily aind c iimi.liiIIIWoUs c01111'ipiressliioins WIil.11lm IlluIi uiuIl.cd liimi.cuimuim ill i.liiou,:m aind eaii 111y dsfliillfiimliillllll l.iiiou:m wl4mcun iui Ocal.cd::: CoimsuIdcuim eaii 111y II'0 Il lllaceixieint. lif ava Ii1W1f111c aind /olim diiiffiiic flt II'V access a iimluiciiilpalcd 10 II1401 II lt il,Zv III'III..: I If no advaimccd aIiimway (11111: 11),,: II I 'I) liiiim II IIIacc,,: coiim°iipressliioims slllmoL llld be coiiml.liii,:m OUS WI111:10ILd. ii ial!,:mL4ll vciml.lilllaliiioins Ilf advainccd aIiimway lis liiin II IIIacc vsifliiilllale g fd Ilorea114ms Il eum li 111lIii,:Kfle WIi1.111m coiml.liii,m OUS,: L�i,miiiml.climiimL�11 1.cd coiixiipressiiioins::: « Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. « Breathing/Airway management after second shock and/or 2 rounds of compressions (2 minutes each round.) « Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. Consider Team Focused Approach assigning responders to predetermined tasks. « Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. « Maternal Arrest-Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport preferably to obstetrical center if available and proximate. Place mother supine and perform Manual Left Uterine Displacement moving uterus to the patient's left side. IWO access preferably above diaphragm. Defibrillation is safe at all energy levels. « Consider mechanical CPR (compression)device if available. « Refer to Dialysis/Renal Failure protocol caveats when faced with dialysis/renal failure patient experiencing cardiac arrest. Consider Opioid Overdose: Naloxone 2 mg IM / IV/ IO/ IN. « Follow manufacture's recommendations concerning defibrillation /cardioversion energy when specified. Protocol • 419 Revised 03//01/2023 Cardiac Arrest: Traumatic History Signs and Symptoms Differential Events leading to arrest • Unresponsive • Blunt Force • Estimated downtime . Apneic 0 Penetrating * Trauma induced + Pulseless + High Energy Injury • Mechanism of Injury • Low Energy Injury • Mortality and Morbidity of Injury 0 Crush Injury g f f lll' YES Meets criteria for Withholding Resuscitative Efforts. NO NO Return of Spontaneous Pupil Response or Circulation Decomposition Spontaneous Body Movement? Rigor mortis YES Dependent lividity Blunt force trauma Begin Continuous CPR Compressions GO t0 Injury incompatible with Push Hard(2 inches)Push Fast(100-120/ Post Resuscitation life min)Change Compressors every 2 minutes Protocol Decapitation (Limit changes/pulses checks<_10 seconds) Place a NRB with 15LPM of 02 on the patient Obviously fatal injury irs t...... 1,11Lj.....!LIL..... tll /AIL... ...II .L::.IlJ.taliI. e!I' Initiate Compressions Only CPR PEA with a rate less than Initiate Automated Defibrillation Procedure 40 BPM If available Call for additional resources ..:. .ii�.q�... rriviil!�..J...11!!!I:.0. .(.III,,,. ...II L:2:.II.p.Il�.q�.er Do not begin resuscitation Assume Compressions or Initiate Automated Defibrillation Procedures Consider BIAD DO NOT interrupt Compressions If BIAD placed ventilate at 6-8 breaths per minute BLS huu u u!L .li.li .g...11....`.2U L .`.II AILS Chest Trauma BLS or ALS YES NO Chest Decompression on the indicated side(s) YES Crush Injury Shockable Rhythm ,,,11117 Crush Injury / 1 Y D r YES ProtocolNO Shock Delivery at 200J Cardiac Monitor Continue CPR Continue CPR 2 Minutes 2 Minutes Repeat and reassess Repeat and reassess Shockable NO Rhythm YES 1 8 Airway Protocols) i I""g Airway Protocol(s) Follow Follow Asystole/PEA VF/Pulseless VT Airway Airway Protocol(s) Protocol(s) But DO NOT utilize ACLS But DO NOT utilize ACLS Medications Medications Notify Destination Or IIIIIEM Contact Medical Control II �.� 420 X Revised 03//01/2023 Cardiac Arrest: Traumatic • Epinephrine in Traumatic Cardiac Arrest has been deemed not helpful and possibly harmful in the outcome of patients. • Traumatic cardiac!arrests rarely occur because of contractility or electrical disruptions of the cardiac muscle. • Epinephrine or other ACLS medications may even exacerbate the loss of circulating blood volume in a traumatic cardiac arrest. • Fluid Replacement and reperfusion of the cardiac muscle should be the primary goal of traumatic cardiac resuscitation. • In the presence of crushing,injuries;.Sodium Bicarbonate and Calcium Chloride are still beneficial due to toxins being the possible cause of cardiac failure. • Patients that have crushing injury leading to the traumatic cardiac arrest may benefit from the Calcium Chloride and Sodium Bicarbonate. • Remember that traumatic arrests are just that,traumatic.These arrests should be limited to a 10 minute on scene time where possible. Pearls ffoliml.s SIIPmoL llld be Oirecled at Illmliigll!m q,L4llliily aind c iimi.liiIIIWoUs couimiulpiressliioins liil.11h IlluIi uiuIl.ed wind eaii lily dsfliillfiimliillllll I.iiioi,m Wiiein iiimdiical.ed CoimsiIdeir eaii lily II'0 Il lllaceixieint lif avaliillla We wind /olim OffiiiU llli II'V access a iimlliciiilpaled I0 II140I III'III.. I If no advainced aIiimway (II III' II) II I 'I) liiiim Il place coiim°iipressiiioims afire fo be coiimlJIii,m OUS WI11!10ILd ii ial!,mL4ll veiml.iilllaIJiioi,m Lfli llless aim advainced aIii tty lis Il lllaced If advainced a�Iiimway liis liim Il place veimliiilllale 8 fd Ilfiireali4ms Il eum Ii 111lIii,,Wle wliil.11l°m coi,,ml.lii111WOUs„ L�iimiii,,ml.ciilit�Il I.cdcoiim.iipressliioins • Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. • Breathing/Airway management after second shock and/or 2 rounds of compressions (2 minutes each round.) • Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. Consider Team Focused Approach assigning responders to predetermined tasks. • Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. • Maternal Arrest-Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport preferably to obstetrical center if available and proximate. Place mother supine and perform Manual Left Uterine Displacement moving uterus to the patient's left side. IWO access preferably above diaphragm. Defibrillation is safe at all energy levels. • Consider mechanical CPR (compression)device if available. • Refer to Dialysis/Renal Failure protocol caveats when faced with dialysis/renal failure patient experiencing cardiac arrest. • Consider Opioid Overdose: Naloxone 2 mg IM / IV/ IO/ IN. • Follow manufacture's recommendations concerning defibrillation /cardioversion energy when specified. Protocol 421 Revised 03/01/2023 Chest Pain : Cardiac and STEMI History Signs and Symptoms Differential • Age + CP (pain, pressure, aching, vice-like + Trauma vs. Medical • Medications(Viagra/sildenafil, tightness) • Angina vs. Myocardial infarction Levitra/vardenafil, Cialis/tadalafil) • Location (substernal, epigastric,arm, 0 Pericarditis • Past medical history (MI,Angina, jaw, neck,shoulder) 0 Pulmonary embolism Diabetes, post menopausal) • Radiation of pain • Asthma/COPD • Allergies + Pale, diaphoresis + Pneumothorax • Recent physical exertion • Shortness of breath • Aortic dissection or aneurysm • Palliation/ Provocation • Nausea, vomiting, dizziness + GE reflux or Hiatal hernia + Quality (crampy, constant, sharp, uumne of Gunsn*t + Esophageal spasm dull, etc.) • Chest wall injury or pain • Region/Radiation/Referred • Pleural pain + Severity (1-10) 0 Overdose(Cocaine)or Time(onset/duration/ repetition) Methamphetamine st Pain Dyspnea/Atypical Exit to <]Ea NO symptoms N0� Appropriate iac etiology Suspect cardiac etiology Protocol 1110• YES11 12 II a*ad IG': CC Il,3rooa*du rcl Asll llll1 i n 81 Ir°mng x d II'30 (dhevia%d) 1, 325 II`mng ': 0 Nitroglycerin 0.310.4 mg Sublingual Repeat every 5 minutes x 3 YES if prescribed to patient and(BP>_100) Cardiac Monitor Transport based on: STlli. 111 Illmsmmmrmodmatd IIINotificatio�n of Facility 11 ld Ilnnll cumta* J11 n S 11.11 11'dll Irsmulmrmodiato Tmarmmsmmssmouln of IIL.CG (S I' °gll n m°II 't i♦YES► if capable Mutnm,.Mwu d°MwuluptoumMwu� II a is dew II Ilfllflliif dog111 Sceine III muooto o 10'Il\Aiirnules NO E �� If transporting to Non PCI Center T �I �I (NI�� I1I1 GI�'e% �I��I� ❑ IV Procedure 10 ProcedureI Lung Exam: Systolic BP>_ 100 NO CHF/Pulmonary NO Edema YES YES Nitroglycerin 0.310.4 mg SL T Repeat every 5 minutes as needed Exit to Normal Saline Bolus 500 mL Adult CHF/Pulmonary P Repeat as needed RX Nitroglycerin Paste SBP Edema Maximum 2 L >+1001 inch SBP>1501.5 Protocol inch SBP>200 2 inch won Fentanyl 1 mcglkg IW 101 IN (50-100 mcg typical adult') Repeat 25 mcg every 5 minutes as needed Maximum 200 mcg Notify Destination or Contact Medical Control 422 Revised 03/01/2023 Chest Pain : Cardiac and STEMI Patients with Positive Clinical Findings suggestive of MI are to have a 12 lead ECG performed within the first moments of assessment wherever possible,with a practical goal of ECG occurring within the first 5 minutes of contact with the patient. A single SL;dose of NTG may be considered in SBP>90 prior to iV attempt Code STEMI and Code Medical-Cardiac Event Criteria A Code STEMI-will be activated by EMS for all patients with Positive Clinical Findings suggestive of MI in the presence of elevation in 2 or more contiguous leads and in the absence of a STEMI Impersonator. A Code Medical—,Cardiac Event will be declared by the EMS Primary Caregiver in the presence of patients with Positive Clinical Findings suggestive of MI and in the presence of a STEMI Imposter Pearls fccouimuuimucu,,mdcd Il;aain' Illffeumfalll Cl.al.m.ms Clll uium, IP' eclllk„ Ill....m.momg, IP°°Illeauiml.,, Xodoixiein, Iliaclllk, II al.reiuxiuloies, II" eU11'o lciuxis liiin IlZed lsal airs l.11l,mc Ilkey Il euifouirixiiauice liiu,,°m6cal.ouims four l.11lmc II;IIIIdB cUl.c Caii3Oiac (C""l""II';Illffll) Cauims l""oollllll(ll « Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 36 hours due to potential, severe hypotension. Patients with STEMI (ST-Elevation Myocardial Infarction) or have a positive Reperfusion Checklist should be transported to the appropriate facility based on STEMI EMS Triage and Destination Plan. « If CHF/Cardiogenic shock resulting from inferior(II, III, aVF) MI, consider Right Sided ECG (V3 or V4). If ST elevation noted, Nitroglycerin and/or opioids may cause hypotension requiring normal saline boluses. If patient has taken nitroglycerin without relief, consider potency of the medication. « Monitor for hypotension after administration of nitroglycerin and narcotics (Morphine, Fentanyl, or Dilaudid). « Nitroglycerin and opioids may be repeated per dosing guidelines. « Diabetics, geriatric and female patients often have atypical pain, or only generalized complaints. « Document the time of the 12-Lead ECG in the PCR as a Procedure along with the interpretation (EMT-P.) « Agency medical director may require Contact of Medical Control prior to administration. Protocol 423 ------------- Revised CHF03/01/2023 / Pulmonary Edema History Signs and Symptoms Differential • Congestive heart failure • Respiratory distress, • Myocardial infarction Past medical history bilateral rales 0 Congestive heart failure • Medications(digoxin, Lasix, • Apprehension, orthopnea • Asthma Viagra/sildenafil, Levitra/ • Jugular vein distention • Anaphylaxis vardenafil, Cialis/tadalafil) • Pink, frothy sputum • Aspiration • Cardiac history --past myocardial 0 Peripheral edema, diaphoresis 0 COPD infarction • Hypotension, shock 0 Pleural effusion • Chest pain • Pneumonia • Pulmonary embolus • Pericardial tamponade Toxic Ex osure Signs/Symptoms _ Airway Patent _ _ Adult Airway Pulmonary Edema Oxygenation ad quate Protocol(s) consistent with CHF/ YES Ventilations adequate NO YES Chest Pain and STEMI 12ILe d [l 'CG "im:;a-du i,e -44—�." P°° � Protocol hV tr gll cclil n 0.4 ing if indicated P Suullo hnguuM Repeat every 5 minutes x 3 if(BP>100) Cardiac Monitor IV Procedure IO Procedure IF Assess Symptom Severity MILD MODERATE/SEVERE CARDIOGENIC SHOCK Normal Heart Rate Elevated Heart Rate Tachycardia followed by Elevated or Normal BP Elevated BP bradycardia Hypertension followed by hypotension V trogll ce%il n 0.4 u°nug SII... V tr gll ce%il n 0.4 unug SII... Repeat every 5 minutes Repeat every 5 minutes CPAP III°Rl)(-Nitroglycerin Paste SBP>1001 RX-,Nitroglycerin Paste SBP>100 P Remove ace inch SBP>1501.5 inches SBP>200 2' 1 inch SBP>1501.5 inches SBP'> if in place inches 2002 inches 9sm Airway Protocol(s) u®; if indicated Improving Dopamine 10-20 mcg/kg/min IIV/10 Titrate to SBP>_90 Y S " Airway Protocol(s) if indicated Notify Destination or Contact Medical Control 424 Revised CHF / PulmonaryEdema 03/01/2023 Pearls ccouimuuimucu,,mdcd Il;xain'r IIMeii laml SWl.Us Slll uium, IP' cclllk Ill....Lmumg, Ii Illeaiml.,, Xodoixiein, Il iaclllk, II xl.ueixiiu1Jcs, II" cUuimo ein'iis liiin Ilfcd Iext afire Ilkey Il cuimfouirixiva1ice iumuieaSUuimcs Used to cvalllUalc Il uimol.ocolll coiumuill lllliiaincc aind caire mmuimoscui�uuidc aind Olpiu6ids Illm mvc II" O l Il eein slllmowin to liiixilprovs flllmc Wl.coiuxies of II';IIIIffS Il alieunts wu11:m IP Lmllliu iou,,,airy sdciuxia II vein ll4moUgl4m l.11lmliis Illflsl.oiiJcall1y eein a ux14 imsl.ay of II;IIIIffS treal.iu ieinl.,, lit uis no Illoingcuim uioUl.liiunemcly urecoiu iiu ieindcd • Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 36 hours due to potential severe hypotension. • Carefully monitor the level of consciousness, BP, and respiratory status with the above interventions. • If CHF/Cardiogenic shock resulting from inferior(II, III, aVF) MI, consider Right Sided ECG (V4). If ST elevation noted Nitroglycerin and/or opioids may cause hypotension requiring normal saline boluses. • If Nitro-paste is used, do not continue to use Nitroglycerin SL. • If patient has taken nitroglycerin without relief, consider potency of the medication. • Contraindications to opioids include severe COPD and respiratory distress. Monitor the patient closely. • Consider myocardial infarction in all these patients. Diabetics, geriatric and female patients often have atypical pain, or only generalized complaints. • Allow the patient to be in their position of comfort to maximize their breathing effort. • Document CPAP application using the CPAP procedure in the PCR. Document 12 Lead ECG using the 12 Lead ECG procedure. Protocol 425 Revised Adult Tachycar is 03/01/2023 Narrow Com I�ea� (51 0 11 sec.. ......... ... ..................................................................................................................................................� 11 fistoiry Sigins and Symptorns [Diiffeireintiiall + Medications + Heart Rate> 150 • Heart disease(WPW,Valvular) (Aminophylline, Diet pills, Thyroid 0 Systolic BP<90 • Sick sinus syndrome supplements, Decongestants, + Dizziness, CP, SOB,AMS, • Myocardial infarction Digoxin) Diaphoresis + Electrolyte imbalance • Diet(caffeine, chocolate) • CHF + Exertion, Pain, Emotional stress • Drugs(nicotine, cocaine) • Potential presenting rhythm 0 Fever Past medical history Atrial/Sinus tachycardia 0 Hypoxia • History of palpitations/heart racing Atrial fibrillation/flutter • Hypovolemia or Anemia • Syncope/near syncope Multifocal atrial tachycardia • Drug effect/Overdose(see HX) + Hyperthyroidism • Pulmonary embolus Unstable/Serious Signs and Symptoms HR Typically > 150 YES Cardioversion Procedure Narrow/Regular:50-100 J NO Narrow/Irregular:100 J E 12 Lead ECG Procedure repeat if needed and P IV Procedure 10 Procedure increase dose with subsequent shocks of Cardiac Monitor 50-100J(Max of 200J) Consider Sedation pre-shock Midazolam 2.5—5.0 mg IV/10 Regular Rhythm Irregular Rhythm May repeat if needed (SVT) (Atrial Fibrillation/Flutter) Maximum 5 mg FPT Attempt Vagal Maneuvers Consider Exit to Adenosine 12 mg IV/10 Appropriate � will Rapid push Protocol Rhythm Converts > May repeat 12 mg IV/10 X 1 dose ' if needed NO May aid rhythm identification Single lead ECG able to Hill IF I diagnose and treat arrhythmia Adenosine 12 mg IV/10 Rapid push YES ool Rhythm Converts 12 Lead ECG not necessary to May repeat 12 mg IV/10 X 1 dose if diagnose and treat, but preferred needed when patient is stable. Diltiazem 20 mg IV 10 If age>_60 give 10 mg then repeat Rhythm Converts YES 10 mg in 5 minutes IIIIIII if SBP>_100 1116W NO Diltiazem 20 mg IV/10 If age>_60 give 10 mg then repeat If no response 10 mg in 5 minutes P Diltiazem 5 me/hr IV/10 if SBP>_100 If rate not controlled,repeat bolus in 15 minutes Diltiazem 25 me IV/10 If no response If age>_60 give 15 me then repeat Diltiazem 5 mg/hr IV/10 10 mg in 5 minutes if SBP>_100 12 Lead ECG If rate not controlled repeat Increase infusion to 10;mny P bolus in 15 minutes Procedure Diltiazem 25 me IV/IO If aye>_60 give 15 me then repeat 10 me in 5 minutes 00 Rhythm Converts if SBP>_100 Rate Controlled Increase infusion to 10 me/hr Notify estlnatlon or Contact Medical Control ............................................................................................................ Revised Adu lt TcAChycar" i 03/01/2023 Narrow Complex (55 0. 11 sec) ..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... *** May consider giving Calcium Chloride with administration of Diltazem only if the blood pressure does not respond to fluid bolus Micromedix*** piII' Pearls a �Recoiiniinended :xaii Mental Status, &Idn, 19e6l(, ung, lleaiii t, Xbdoiiinen, 1a6�(, eiiinufles, 19euii o 0 Most iiin�poii tant goal us to 6ffeii enflate flie ty�pe of ta6hycaii d u a a in d u f S I A 1�f....I:� our. U�I19 S I A��1 It at any Ill 6nt Ill atent IVbecoiines unstal)le inove to unstal)Ie aiii iun uin aligoiii utllviin PIT, Symptomatic tachycardia usually occurs at rates of 120 -150 and typically? 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF. Serious Signs/Symptoms: Hypotension.Acutely altered mental status. Signs of shock/poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.)Acute CHF. Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker(e.g. Diltiazem) or Beta Blockers. Use caution with Adenosine and give only with defibrillator available. Typical sinus tachycardia is in the range of 100 to (200 bpm -patient's age) beats per minute. • Regular Narrow-Complex Tachycardias. Vagal maneuvers and adenosine are preferred. Vagal maneuvers may convert up to 25 %of SVT. Adenosine should be pushed rapidly via proximal IV site followed by 20 mL Normal Saline rapid flush. Agencies using both calcium channel blockers and beta blockers need to choose one primarily. Giving the agents sequentially requires Contact of Medical Control. This may lead to profound bradycardia/hypotension. Irregular TachVcardias: First line agents for rate control are calcium channel blockers or beta blockers. Agencies using both calcium channel blockers and beta blockers need to choose one primarily. Giving the agents sequentially requires Contact of Medical Control. This may lead to profound bradycardia/hypotension. Adenosine may not be effective in identifiable atrial fibrillation/flutter, yet is not harmful and may help identify rhythm. Synchronized Cardioversion: Recommended to treat UNSTABLE Atrial Fibrillation,Atrial Flutter and Monomorphic-Regular Tachycardia (VT.) Monitor for hypotension after administration of calcium channel blockers or beta blockers. • Monitor for respiratory depression and hypotension associated with Midazolam. • Continuous pulse oximetry is required for all tachycardias. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. 7 Revised Adult Tachycardia 03/01/2023 Wide Complex (�!0.12 sec History Signs and Symptoms Differential + Medications • Heart Rate> 150 • Heart disease(WPW,Valvular) (Aminophylline, Diet pills, Thyroid 0 Systolic BP<90 • Sick sinus syndrome supplements, Decongestants, « Dizziness, CP, SOB,AMS, • Myocardial infarction Digoxin) Diaphoresis + Electrolyte imbalance • Diet(caffeine, chocolate) • CHF + Exertion, Pain, Emotional stress • Drugs(nicotine, cocaine) • Potential presenting rhythm 0 Fever + Past medical history Atrial/Sinus tachycardia 0 Hypoxia • History of palpitations/heart racing Atrial fibrillation/flutter • Hypovolemia or Anemia • Syncope/near syncope Multifocal atrial tachycardia • Drug effect/Overdose(see HX) Ventricular Tachycardia + Hyperthyroidism • Pulmonary embolus r_< Unstable/Serious Signs and Symptoms HR Typically > 150 YES Cardioversion Procedure NO Wide/Regular;100J Wide/Irregular:1001Moy E 12 Lead ECG Procedure repeat if needed and increase P IV Procedure 10 Procedure dose with subsequent shacks of'50-100J(Max of 200J) Cardiac Monitor Consider Sedation pre-shock Midazolam 2.5—5,0 mg IV/to May repeat if needed Regular Rhythm Irregular Rhythm Irregular Rhythm Maximum 5 mg Monomophic Complex Monomorphic Complex Polymorphic Complex (VT or (Pre-excitation (Torsades de pointes) SVT with aberrancy) Atrial Fibrillation) Exit to h Appropriate Protocol Consider Contact Medical Defibrillation Adenosine 12 mg IV/IQ ControlP Procedure Rapid push Follow Unstable Arm May repeat 12 mg IV/IQ X 1,dose if needed Rhythm Converts NO YES Rhythm Converts Amiodarone Exit to Magnesium 150 mg in 100 mC of DSW Adult VF/ Sulfate IV/10 Pulseless VT P 2 gm IV/to Over 10 minutes Protocol Over Z minutes May repeat x 1 if no i r response Y S If no response Amiodarone 150 mg/100 mL of DSW 1 mg/min(40mL/Mr) Rhythm Converts YES E 12 Lead ECG Procedure after rhythm conversion NO Notify Destination or Contact Medical Control pill • • • � 428 Revised Adult Tachycardia 03/01/2023 Wide Complex (�!0.12 sep Pearls ccouimuuimucu,:mdcd Il',,,,,,xain'rr Ill ii lal S1.a1.Us,,: Slll uium, IP' cclllk,,: Ill....Lfumg, II':Ileaiml.,,: Xodoixiein, 3aclk, Il xl.ueixiiu1Jcs, INeUllimo Most liiixii ouiml..aint goall uis to OffsuimcuflJal.c 114mc type of l.a6:Wcauir6a aind u1' S""I A11113111 :II or dll"fS 1 A 11113111 :II f at ainy Il 611d 11 alJeiid Ilfccoiumuics Lflisl.albfle iuxiovc 10 Lflnsl.aIbfle airiuxii liiin aIgouimliiI]11ui1iu::: • Symptomatic tachycardia usually occurs at rates of 120— 150 and typically>_ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF. • Serious Signs/Symptoms: Hypotension.Acutely altered mental status. Signs of shock/poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.)Acute congestive heart failure. « Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. • If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker(e.g., Diltiazem) or Beta Blockers. Use caution with Adenosine and give only with defibrillator available. « Typical sinus tachycardia is in the range of 100 to (220bpm—patients age) beats per minute. « Reaular Wide-Complex Tachvcardias: Unstable condition: Immediate cardioversion or pre-cordial thump if defibrillator not available. Stable condition: Typically VT or SVT with aberrancy. Adenosine may be given if regular and monomorphic and if defibrillator available. Verapamil contraindicated in wide-complex tachycardias. If using Amiodarone, Procainamide and Lidocaine, the PMD needs to choose one primary agent. Giving multiple anti-arrhythmics requires contact of medical control. Atrial arrhythmics with WPW should be treated with Amiodarone or Procainamide « Irreaular Tachvcardias: Wide-complex, irregular tachycardia: Do not administer calcium channel or beta blockers, adenosine as this may cause paradoxical increase in ventricular rate. This will usually require cardioversion. Contact medical control. « Polymorphic/Irreaular Tachycardia: This situation is usually unstable and immediate unsynchronized shock is warranted. Pearls When associated with prolonged QT this is likely Torsades de pointes: Give 2 gm of Magnesium Sulfate slow IV/ 10 over 2 minutes. s'c � ihtmerl06, AlIffirp ewo:o:O N T administer a Calcium « C� n et1��j�cardiaS. f �aRW&Mt Mp h uVf'Ach therapeutic intervention. « fll��rrr>'u i WAT� Af F4PoRRhFff-when specified. { $ri°�a �'� �gBi�hdar�y�A ��'(> '15 $�fi� "Vi�r�{f� r�l�or polymorphic VT, do not delay �i$ sF�� 1yr � e �yesdisor � �P �nergy, unsynchronized shocks. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. 429 Revised Ventricular Fibrillation 03/01/2023 Pulseless Ventricular Tachycardia History Signs and Symptoms Differential + Estimated down time + Unresponsive, apneic, pulseless Asystole • Past Medical History 0 Ventricular fibrillation or ventricular • Artifact/Device Failure Medications tachycardia on EKG Cardiac • Events leading to arrest Endocrine/Medicine • Renal failure/Dialysis • Drugs DNR or MOST form + Pulmonary V"""'2 Cardiac Arrest Protocol Follow algorithm for CPR compressions listed in the Cardiac Arrest Protocol Dialysis/Renal For one,two and three providers. Failure Protocol if indicated pefibril late 200J(Max360J) iI Airway Protocol(s) 1111111fla S IV Procedure 10 Procedure Epinephrine(1:10,000) 1 mg IV/10 One Dose Only III defibrillate 200J(Max 360J)' Return of Spontaneous Circulation IF °'1110f Follow algorithm for CPR compressions listed Torsades de pointes 0110in the Cardiac Arrest Protocol Low Magnesium States For one,two and three providers. (Malnourished/alcoholic) Go to Suspected Digitalis Toxicity Post Resuscitation If Rhythm Refractory Protocol defibrillate J) J Continue CPR and give Agency specific Anti- arrhythmics/Epinephrine during compressions.compressions. Continue CPR up to the point where you are ConsiderSulfate IV/1um ready to defibrillate with device charged. sulfate 2g lu/ over 2 minutes Repeat pattern during resuscitation. Amiodarone 1 mg/min Amiodarone 300 mg IV/10 Iv/10 May repeat at 150 mg IV/10 P P if no response if rhythm converts defibrillate 200 J(Max 360J) Return of Spontaneous Circulation N 0 YES AND/OR Exit to Post Resuscitation Consider Protocol Discontinuation Notify Destination or of Resuscitation Policy Contact Medical Control 430 Revised Ventricular Fibrillation 03/01/2023 Pulseless Ventricular Tachycardia Pearls fccoium.uiixiicu:mdcd II':Illllll aiumr III' cuml.aml Stal.Us 0, ff01111.s SIP.moL lld be directed :gymt. l,miig!,m gUam� Idly aind coii,m�lJiuWoUs c01111.:'ipressiioins i11l:.m Illoiiuxuiu1ed aind eaiimlly dsfliillfuimliillllll ml.liiou,:m wl4mcun Viin6caled::: CoinsuMeim eaii lily II'O lP lllaceixieint uif OffiiiU llfl II': its au,:,ml.liicuilpal.cd::: l0 II1401 11III..: l II f uno advaincsd amiiirway (I11 lll': ll),,, II l I Il lllacc,,: coium°uipresslibins slllmoL llld be coiiml.liiu,:WoUs W11:!1OLd iuxial!,:mL4ll vcuml.uilllalJiioins Ilf adva1iced aiiiirway alum Ig lllacc,,: ve1itulllal.c 0 10 Il ireat.11lms ll cuim ui1u11iui11Ul.e Wiil.11lm coirml.lii 1WOUs,,: Lmiimuiuml.cuimui Lmll l.cd coium.uii pressiiiou:°ms::: • Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. • Breathing/Airway management after second shock and/or 2 rounds of compressions (2 minutes each round.) • Avoid Procainamide in CHF or prolonged QT. • Effective CPR and prompt defibrillation are the keys to successful resuscitation. If no IV/ 10, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV/ 10 is the preferred route when available. • Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. • Do not stop CPR to check for placement of ET tube or to give medications. • If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5 defibrillation sequences have been completed. • Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions. • Sodium bicarbonate is no longer recommended. Consider it in the dialysis/renal patient, known hyperkalemia or tricyclic overdose at 50 mEq total IV/ 10. • Follow manufacture's recommendations concerning defibrillation /cardioversion energy when specified. Protocol 431 Revised Persistent Ventricular Fibrillation 03/01/2023 Pulseless Ventricular Tachycardia History Signs and Symptoms Differential Verified execution of • Unresponsive, apneic, pulseless • Asystole resuscitation checklist 0 Persisted in ventricularfibrillation/ • Artifact/Device Failure tachycardia or returned to this rhthm • Cardiac post-ROSC/other rhythm change 0 Endocrine/Medicine • Drugs Pulmonary V-Fib/V-Tach Protocol Complete and A I AID Y I I IVf E A I AI"�Y I I IVf E V-Fib/V-Tach is still present Rhythm Changes Return of To Nonshockable Spontaneous Rhythm Circulation uuuuolm !!!-M Go to Post Appropriate Protocol Go to Appropriate Resuscitation 111,1111MM Did V-Fib Break at all? Protocol Protocol Pie Yes Apply second set of Defib Pads at new site After 5 cycles of CPR check rhythm and Pulse, if persistent pulseless VF/VT: After 5 cycles of CPR check rhythm and P Repeat Defibrillation 200 Joules Pulse, if persistent pulseless VF/VT: After Defibrillation resume CPR without pulse check Double Sequential External Defibrillation 200 Joules with two monitors (if available) Pause 5 secs max to check Rhythm/pulse,resume CPR Repeat as Necessary 111111011 Did V-Fib/V-Tac break at all? Yes �� Proceed to appropriate protocol �111111111 ®loom I No Contact Medical Control Pearls Recurrent ventricular fibrillation/tachycardia is defined as being successfully broken by standard defibrillation techniques (i.e. 360j), but subsequently returns. It should not be treated by double sequential external defibrillation. It is managed by treatment of correctable causes and use of anti-arrhythmic medications in addition to standard defibrillation. • It is initially managed by treating correctable causes and with anti-arrhythmic medications. If these methods fail to produce a response, double sequential external defibrillation may be utilized by an approved ALS provider. • Prior to double sequential defibrillation, providers should verify that pads are well-adhered and not touching; refer to the double sequential external defibrillation procedure for instructions regarding documentation and equipment. Prolonged cardiac arrests may lead to tired providers and decreased compression quality. Ensure compressor rotation, summon additional resources as needed, and ensure provider rest and rehab during and post-event. 432 Revised 03/01/2023 Post Resuscitation History Signs/Symptoms Differential + Respiratory arrest + Return of pulse • Continue to address specific • Cardiac arrest differentials associated with the original dysrhythmia Repeat Primary Assessment Optimize Ventilation and Oxygenation + Maintain Sp02 >_94% + Advanced airway if indicated ETCO2 ideally 35—45 mm Hg Respiratory Rate 8—12/minute . Remove Impedance Threshold Device I\Procedure 10 Procedure E 12 Lead ECG Procedure Cardiac Monitor Monitor Vital Signs/Reassess Normal Saline Bolus 500 mL IV/If) Hypotension May repeat as needed YES Systolic BP<90 if lungs remain clear Maximum 2 L NO Induced Hypothermia Dopamine Follows Comman NO---ow- Protocol 10-20 mcg/kg/min IV/IQ if available Titrate to SBP?90 YES STEMI / Chest Pain and Suspicion of MI YE �ii��i�m STEMI Protocol UNu" STEMI EMS Triage and S NO Destination Plan Bradycardia; " Pulse Present -4—YES—w- Symptomatic Bradycardia Protocol NO Continue Antiarrhythmic NO ROSC with YES Utilized Antiarrhythmic given Refer to Adult Tachycardia NO Protocol Arrhythmias are common and usually self limiting Consider Sedation/Paralysis after ROSC Use only with definitive airway in place Versed 2.5 5.0 mg IV/IU May repeat in 5 minutes if needed �iiiihuum And/4r If Arrhythmia Persists P Fentanyl 1 mcg/kg IV/IU bolus follow Rhythm May repeat every S minutes Appropriate Protocol As needed Maximum 200 mcg *or* Ketamine 1-2mg/kg Notify Destination or FT— Contact Medical Control 433 Revised 03/01/2023 Post Resuscitation Dopamine Calculation Chart When usina 800 main 500 mL.the concentration will remain 1.600 mca/ml ee of 400, mg Dopaimino25,0 #611 615 rnc0 kq, Pationt's Weigbil hi lKilogisaitts tointat 2.5 5 1l0 0 30 40 50 60 0 00 00 100 i to crll 12, 2 34 0 ttc1 1 3 0 0 0 11 13 15 17 110 10 wic-0 1 2 1 0 11 1', ll 10 23 2,16 30 ' � 30 0 nri 0 21 3 0 15 23 3 , ;38 3 �53 GO 0 With a,$4,0iop per mi 4rip 90 this Is the twer r l 0 ps ) e(ter Iiku Observe lot`tit 'li, l l w, swaffing, pallor, pain, Oft. l IV SIN. Pearls ccoulmuulmuculmdcd Il;xaix IlMeii laI Sl.aIUS, INecllk SlllkuIin Ill....U1111gc„ II'I°°°IlIeailml.,, I d'olumiein, Il x1rein'iJlJes, IINeU 111`0 IIm'l'.IIIIIMc 'l'.o seaill"III!U I III" I o'lcll`ml.lal I caUse of cairdlIac alll"III"est dU.Ulll IIIIImg post reSU.Ucclll'l'.allllolu°m caire • Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided at all costs. • Initial End tidal CO2 may be elevated immediately in post-resuscitation but will usually normalize.While goal is 35—45 mmHg, avoid hyperventilation. • Consider transport to facility capable of managing the post-arrest patient including hypothermia therapy, cardiac catherterization and intensive care service. Most patients immediately post resuscitation will require ventilatory assistance. • The condition of post-resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. Appropriate post-resuscitation management may best be planned in consultation with medical control. Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and medication reaction to ALS drugs. Titrate Dopamine or other vasopressors to maintain SBP >_ 90. Ensure adequate fluid resuscitation is ongoing. Protocol 434 Revised Abdominal Pain 03/01/2023 ------------------------------------------------I--------------------------------------------------I---------------------------------------------------- • Age • Pain (location/migration) « Pneumonia or Pulmonary embolus Past medical/surgical history « Tenderness « Liver(hepatitis, CHF) • Medications • Nausea Peptic ulcer disease/Gastritis • Onset « Vomiting • Gallbladder Palliation/Provocation • Diarrhea • Myocardial infarction • Quality (crampy, constant, sharp, 0 Dysuria • Pancreatitis dull, etc.) 0 Constipation • Kidney stone • Region/Radiation/Referred . Vaginal bleeding/discharge 0 Abdominal aneurysm • Severity (1-10) • Pregnancy 0 Appendicitis • Time (duration/repetition) « Bladder/Prostate disorder • Fever ; rnr -)orns° • Pelvic(PID, Ectopic pregnancy, Ovarian • Last meal eaten r err er.« ��art� � cyst) Last bowel movement/emesis Fever, headache,weakness, malaise, « Spleen enlargement • Menstrual history (pregnancy) myalgias, cough, headache, mental « Diverticulitis status changes, rash 0 Bowel obstruction • Gastroenteritis • Ovarian and Testicular Torsion . Serious Signs/Symptoms NO YES Hypotension, poor perfusion FIR IV Procedure IV Procedure IO Procedure M. Adult Pain Control Protocol Normal Saline Bolus 500 mL 0111111I1I if indicated P Repeat as needed Titrate S B P�!90 .Maximum 2 L E Cardiac Monitor 1 Adult Pain Control Protocol ®°°°" if indicated Signs/Symptoms Appropriate Signs/Symptoms % Suggesting Cardiac �� Cardiac Protocol Suggesting Cardiac F Etiology ® ' as indicated EtiologyNEI gdansetron 4 mg % PER Nausea and/ YES IV/ /IM/ODT YES Nausea and/ or Vomiting May repeat in 15 minutes or Vomiting � IN j NO NO �f YE Improving NO Exit to 111111100 Hypotension/Shock Protocol Notify Destination or Contact Medical Control i r it i / i 435 Revised Abdominal Pain 03/01/2023 mm m + On any abdominal pain with significant signs and symptoms, a 12 Lead ECG must be m 9 obtained. 9 Jim, oil loin 0 %1 j ND . • Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lung,Abdomen, Back, Extremities, Neuro • Document the mental status and vital signs prior to administration of anti-emetics • Abdominal pain in women of childbearing age should be treated as pregnancy related until proven otherwise. • Antacids should be avoided in patients with renal disease. • The diagnosis of abdominal aneurysm should be considered with abdominal pain especially in patients over 50 and / or patients with poor perfusion. • Repeat vital signs after each fluid bolus and assessment of lung sounds. • The use of metoclopramide (Reglan) may worsen diarrhea and should be avoided in patients with this symptom. • Choose the lower dose of promethazine (Phenergan) for patients likely to experience sedative effects (e.g., Age>_ 60, debilitated, etc.)When giving promethazine IV dilute with 10 mL of normal saline and administer slowly. • Consider cardiac etiology in patients > 50, diabetics and /or women especially with upper abdominal complaints. / , f 1 436 Revised 03//01/2023 Allergic Reaction / Anaphylaxis axis I4 to rY `,Igi .Li[td `,,rnptorn,,,',",, 'ffeieitsly Onset and location + Itching or hives . Urticaria + Insect sting or bite • Coughing/wheezing or respiratory + Anaphylaxis(systemic effect) Food allergy/exposure distress Shock(vascular effect) Medication allergy / exposure + Chest or throat constriction Angioedema (drug induced) + New clothing, soap, detergent + Difficulty swallowing . Aspiration/Airway obstruction Past history of reactions + Hypotension or shock . Vasovagal event + Past medical history + Edema + Asthma or COPD + Medication history + N/V CHF Assess MILD Symptom Severity SEVERE MODERATE Epinephrine 1:1000 E Auto-Injector IM i IV Procedure f available if indicated Epinephrine 1:1000 E Auto-Injector IM Epinephrine 1:1000 P Diphenhydramine if available � 0.3—0.5 mg IM 25-50 mg Repeat in 5 minutes if no PO/IV/IM/10 improvement Airway Protocol(s) Epinephrine 1:1000 if indicated 0.3-0.5mgIM Repeat in 5 minutes if no IV IO Monitor and Reassess improvement Procedure Procedure % E Monitor for Worsening /;f Signs and Symptoms IV Procedure Diphenhydramine Diphenhydramine 25if not0already/ readymg IV/gMenO 25-50mg IV/IM/10 if not already given PO Albuterol Nebulizer 2.5-5mg Albuterol Nebulizer **OR** 2.5—5 mg P Xopenex 1.25 mg **OR** Ipratropium 0.5 mg Xopenex 1.25 mg Repeat as needed x 3 +/-Ipratropium 0.5 mg if indicated Repeat as needed x 3 if indicated Normal lV/IBolus 500L Re eat as needed Methylprednisolone Maximum 2 Liters 125mgIV/1© MethuinmdInkninnp 121, Cardiac Monitoring ERim� Administe Indicated for Moderate and Severe Reactions ar- 10 r Notify Destination or Contact Medical Control r i l i 437 Reaction A X Revised A 03//01/2023 Allergicf�►eaction � nRr ph lax"I� l Epinephrine Ampule Dosing Chart /p 0.1 1. L 0 J 0,2Inr�m L f 0.,3 Innsg 3Inl L. //% 0.4 Ir i Im L , 0.5 Inr�m , 5 m L 0.6 nig 6 m L. %rf 0. Ini7 I'11m LAl f 0.8 8 m L 0, , nig ' Im L II'lli , I. mi L ai I, to*coirmmumma*u dui*d II xsirm II'dcln[M Status, &<l , II Illa*sirt, IL..a ngs Ansphym laAs us an scumta*and Ilaota*untnslllld Ila*tlhM ummWUsdstm*u°mm slHcl%irglic urm*sctusul. au ill m*Ilslhruill(:I% Is tll c,%du uug of 6h6cm*and dic1% Hirst du uug tllmst sllhoWld Ilium* sdi nh nusteircl%d ui in scuuta*a nsll lludllsxus)II'dcdm*urstm*I da*sa*urm* ddummll tolins.) • Symptom Severity Classification: Mild symptoms: Flushing, hives, itching,erythema with normal blood pressure and perfusion. Moderate symptoms: Flushing, hives, itching,erythema plus respiratory component(wheezing, dyspnea, hypoxia) or gastrointestinal symptoms(nausea,vomiting,abdominal pain)with normal blood pressure and perfusion. Severe symptoms: Flushing, hives, itching,erythema plus respiratory component(wheezing, dyspnea, hypoxia) or gastrointestinal symptoms(nausea,vomiting,abdominal pain)with hypotension and poor perfusion. • Allergic reactions may occur with only respiratory and gastrointestinal symptoms and have no rash/skin involvement. • Angioedema is seen in moderate to severe reactions and is swelling involving the face, lips or airway structures.This can also be seen in patients taking blood pressure medications like Prinivil/Zestril (lisinopril)-typically those that end in A. + Patients who are>50 years of age, have a history of cardiac disease,take Beta-Blockers/Digoxin or patients who have heart rates>150 give one-half the dose of epinephrine(0.15—0.25 mg of 1:1000.) Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG at some point in their care, but this should NOT delay administration of epinephrine. • EMT-B may assist in administration of Epinephrine IM by Auto-Injector if prescribed to the patient. Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine. • The shorter the onset from symptoms to contact,the more severe the reaction. i 1 1 438 RevisedAltered Mental Status 03/0101/2023 20 .... ......"I............................................................................................................................................................................................................................................. + Known diabetic, medic alert • Decreased mental status or lethargy . Head trauma tag 0 Change in baseline mental status . CNS(stroke,tumor, seizure, infection) • Drugs, drug paraphenalia « Bizarre behavior . Cardiac(MI, CHF) Report of illicit drug use or • Hypoglycemia (cool, diaphoretic . Hypothermia toxic ingestion skin) . Infection (CNS and other) • Past medical history + Hyperglycemia (warm, dry skin;fruity 0 Thyroid (hyper/hypo) Medications breath; Kussmaul respirations; signs 0 Shock(septic, metabolic,traumatic) History of trauma of dehydration) 0 Diabetes(hyper/hypoglycemia) Change in condition • Irritability 0 Toxicological or Ingestion Changes in feeding or sleep 0 Acidosis/Alkalosis habits . Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality mmmeeeemmmmeeeemmmmeeeemmmmeeeemm--- ..................................... Psychiatric disorder inal Immobilization Protocol 0 Airway Protocol(s) ®'lik if indicated Utilize Sp where circumstances Blood Glucose Analysis Procedure suggest a mechanism of injury. E 12 Lead ECG Procedure P IV Procedure 10 Procedure Blood Glucose<_69 or z 250 YES P""fin Exit to ®uuuuum Diabetic Protocol NO Exit to % °t Signs of shock/Poor perfusion YES , Hypotension/Shock 9 - �;iJ Protocol � o NO % f Exit to Overdose/Toxi c Exposure Protocols NO NZ, Exit to w��i CVA/Seizure Signs of CVA Or Seizure YES finProtocol as indicated %j %f NO j Exit to Signs of Hypo/Hyperthermia YES 11111110MHypo Protocol Prot as indicated NO Exit to Arrhythmia STEMI YES �1111111-m Appropriate Cardiac Protocol 6ti�� as indicated O Notify Destination or FF— Contact Medical Control o aoi io ao aoi i r r i f f / 439 Revised Altered03/01/2023 Mental Status lt>! %j �r 6 ccouimuuimucu,,mdcd Il;xain,r IIIMeiifl mlll SWIUS IP,III II 14 1 SlllkuIin II' leairl, III Uings I doiumuicum, Il;3aclllk, Il llxlrei i. IilJes, INeLflimo gay cairefLmlll affsumtJoum t.o 11he Ihead cxcuim°1111 foul sliigums of Il is UIisliiu,,mg ouim o1.l4msuim uiumjUuimy • Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. • It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose q 5 min. Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia and may have unrecognized injuries. Consider Restraints if necessary for patients and/or personal protection per the restraint procedure. 1 r 440 Revised 03//01/2023 Adult COPID1 Asthma ...................................................................................................................................................................................................................................................................................... `1 0 G-y `iltL.l lftd Sylfflctorna",',,, « Asthma, COPD--chronic bronchitis, + Shortness of breath « Asthma emphysema, congestive heartfailure « Pursed lip breathing • Anaphylaxis + Home treatment(oxygen, nebulizer) + Decreased ability to speak Aspiration « Medications(theophylline, steroids, + Increased respiratory rate and COPD (Emphysema, Bronchitis) inhalers) effort • Pleural effusion Toxic exposure, smoke inhalation « Wheezing, rhonchi « Pneumonia Use of accessory muscles • Pulmonary embolus • Fever, cough « Pneumothorax « Tachycardia + Cardiac(MI or CHF) • Pericardial tamponade « Hyperventilation • Inhaled toxin (Carbon monoxide, etc.) .............. .......... ............................... /Symptoms Airway Patent _ _ <cLonsistent with COPD Ventilations adequate NO ► Adult Airway iumiiiii PfOtOCOI(S) Asthma Oxygenation adequate Allergic Reaction Anaphylaxis YES Allergic Reaction Anaphylaxis Protocol E 12 Lead ECG Procedure P IV Procedure 10 Procedure P Cardiac Monitor WHEEZING Lung Exam STRIDOR Albuterol Nebulizer 2.5—5 mg Albuterol Nebulizer 2.5—5 mg %� enex 25 p p. g /-I ratro Or III / / as n eded x 3 g Ir t opeum 0.5 mmg + Or ��(„IIi� p um 0 5 mg Repeat Repeat as needed x 3 Methylprednisolone j Improving 125 g lV/IQ Airway CPAP Procedure j NO Albuterol Nebulizer 2.5—5 m YES S Epinephrine Nebulizer Improving *OR* P 1 mg(1.1000)/2 mL of NS 1x Xopenex 1.25mg 0 NO Repeat as needed Methylprednisolone 3 Epinephrine 1:1000 125 mg IV/If) /!J 0.3-0.5mgIM N Magnesium Sulfate 2 g IV/IQ Over 10 minutes Improving iii.I. Adult Airway Protocol(s) YES YES as indicated Notify Destination or Contact Medical Control i r f 1 i // 441 X Revised 03/01/2023 Ad�ul�t COR D As t hma Administration of steroids should be based on assessment. If improvement in the patient's condition is the result of 19 nebulizer treatment,withholding steroid administration should be considered. However in the presences of an acute respiratory distress patient, Methylprednisolone should be considered as a first line medication. .......... l 111011, U ............. ;M M/ PON' MIN .. ...................................................................................................................................... ,,xaixr IIMeiiflalll StalUS, iIIIII I14 I S kll i i, II"4 e c k, i leairl, U1111gS, Xodoixiein, x1rein'iJiJes, NeLfl'O :1eixis liiin Ilfed I ext afire Ilkey Ilpeirfoinxia 1 ice iumuieaSUireS Used io evalllUale Ilpiiooloc6 coin xii p�liia 1 ice mind caire Coliflact Illffediiicaml Coiiflr6 Ili wmuiouim io adiiii,iiiliiiiiiiiisfeiiioiiiiilig ell iiiumellml4muimliiume uiiim IPpalibints Wim afire >50 yeairs of age,,: IIPm mve a :flstoiry of caiioOac Osease, oir if U:ie IlpaiJeint's Illme muimi. uimale liis >150 xiay Ilpiioe6pu1ale caiio6ac is6:ieixiJa A 12 Illead 1111111USt Ilbe Ilpeirfoinxied oin Chese IlpaiJeints • Patients who are 2:50 years of age, have a history of cardiac disease,take Beta-Blockers/Digoxin or patients who have heart rates 2: 150, give one-half the dose of epinephrine (0.15—0.25 mg of 1:1000.) Epinephrine may precipitate cardiac ischernia. Pulse oximetry should be monitored continuously. ETCO2 should be used when Respiratory Distress present. A silent chest in respiratory distress is a pre-respiratory arrest sign. EMT-13 may assist in the administration of Epinephrine IM Auto injector in anaphylaxis only. Patients with inadequate ventilation, not associated with Asthma, are candidates for the use of CPAP. Inadequate ventilation could be as a result of pulmonary edema, pneumonia, COPD, etc. // 2 X Revised 0/01/2023 Diabetic' Adul --------------- to ry `gi ai[d yrnpgal� � �ffei iit�s • Past medical history 0 Altered mental status + Alcohol/drug use • Medications • Combative/irritable + Toxic ingestion • Recent blood glucose check 0 Diaphoresis Trauma; head injury • Last meal 0 Seizures Seizure • Abdominal pain + CVA • Nausea/vomiting Altered baseline mental status. • Weakness • Dehydration • Deep/rapid breathing , .............................................................., ------ ------ ------- ------ ------ ------.---- Blood Glucose Analysis Blood Glucose<69 m ,/Altered Mental Status E _ g/dLand Procedure symptomatic s m Protocol Y p if indicated 12 Lead ECG Procedure No venous access ® E if indicated P initiate 10 access - P Cardiac Monitor P IV Procedure 10 Procedure Blood Sugar Blood Sugar Blood Sugar :569mg/dL 70-249mg/dL >_250mg/dL Awake and alert/ Lhdation with Symptomatic Exit to dence of /M Appropriate Protocol /Fluid rload j YES YES If no improvement j D10!25 gm/250mi IV/f0 �� Normal 5aiin Bolus Titrated to Effect 500 mL iV/10 NO NO May repeat as needed Blood Then infuse 150 mL/hr Procedure f condition S r% ® t SJU Exit to Improving ypo nsion roto /Shock YE NO ES Hypot nsion 1 N Repeat D10 per appropriate ro riate treatment Request transport? YES Transport arm _ NO Every 5 minutes FSBS is>69mg/DI Until Blood Glucose Pt.is�AOx4 Ht. a ye use 70 mg/dL or greater Pt.has someone t home to YES No contact with Medical Control monitor for re rrence ed Will eat within 30 minutes T7 443 Notify Destination or Contact Medical Control 444 X Revised 0/01/2023 Diabetic' Acid ............. ............. ............. ............. ............. ............. ............. . m ............. ............. ............. . m °he �patient may r0 50 ba lui IIII IIII h0 Emergeilcy W � it ist without 9� i % coulitacting rn ` �lil l lulu tr l afteir, tire r uu t-, if III l of the fdHbwiiuig criteiriauu�0 0 uue : j% • The pinger atient sttConnsci us and Alert to Person Plack Blood Glucose is above 69 Dce, Time and Event. %°lf p • The patient has a friend, family member or caretaker with them, that will remain to observe % for recurrent hypoglycemia • The patient will eat within 30 minutes of treatment of the hypoglycemia It is preferable that the EMS technician witness the intake of food prior to leaving the , scene. 0 • The EMS Technician will document all of the above in the Patient Care Report TIE, % i ccouimuuimucu,,mdcd cxaixii III cuflal WIUS Illkuiiim,. Il tes iiiimal.limiims aind cffoiiml, IINeLflmo • Patients with prolonged hypoglycemia may not respond to glucagon. • Do not administer oral glucose to patients that are not able to swallow or protect their airway. • Quality control checks should be maintained per manufacturers recommendation for all glucometers. • Patient's refusina transport to medical facility after treatment of hypoglycemia: Oral Aaents Patient's taking oral diabetic medications should be strongly encouraged to allow transportation to a medical facility. They are at risk of recurrent hypoglycemia that can be delayed for hours and require close monitoring even after normal blood glucose is established. Not all oral agents have prolonged action so Contact Medical Control for advice. Patients who meet criteria to refuse care should be instructed to contact their physician immediately and consume a meal. Insulin Aaents Many forms of insulin now exist. Longer acting insulin places the patient at risk of recurrent hypoglycemia even after a normal blood glucose is established. Not all insulins have prolonged action so Contact Medical Control for advice. Patients who meet criteria to refuse care should be instructed to contact their physician immediately and consume a meal. i i r i r 445 Revised 03/01/2023 Dialysis Renal Failure ............... ............. 4 to r y `Milli a i[d Syrnptorn,,,,,,,,, f f e i,e i taI • Peritoneal or Hemodialysis 0 Hypotension Congestive heart failure Anemia 0 Bleeding Pericarditis Catheter access noted 0 Fever Diabetic emergency • Shunt access noted 0 Electrolyte imbalance Sepsis Hyperkalemia 6 Nausea and/or vomiting Cardiac tamponade 0 Altered Mental Status 0 Seizure 0 Arrhythmia ............................ ................... ............... Apply firm finger tip pressure to bleeding site eding YES E Apply dressing but avoid bulky dressing Shunt< % Dressing must not compress fistula/shunt NO as this will cause clotting of the shunt Exit to CHF YES-mo-'CHF Pulmonary Edema Pulmona y Edema Protocol NO Exit to enous Appropriate ArrestNO Signs/symptoms NOS Protocol <: 11111131M 'All ONE YES YES Calcium Chloride I gm IV 10 E Blood Glucose Analysis Procedure 1571 A P E 12 Lead ECG Procedure Sodium Bicarbonate 50 mEq IV 10 P IV Procedure 10 Procedure M-M Cardiac Monitor WW1/ MP Exit to Exit to Diabetic .ii�111111111 Appropriate protocol Blood Sugar 69 Or z 250 YES-p, Protocol Nb Systolic Blood dialysis in past N,11 ES N70 Normal Saline Bolus 250 ml. P Repeat as needed Maximum 1 Liter If lungs remain cleor Calcium Chloride I gm IV/10 -4YESSigns of Over 2 to 3 minutes yp NO P Sodium Bicarbonate NO 50 mEq IV/10 Notify Destination or Contact Medical Control Revised 03/01/2023 Dialysis J Renal Failure Hyperkaleia can be asymptomatic,meaning that it causes no,symptoms. Sometimes,patients with hyperkalemia report vague symptoms including: • Nausea • Fatigue' • muscle weakness • tingling sensations. % o �f 00 More serious symptoms of hyperkalemia include slow heartbeat and wear pulse. Severe hyperkalemia can j result in fatal cardiac standstill(heart stoppage). Generally, a slowly rising potassium level(such as with chronic kidney failure)is better tolerated than an abrupt rise in potassium levels. Unless the rise in potassium has been very rapid, symptoms of hyperkalemia are usually not apparent until potassium levels are very high (typically or higher). j (tYp Y 7.0 mE /1�1 p Symptoms may also be present that reflect the underlying medical conditions that are causing the hyperkalemia. IN l / f Do not give calcium in presences of suspected dig toxicity 6 ccouimuuimucu,,mdcd cxaixii III cumlaml sl.aIUS II" eU111'6l0guicaml Uumgs II' leaimi. + Do not take Blood Pressure or start IV in extremity which has a shunt/fistula in place. Access of shunt indicated in the dead or near-dead patient only when no other access is available. 10 if available. • Use of tourniquet with uncontrolled dialysis fistula bleeding requires Contact of Medical Control. • Always consider Hyperkalemia in all dialysis or renal failure patients. Sodium Bicarbonate and Calcium Chloride should not be mixed. Ideally give in separate lines. + Renal dialysis patients have numerous medical problems typically. Hypertension and cardiac disease are prevalent. i � r � // 447 Revised Hypertension 03/01/2023 &gi a i[d ` r pt %i'n'r� 'ffei ;ei its ,LIB • Documented Hypertension 01 G„ese, Hypertensive encephalopathy • Related diseases: Diabetes; CVA; Renal • Systolic BP 220 or greater • Primary CNS Injury Failure; Cardiac Problems 0 Diastolic BP 120 or greater Cushing's Response with • Medications for Hypertension Bradycardia and • Compliance with Hypertensive 'AI J ID at I a � �i t I Hypertension Medications • Headache • Myocardial Infarction • Erectile Dysfunction medications 0 Chest Pain Aortic Dissection/Aneurysm • Pregnancy • Dyspnea • Pre-eclampsia/Eclampsia • Altered Mental Status Seizure Or Epistaxis . . *]I. the Ipa"'li&n ° IIr un'° li tlll "focaIII stroke syrqatarnsnrn IlriI" , c i aIII III:' IIrOOII"" &Lflnred SIl" Ilh lillllll nO.t treat the Il fl&n't's Nood Ilr Lfir III IIr 011r .t treat rn&ll m t of any l lh lrte Insive h fl e l m t, &'ISLfire hpaikn and anxie'ty are addressed firs"t Systolic BP 220 or greater Or Diastolic BP 120 or greater Obtain and Document BP (BP taken on 2 occasions at least 5 YES Measurement in Both Armsminutes apart ain and Anxiety are addressed E 12 Lead ECG Procedure IV Procedure %r NO Cardiac Monitor Exit to Appropriate Protocol s � j - If S&S are present with BP 220/120 or greater, OR BP 160/100 in the presence of CHF. f, Consider IWO Labetalol 10 MG Slow IVP. Did S&S Improve after 10min? If YES proceed to appropriate protocol. If NOT, may give 20 MG Slow IVP. Did S&S Improve after 10min? If YES proceed to appropriate protocol. If NOT, may give 40 MG Slow IVP. MAX DOSE OF 70 MG. Notify Destination or Contact Medical Control mmmeeeemmmmeeeemmmmeeeemamaeeeemmmmeeeemmmmeeeemmmmeeeem mmmeeeemmmmeeeemmmmeeeemamaeeeemmmmeeeemmmmeeeemmmmmm®, 11cicoirm ine%ndm:*d II xsirmu II'dcln[M Status,dlkhn, IINecll<, Il. ung, IIL, k*su t,Nidouuua�lin, II ta6k, II xtura�*irmuotom*s, INcl uiro Elevated blood pressure is based on two to three sets of vital signs. Symptomatic hypertension is typically revealed through end organ dysfunction to the cardiac, CNS or renal systems. • All symptomatic patients with hypertension should be transported with their head elevated at 30 degrees. • Ensure appropriate size blood pressure cuff utilized for body habitus. i a ilia io io is i i i f r i i 448 Revised 03/01/2023 Hyp otension S hock ................................................. 4 to r y &gi a i[d Syrnptorn,,,/,",, f f e i,e it. Blood loss-vaginal or 0 Restlessness, confusion • Shock gastrointestinal bleeding, AAA, 0 Weakness, dizziness Hypovolemic ectopic 0 Weak, rapid pulse Cardiogenic • Fluid loss-vomiting, diarrhea, fever * Pale, cool, clammy skin Septic • Infection 0 Delayed capillary refill Neurogenic • Cardiac ischernia (MI, CHF) 0 Hypotension Anaphylactic • Medications * Coffee-ground emesis • Ectopic pregnancy • Allergic reaction 0 Tarry stools Dysrhythmias • Pregnancy Pulmonary embolus • History of poor oral intake Tension pneurnothorax Medication effect/overdose • Vasovagal Physiologic(pregnancy) ............... ................ ............... .............. Diabetic Protocol Blood Glucose Analysis Procedure Cardiac/Arrhythmia if indicated 10M E 12 Lead ECG Procedure No 1111111 ffi Protocol s� if indicated ��()Wd be fl trated U) P IV Procedure 10 Procedure a systoIhc (A:90 P Cardiac Monitor tllR uuuUNi Airway Protocol(s) A Tiean arteiJW pressure if indicated History, Exam and Circumstances Suggest C Type of Shock FEE, Hypovolemic Cardiogenic Distributive Obstructive Spinal Immobilization Right Spinal Immobilization Spinal Immobilization Procedure Sided MI Procedure Procedure E if indicated if indicated if indicated dy Y S NO P Airway Cricothrotom 1 Normal Saline Normal Saline y yy V s'- Bolus 500 mL IV/10 Bolus 500 ml.IV/10 P Surgical 9 Normal Saline Bolus if indicated P Repeat to effect P Repeat to effect 500 mL IV/10 Maximum 2 L Maximum 2 L P Repeat to effect Normal Saline %,% Bolus 500 ml.IV/10 Maximum 2 L or, P Repeat to effect -20 Dopamine 10 N, P mcg/kg/min IV/10 Maximum 2 L %l Trauma NO Doparnine 10-20 Titrate to effect P mcg/kg/min IV/10 1 Y Y S Titrate to effect Dopa mine 10-20 Trauma NO P mcg/kg/min IV/10 Wound Care < Titrate to effect Procedures Normal Saline Bolus YES as indicated P 250 ml.IV/10 Control Hemorrhage Then TKO Doparnine 10—20 Exit to NO Trauma Multiple Trauma kg/min IV/10 Protocol Exit to P mcg/ YES Multiple Trauma Titrate to effect T Protocol Exit to "I'M Multiple Trauma Notify Destination or Protocol Contact Medical Control X Revised Hypotension S h o V 03/01/2023 .......... Dopamine Calculation Chart When us*na 800 main 500 mL the concentration will remain 1.600 mcalm IF Do n'-,jo 1pamine jIntropin) 2 - 20 mcg*g1m1n A i4xboo of 4010 my Dopiomin*1" 260 W 1)61001 mog/ml torg"11I P;oietsts Weitjht 1n; tointil 101 �O 30 4,0 50 (W 70, 80 100 ............ ........... 5 11 2 A 6 a 9 1,11 13 15 17 "19 10 nscq '1 2 4 8 11,11 1 "IS 111 23 26 30 '34 38 .............15 rocfj 1 6 It 17 39 45 51 516 210 (#C9 2 4 '15 23 10 6 0 7-5 AOf M,a 150 Mop pet mil drip so thils Is the nuipblet lot diapOsinute(of �j NO() Obivowt,111ot extravassfilon-melfing, pallor, pshi,rW at IV sltv ,,xain, IMeiifla�I SWIUS, &(�Illl, Ieairl, Uings, Xodoixiein, Il 3a6k, Il ixl.umeixiiuIliiiss, II1geU11mo Hypotension can be defined as a systolic blood pressure of less than 90. This is not always reliable and should be interpreted in context and patients typical BP if known. Shock may be present with a normal blood pressure initially. Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation. Consider all possible causes of shock and treat per appropriate protocol. Hypovolemmc Shock: Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding. CardmoaenmcShock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventrical/septum/valve or toxins. Distributive Shock: Sepsis Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins Obstructive Shock: Pericardial tamponade. Pulmonary embolus. Tension pneurnothorax. Signs may include hypotension with distended neck veins, tachycardia, unilateral decreased breath sounds or muffled heart sounds. Acute Adrenal Insufficiency: State where body cannot produce enough steroids (glucocorticoids mineralocorticoids.) May have primary adrenal disease or more commonly have stopped a steroid like prednisone. Usually hypotensive with nausea, vomiting, dehydration and/or abdominal pain. If suspected, EMT-P should give Methylpred n iso lone 125 mg IV/ 10. May use steroid agent specific to your drug list. For non-cardiac, non-trauma hypotension, Dopamine should only be started after 2 liters of NS have been given. Revised 03/01/2023 Overdose / Toxic Ingestion r 11 • „ ls.�r�l � `�[k;Yl fs aY"fd Sf„j,�,rrr,,i.a fi,,r r"[,l: k • Ingestion or suspected ingestion of a 0 Mental status changes Tricyclic antidepressants(TCAs) potentially toxic substance 0 Hypotension/hypertension Acetaminophen (Tylenol) • Substance ingested, route,quantity 0 Decreased respiratory rate Aspirin • Time of ingestion 0 Tachycardia,dysrhythmias Depressants • Reason (suicidal,accidental,criminal) 0 Seizures Stimulants • Available medications in home 0 S.L.U.D.G.E. Anticholinergic • Past medical history, medications 0 D.U.M.B.B.E.L.S Cardiac medications • Solvents,Alcohols, Cleaning agents • Insecticides(organophosphates) .... .. Scene YES Adequate Respirations/ NO Safe Oxygenation/Ventilation NO Naloxone-0.4 mg Max of 2mg YES IV/10/IM/IN T L P Naloxone is titrated to Call for help/additional E 12 Lead ECG Procedure effect adequate ventilation resources P IV Procedure 10 Procedure and oxygenation f Stage Until scene sae Cardiac Monitor YES Altered Mental Status mgAppropriate Airway Protocol(s) if indicated FTBlood Glucose Analysis NO j" Procedure Hypotension/Shock Protocol Systolic BP <90 YES G E if indicated Diabetic/AM S i IBM 111H Behavioral Protocols NO O as indicated Potential Cause ooi 0 Serious Signs/Symptoms Beta Blocker Calcium Tricyclic Cyanide OD Channel Blocker Antidepressant Erg anophosphate Carbon Monoxide OD OD OD L,,j Consider QRS %////////% O, r//iir//// Cardiac External Pacing >_0.12 sec "' /// Exit to Procedure for Severe Cases PI( , " YES d ,� /��iiiii o ,,,,,i ,, ,,,,,�,�„ Appropriate � � � �� , Sodium Bicarbonate " Protocol � if indicated SO mEq IV/to Sodium Bicarbonate FID 1,IN 50 mEq IV/14 nil P Calcium Chloride 1 gm IV/to Over 3 minutes DR Exit to May repeat NO � WMD/ Nerve Agent Dopamine 10—20 Protocol If Needed: Mcg/kg/min IV/IU if indicated Florida Poison if no response Control 1-800-222-1222 Notify Destination or Contact Medical Control oil or, o ✓i i o, f i 5 Revised 03/01/2023 Overdose / Toxic Ingestion 0 Dry pulmonary secretions 0 Adequate oxygenation 0 Tachycardia is NOT a contraindication for Atropine administration in setting of organophosphate poisoning. Routine usage of Narcan without signs and symptoms of respiratory compromise is contraindicated. Z When administration of Sodium Bicarb drip, be sure to withdraw 50 mL from the IV bag to provide for correct concentration. Dopamine Calculation Chart When using 80(l mc I in 500 mL, the concentration will remain 1,600 mca/ml Dopamine (Intralplin)2-2,0 mic9*91mlin A mixtuen at 400 Insy Dopumine in,250 tial a 1p6010 as alftWI mcq4g, Pali owls Wtqiht in Ki1fp(J$4 H119 misorte 2,5 IS 10 A M 40 "1 60 70 00 90 100 2 mcg 1 2 2, 3 4 5 5 6 7 8 .......... — k...................................... 5 1110sq) 2 4 6 8 9 11' 13 $5 >111.. 1V F, 10 imcq 1 2 4 8 111 i'15 19 !1 26 10 34 38 LLJ 15 npcg 1 6 11 17 123 20 X 39 56 2,10 nicq 2 4 $ 15 23 130 36 45 53 so 1�a 75, VMJh a 60 drop per ml drip scl Wvs is the numbu of dropshirafle(or w1ft) Mom 11of =00ag,pallor,III esc,st IN tits 00 Pf.'l,,,,,1 r 111111 �1cicoinine%ndcd xaim: 'Acln[M Status, &<�n, II III Iclart, II ungs,Aiidoincln, G:x[reiYflfle%s, 14c'Miro Do not rely on patient history of ingestion,especially in suicide attempt. Make sure patient is not carrying other medications or has any weapons. Bring bottles, contents,emesis to ED. S.L.U.D.G.E: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis D.U.M.B.B.E.L.S: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation,Salivation. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma-, rapid progression from alert mental status to death. Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liverfailure. Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal dysfunction, liver failure, and/or cerebral edema among other things can take place later. Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils Stimulants: increased HR, increased BP, increased temperature, dilated pupils,seizures Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes Cardiac Medications: dysrhythmias and mental status changes Solvents: nausea, coughing, vomiting, and mental status changes Insecticides: increased or decreased HR, increased secretions, nausea, vomiting,diarrhea, pinpoint pupils Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. Nerve Agent Antidote kits contain 2 mg of Atropine and 600 mg of pralidoxime in an autoinjector for self administration or patient care. These kits may be available as part of the domestic preparedness for Weapons of Mass Destruction. Consider contacting the State of Florida Poison Control Center for guidance. ., / 4 2 Revised Seizure 03/01/2023 r <„ a i f 1 Sy n pt c l((.d,. ,,,I • Reported/witnessed seizure • Decreased mental status • CNS(Head)trauma activity • Sleepiness • Tumor • Previous seizure history • Incontinence Metabolic, Hepatic, or Renal failure • Medical alert tag information 0 Observed seizure activity Hypoxia • Seizure medications • Evidence of trauma • Electrolyte abnormality (Na, Ca, Mg) • History of trauma • Unconscious • Drugs, Medications(non-compliance) • History of diabetes • Infection/Fever • History of pregnancy • Alcohol withdrawal • Time of seizure onset • Eclampsia • Document number of seizures • Stroke • Alcohol use, abuse or abrupt • Hyperthermia cessation 0 Hypoglycemia • Fever ...... ------,,,,------,,,, ------,,,,------,,,,-------------- NO Active Seizure YES Activity II pla9 Glux:; se Analysis I"i,o�.a.a9u„ia,,k Airway Protocol(s) ® as indicated Spinal Immobilization Procedure Diabetic Protocol E if indicated if indicated E II,lood Gkxa os e Analysis "ios�: duaia��k Loosen any constrictive clothing Loosen any constrictive clothing Protect patient Protect patient IV Procedure P IV Procedure IO Procedure if indicated Cardiac Monitor � Midazolam 2.5— lv/lo/lN S.0 mg /iM if indicated If no IV/IQ access May repeat every 3 to 5 minutes as P needed % Maximum 10 mg ,, Cardiac Monitor Spinal Immobilization Procedure if indicated Consider j% Altered Mental Status Awake,Alert Protocol j Normal Mental Status if indicated YES NO, IJt NO Status Epilepticus °J% %' Or Postictal State Monitor and Reassess Monitor and Reassess YES Active Seizure in Known or Suspected Pregnancy >20 Weeks Magnesium Sulfate. 2gIIV/lO Over 2—3 minutes May repeat...dose x 1 Notify Destination or Contact Medical Control i alai io is aai as i, ail ii i r f i i i 453 Revised Seizure 03/01/2023 Status;Epilepticus is defined as continuous seizures occurring for longer than 30 minutes or 2 or more sequential seizures without full recovery between. Administration of benzodiaza roes i� to relieve active;seizures not to revert reoccurance. p a p �rD %j J% %r %f ccouimuuimucu,,mdcd Il; in' III' cuflal i.alUS II', "']14 1 I1Illeairl.,, III Uings, II l.ueixiiu1Jcs, IINeLflmo 1einius liiin Il'Red Iext afire Ilkey Il eirfouirixiva1ice iuxuisasrUreS Used l.o cvalllUalc Il irol.oc6 coiuxuill lllliiaincc aind caire • Midazolam 5— 10 mg IM is effective in termination of seizures. Do not delay IM administration because of difficult IV or 10 access. IM Preferred over 10. • Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. • Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. • Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness • Be prepared for airway problems and continued seizures. • Assess possibility of occult trauma and substance abuse. • Be prepared to assist ventilations especially if midazolam is used. • For any seizure in a pregnant patient, follow the OB Emergencies Protocol. i r 1 1 f 454 Revised Suspected Stroke 03/01/2023 • Ischemic or Hemorrhagic CVA • Altered mental status + See Altered Mental Status • Previous cardiac/vascular surgery • Unilateral Weakness/Paralysis • TIA(Transient ischemic attack) • Associated diseases:diabetes, 0 Blindness or other sensory loss + Seizure hypertension, CAD • Aphasia/Dysarthria + Todd's Paralysis • Atrial fibrillation • Syncope + Hypoglycemia <50 • Medications(blood thinners) • Vertigo/Dizziness Hyperglycemia >400 • History of trauma • Vomiting Stroke • Headache Thrombotic or Embolic(-85%) • Seizures Hemorrhagic(-15%) • Respiratory pattern change • Tumor • Hypertension/hypotension • Trauma • Dialysis/Renal Failure mmmeeeemama°eeemmmmeeeemmmmeeeemmmmeeeeee., ..................................... IcSigns and Symptoms consistent with Stroke CConsistent � Transport based one indings twmo of f)mm ,�° u0m Tm�. II omll° III�' IKYES eeni�d onnall iii with Acute < ,�� t, i ides Scene III uuiometo 5 1 'IlWiinu�tetroke tooii iuiemmedwete III eiffi cab oiuI i eoifitd for Code Stroke NO NO � 1 0 j % Exit to j f Appropriate Protocol Diabetic Protocol o E if indicated ot E 12 Lead ECG Procedure IV Procedure /„% Cardiac Monitor C BP>220 See h ertension dingsBitaterally YE protocol 9r 1' least 5 minutes apart fill Notify Destination or Contact Medical Control / o aoi io ao aoi / / / � f� r i J / 455 f" o ro2o2s Suspected Stroke Code Stroke Exclusions MEND Exam Criteria Last time seen normal >300 minutes +�Mental Status Y Stroke of an kind in last 3 months Unresolved Hypoglycemia or • Level of Consciousness (AVPU) Hyperglycemia • Speech. You cant teach an old dog new tricks" • Head Trauma at onset of symptoms • Ques#ions: (age, month) • History of GI or GU bleeding within the • Commands (close, open eyes) last 21 days • History of a Arterial Puncture at a non- Cranial Nerves compressible site in previous 7 days +� Facial Droop (show teeth or smile) • History of Lumbar Puncture in previous • Visual Fields (four quadrants) 7 days ! AN • Horizontal Gaze (side to side) • History of Major Surgery or Biopsy of j2, parenchymal or solid organ in previous o Limbs 14 days. +� Drift-Arm (close eyes, extended arms palms . History of prior intraeranial ' down +� Drift- Le en eyes, lift each le separately) hemhorrage Dri g (op Y g • Sensory-Arm (close eyes and touch, pinch) 1, • Sensory- Leg (close eyes and touch, pinch) • Coordination-Arm (finger to nose) • Coordination- Leg (heel to shin) ccouimuuimucu,,mdcd Il; in, IIMeiifl�lll SWIUS, "']14 W,, II' leaiml.,, III Uings I doiumuiein II' lreium.uiuIics IINeUllmo gfW12 JW"glf ' gftlll" IIg hg hWll'mft Ill fliflllf) h ,I'LD g)gll'mg 't Ilftg1 522a Illlmdlll"IIUIIIIfIJ Lniuf Ulf Ghilnst 1 f) ft ffll'mh �IIIWfW daagaf)IIIII'mft gll'm I'L grfllfrf fill 111 g and W" ggfWlll"gig g)hgfWlll b2gi WWdal lfftg f) gllm 1, gaff; V11111�' III"Wffft ana mfftlllQn Illffll' W uiuirluc of Oinset our IIL..cst Seein INoiriurui4 Oine of l.Illmc iurluost uiixiull our lainW IiI.cium.Iis Clhe Il w c llhosll uI.al IlrurovVMeir can olbla iin of Wi liiclllm allllll lreafiurlucint de6sliioins airc Ilbased II We vcury Ilrurccuisc liium g��W.11lmcuruiumg dr�fr� W.o ssfr�llrlllliislI W.Ill.mc fuiuirluc of oumscW aumd report as an ai hml fhne )lii e. 13 17 IINJ0..W.°''aWlrotd 1115 aural iniid s agsr 1`11)"WOWfhoiiid tNs uiinfoirrinatioin Ilfrafinermf uruiay not be rill lllc fo urcc6vc W.III°murouir°lull olllyW.liics at facliillliI.y Mlrc rfllr sfumolllrc Wiiiiuxie stairW.s W:iein Ilpatfuciid was IIIast asrMlrc « Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. waking with stroke symptoms would be defined as an onset time when the patient went to sleep or last time known to be symptom free.) « The differential listed on the Altered Mental Status Protocol should also be considered. « Be alert for airway problems (swallowing difficulty, vomiting/aspiration). « Hypoglycemia can present as a localized neurologic deficit, especially in the elderly. Document the Stroke Screen results in the PCR. i i i i / / 456 Revised Suspected Sepsis 03/01/2023 orb S ii, ire ,rt d .,�rn-)t erns LDi ermi r I ' • Known infection Must have at least two of the following • Anaphylaxis • Illness suggestive of infection • Temp> 101 F or<96.8 F • Hypovolemic shock • Previous sepsis diagnosis • Hypotension SBP< 90 0 Local Infection • Indwelling lines or catheters • Elevated white count>11 K/mm3 0 Hyperglycemia • Recent surgical procedure • HR> 100 BPM • Acute Renal Failure • Resp rate >20 or ETCO2<35mmHg • ARDS OR ETCO2>45mmHg • Toxic Shock Syndrome • Adrenal Crisis Signs and Symptoms Consistent with Sepsis IV E 12 Lead ECG Procedure IV Procedure If systolic BP<100mmHg *or* or MAP<65mmhg Normal Saline Bolus 20 m1/kg IV/IU *Monitor Lung Sounds'* 1' j % Consider Vasopressor j BP>90mmHg support MAP>65mmHg Dopamine f After 20ml/kg Bolus 10-20mcg/kg/min IV/10 YES Proceed to the most appropriate protocol for continued symptoms or complaint i r i i r 457 Revised Syncope 03/01/2023 :0 i y `,itlira; rrird Syiirp:orn� f, Cardiac history, stroke, seizure + Loss of consciousness with recovery + Vasovagal • Occult blood loss(GI, ectopic) 0 Lightheadedness, dizziness . Orthostatic hypotension • Females: LMP, vaginal bleeding . Palpitations,slow or rapid pulse 0 Cardiac syncope • Fluid loss: nausea, vomiting, 0 Pulse irregularity 0 Micturition/Defecation syncope diarrhea . Decreased blood pressure . Psychiatric • Past medical history + Stroke Medications . Hypoglycemia Seizure • Shock(see Shock Protocol) • Toxicological (Alcohol) + Medication effect(hypertension) PE AAA Airway Protocol(s) NO Diabetic Protocol if indicated if indicated Blood Glucose Analysis Procedure Appropriate �i E Orthostatic Vital Signs if no Cardiac/Arrhythmia � Protocol suspected trauma STEMI/CP Protocol if indicated 1111111HE if indicated P Cardiac Monitor/ !2 Lead ECG ®11 FPTIV Procedure Spinal Immobilization Protocol IV Suspected or YES Multiple Trauma Protocol Evident Trauma I® if indicated j NO % Mgt f Altered Mental ��,Altered Mental Status Protocol Status YES � .� if indicated 02"f; NO Hypotension/ Hypotension/Shock Protocol YES Poor Perfusion if indicated / n %J NO Notify Destination or FF- Contact Medical Control i r i i i r f f � 1 458 Revised Synco 03/01/2023 p C}rthostatic 1/S<To obtain reliable,orthosfa#ic vs.,the patient must 4e in a seated or standing position for>2 rains pnor to evaluation. When possible,in the setting of the non-emergent patient,it is recommended that supine,seated and standing positions be evaluated for accurate orthostatic vs.assessment. Positive Findings. Dizziness with any change in position is considered a positive finding. Systolic blood pressure decrease by>20 mmHg with change in position Heart rate increase>24 b m p �r0 jJ �1 ; ; a i, ccouimuuimucu,,mdcd Il,,xai ur IIMeiifl ml WIUS IllkuiIlh II' 11' I I14 I,, Ii Illeairl, III Uings I doiu rein, Il;3aclllk, NeUllimo « Assess for signs and symptoms of trauma if associated or questionable fall with syncope. • Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope. These patients should be transported. « More than 25% of geriatric syncope is cardiac dysrhythmia based. f r , f 1 459 Revised Vomitingand Diarrhea 03/01/2023 + Age • Pain CNS(increased pressure, headache, stroke, • Time of last meal • Character of pain (constant, CNS lesions,trauma or hemorrhage, vestibular) • Last bowel movement/emesis intermittent, sharp, dull, etc.) • Myocardial infarction • Improvement or worsening • Distention • Drugs(NSAID's, antibiotics, narcotics, with food or activity 0 Constipation chemotherapy) • Duration of problem • Diarrhea • GI or Renal disorders • Other sick contacts • Anorexia • Diabetic ketoacidosis • Past medical history 0 Radiation • Gynecologic disease(ovarian cyst, PID) • Past surgical history yrn-)t fi sr Infections(pneumonia, influenza) + Medications I <r r �u,rc. • Electrolyte abnormalities • Menstrual history (pregnancy) Fever, headache, blurred vision, + Food or toxin induced • Travel history weakness, malaise, myalgias, cough, • Medication or Substance abuse Bloody emesis/diarrhea headache, dysuria, mental status • Pregnancy changes, rash • Psychological Serious Signs/Symptoms NO Hypotension, poor YES perfusion IV Procedure IV Procedure 10 Procedure P Normal Saline IV TKO IV Procedure Or Consider 2 Large Bore sites Saline Lock P Normal Saline Bolus 500 mL Repeat as needed Titrate SBP 2 90 Maximum 2 L (3dansetron 4 mg Nausea/ ling P IV/IQ/IM/ODT Nausea/Vomiting j May repeat in 15 minutes ] �► '' 6t E Blood Glucose Analysis �,,,,��, Diabetic Protocol E Blood Glucose Analysis Procedure ®�� if indicated Procedure %1„/ Adult Pain Control " 8' Protocol AYES Abdominal Pain j Abdominal Pain YES P.- 1�� if indicated j j Signs/Symptoms 01 Appropriate Signs/Symptoms , Suggesting Cardiac �;t Cardiac Protocol(s) Suggesting Cardiac Etiology as indicated Etiology Improving YES —YES Improving NO NO � Normal Saline'Bolus 500 mL Exit to Then 150 mL/hr 1'1 ill Hypotension/Shock Protocol Notify Destination or Contact Medical Control � r i i i it i i / r/alai io /o ioi i f 460 f" Revised Vomiting and Diarrhea 03/01/2023 0°l �i r% % j ccouimuuimucu,,mdcd Il,,xainur IIIMeiifl ml St.al.Us Slllkuium. ]4 1 IINecllk IP,Illeaiml.,, III Uumgs I doiu iein,. Il;3acllk, NeUllimo • 12 Lead ECG should be considered in patients with increased risk factors for cardiac disease. • The use of metoclopramide (Reglan) may worsen diarrhea and should be avoided in patients with this symptom. Isolated vomiting in pediatrics may be caused by pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures). , f 1 461 Revised Childbirth03/01/2023 1 Labo (History Si gins and Syirnlptoirns Differential + Due date + Spasmodic pain • Abnormal presentation • Time contractions started/how often + Vaginal discharge or bleeding Buttock • Rupture of membranes • Crowning or urge to push Foot • Time/amount of any vaginal bleeding + Meconium Hand • Sensation of fetal activity + Prolapsed cord • Past medical and delivery history + Placenta previa • Medications 0 Abruptio placenta • Gravida/Para Status • High Risk pregnancy Left lateral position Obstetrical Emergency Abnormal Vaginal Bleeding/ YES t Protocol Hypertension/Hypotension as indicated NO Inspect Perineum FT (No digital vaginal exam) E36 owning No Crowning ks Gestation Priority symptoms: Crowning <36 weeks gestation IV Prtocol Abnormal presentation Monitor and Reassess o Severe vaginal bleeding Document frequency and Childbirth Procedure Multiple gestation duration 1 of contractions Prolapsed Cord Expedite transport Shoulder Dystocia Breech Birth Hips Elevated Transport Knees to Chest Unless delivery (III imminent IIi® Unable to Deliver Encourage Mother Insert fingers into Delivery vagina to relieve to refrain from Create air passage by pushing supporting presenting pressure on cord Support Go to part of infant. Saline Dressing Presenting Parts Newly Born Place 2 fingers along Over cord Do Not Pull Protocol side nose and push away from face Transport in Knee to Chest Position or Left Lateral Position �L Notify Destination or Contact Medical Control WEENNEEMNOMMEM ip-2 Revised Childbirth03/01/2023 Labor APGAR Score Table ili 1Ehe ,Vf(1 �trcve, I fe'art Kate I Absent i 1 1V°rrtNwa li�d�'� lu�4"a�wlf �.. . ..,.., w,.......... .. e e'gxo,uio,, u ®u, i Be sure to link mother and baby (s)together with proper banding identification Pearls ccouimuuimueu,:mdcd Il; ain'I (of IIIMoU:meuim): III' euf aI StalUs, II':IIeairl, Ill....Uumgs,,: Xodoixiein, II" eU111`0 Document all times (delivery, contraction frequency, and length). If maternal seizures occur, refer to the Obstetrical Emergencies Protocol. • After delivery, massaging the uterus (lower abdomen)will promote uterine contraction and help to control post- partum bleeding. • Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal. Record APGAR at 1 minute and 5 minutes after birth. 463 Revised Newly Born 03/01/2023 (History Si gins and Syirnlptoirns Differential • Due date and gestational age 0 Respiratory distress • Airway failure • Multiple gestation (twins etc.) • Peripheral cyanosis or mottling Secretions • Meconium (normal) Respiratory drive • Delivery difficulties • Central cyanosis(abnormal) • Infection • Congenital disease • Altered level of responsiveness • Maternal medication effect • Medications(maternal) 0 Bradycardia • Hypovolemia • Maternal risk factors Hypoglycemia substance abuse • Congenital heart disease smoking • Hypothermia Care of mother erm Gestation Provide warmth/Dry infant Appropriate Protocol Breathing or Crying YES E Clear airway if necessary �Vuuuum Good Muscle Tone Monitor and Reassess NO T t E Warm, Dry and Stimulate NO Clear airway if necessary Airway Suctioning Heart Rate< 100 NO Labored breathing/ Routine suctioning of the Agonal breathing or Apnea Persistent Cyanosis newborn is no longer recommended YES Clear amniotic fluid: E BVM Ventilations YES Suction only when obstruction is present and/ E Pulse Oximetry or if BVM is needed. Cardiac Monitor Meconium present: Non-vigorous newborns 1 Heart Rate< 100 NO may undergo: Direct Endotracheal YES Suctioning uctiononmguuuuuuuuuuuuuuuuuuuuuuuuuuum Supplemental Oxygen BVM Ventilations Maintain Sp02>_94% If repeating cycle take corrective E NO action: Change in position or BVM Maintain warmth Technique. If no improvement move Monitor and Reassess (III down algorithm to intubation Ili® Most newborns requiring resuscitation will respond to Heart Rate< 60 ventilations/BVM, compressions and/or YES epinephrine. Pediatric Airway Protocol(s) If not responding consider no I hypovolemia, E Chest Compressions Epinephrine 1:10,000 pneumothorax and/or 0.01 mg/kg IV 110 hypoglycemia (<40.) P IV Procedure IO Procedure Every 3 to 5 minutes as needed Normal Saline Bolus (iE —NO Heart Rate<60 YES 10 mL/kg IV 110 May repeat x 1 Notify Destination or Contact Medical Control GENNEENEWW&RUMMEEM 464 Revised Newly Born 03/01/2023 APGAR Score face I 1"),ke AKA,Rwtvr SCORE swift I" �4earl Kate , l"Po"rwl �fa,Gbi��°w,u,lrro ��, „111 �aHngi i IF VVe4 �p ,i az ,�rm N ellh p p�If,�W p � p 'C� l4�' J NVA Be sure to link mother and baby ( )together with proper banding identification IPearls lccouimuuimueu,,mdcd Il;xain' III ii lalll SWI.US &(ll ium, 11 I141"1, I" ecllk CIIPmest.,, II' leauiml.,, Xodoixiein, II;IxlreiuxGili1Jes, IP' eU111`o « Term gestation, strong cry/breathing and with good muscle tone generally will not need resuscitation. « Most important vital signs in the newly born are respirations/respiratory effort and heart rate. • Heart rate best assessed by auscultation of the pre-cordial pulse followed by palpation of the umbilical pulse. « Pulse oximetry should be applied to the right side of the body. « Expected pulse oximetry readings: Following birth at 1 minute = 60 - 65 %, 2 minutes = 65—70%, 3 minutes = 70—75 %, 4 minutes = 75—80 %, 5 minutes = 80—85 % and 10 minutes = 85—95%. CPR in infants is 120 compressions/minute with a 3:1 compression to ventilation ratio. • It is extremely important to keep infant warm. « Maternal sedation or narcotics will sedate infant (Naloxone is NO LONGER recommended; supportive care only). « Consider hypoglycemia in infant. « D50 = D10 diluted (1 ml of D50 with 4 ml of Normal Saline) • Document 1 and 5 minute APGAR sores in PCR. 465 Revised 03/01/2023 Obstetrical Emergenc (History Si gins and Syirnlptoirns Dlifferentliall • Past medical history • Vaginal bleeding • Pre-eclampsia/Eclampsia • Hypertension meds • Abdominal pain • Placenta previa • Prenatal care • Seizures • Placenta abruptio • Prior pregnancies/births • Hypertension 0 Spontaneous abortion • Gravida/Para Severe headache • Visual changes • Edema of hands and face NO Vaginal Bleeding/Abdominal Pain YES Exit to Known or Suspected Known or Suspected • Abdominal Pain Protocol Pregnancy/ NOt �� Or ENO Pregnancy/ Missed Period Appropriate Protocol Missed Period YES _ YES Left lateral recumbant position Left lateral recumbant position IV Procedure P IV Procedure 10 Procedure Exit to Childbirth AYES Labor NO Hypertension Protocol I YES NO NO Seizure Activity YES Seizure 0000, Activity NO YES Exit to Hypotension/ Abdominal Pain f NO Poor Perfusion/ Protocol Shock r• MidazolaKn 2.5—5.0 mg �'�'� YES IV/10/IM/IN P Repeat May repeat every 3 to 5 (III minutes as needed Normal Saline Bolus Maximum 10 mg 500 mL IV/to Repeat as needed to effect SBP�90 Maximum 2 L � Exit to Blood Glucose Analysis Diabetic E Procedure Protocol Shock � NO Improving Protocol Magnesium Sulfate 2 g lV/10 ruuu umu YES P over 2-3 minutes May repeat dose x 1 Cardiac Monitor Notify Destination or Contact Medical Control 466 Revised 03/01/2023 Obstetrical Emergency IPearls ccouimuuimueu,,mdcd Il; aiumur Ill eumlaml SWl.Us I d'oiumiein, II'Ileac 1, Ill Uu,,mgs, II" eLmuimo • Severe headache, vision changes, or RUQ pain may indicate preeclampsia. In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure. • Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome. • Ask patient to quantify bleeding - number of pads used per hour. • Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation. Greater than 20 weeks gestation generally requires 4 to 6 hours of fetal monitoring. DO NOT suggest the patient needs an ultrasound. Magnesium may cause hypotension and decreased respiratory drive. Use with caution. Midazolam 5— 10 mg IM is effective in termination of seizures. Do not delay IM administration because of difficult IV or 10 access. 467 Revised Adult03/01/2023 Thermal Burn I Stoury &guns and Sduriptoins t ffclrclnUM • Type of exposure(heat, gas, • Burns, pain,swelling • Superficial (15t Degree) red- painful (Don't include in chemical) • Dizziness TBSA) • Inhalation injury • Loss of consciousness • Partial Thickness(2"d Degree) blistering • Time of Injury • Hypotension/shock • Full Thickness(3rd Degree) painless/charred or leathery • Past medical history and 0 Airway compromise/ skin Medications distress could be • Thermal injury • Other trauma indicated by 0 Chemical—Electrical injury • Loss of Consciousness hoarseness/wheezing • Radiation injury �.• Tetanus/Immunization status -,� • Blast injury Assess Burn/Concomitant Injury Severity Minor Burn Serious Burn Criticial Burn <5%TBSA 2"d/3rd Degree Burn 5-15%TBSA 2"d/3rd Degree Burn Suspected inhalation injury or requiring No inhalation injury, Not Intubated, intubation for airway stabilization GCS 14 Nor e Hypotension or GCS 13 or Less o or r Greater a (When reasonably accessible, transport to a Burn Center) LI Remove Rings, Bracelets/ Constricting Items Remove Rings, Bracelets/Constricting Items 11 Dry Clean Sheet or Dressings Dry, Clean Sheet or Dressings ull Adult Multiple Trauma Protocol �1111109 Adult Multiple Trauma Protocol f lllllll •1111111M if indicated WWII, if indicated Adult Airway Protocol(s) Adult Airway Protocol(s) 111111107a•n1f��'t as indicated ® k as indicated IV Procedure IV Procedure if indicated Consider 2 IV sites if greater than 15 %TBSA Normal Saline P 10 Procedure if indicated ulllll 0.25 mL/kg(x% TBSA)/hr Normal Saline for up to the first 8 hours. 0.25 mL/kg(x /o TBSA)/hr "6.. (More info below) III'°°��„X.... for up to the first 8 hours. Z11IIII Lactated Ringers (More info below) if availablei,I;X: Lactated Ringers if y Adult ifindicatedin Control Protocol R Adult ifindicatedin Control Protocol ®;ffff Carbon " p„ Carbon Monoxide/ Monoxide/ ar on Monoxide �Z11 Cyanide Exposure Cyanide Protocol Cyanide Exposure Transport Facility of Choice Rapid Transport to appropriate destination Notify Destination or Contact Medical Control F1. Lactated Ringers preferred over Normal Saline. Use if available,if not change over once available. 2, Formula example;an 80 kg(196 lbs.)patient with 50% TBSA will need 1000 cc of fluid per hour. �i,„. . IIIIIII 468 Revised Adult03/01/2023 Thermal Burn ", I) .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Front of Body Back 0f Body IRLfle of IIVl ii m s + Seldom do you find a complete isolated p" body part that is injured as described in the 4. co/'Neck k N 31%Back CAIHead/Neck J Rule of Nines. + More likely,it will be portions of one area, Entire Head/ eck 90A Entire Head/Neck portions of another,and an approximation will be needed. + For the purpose of determining the extent w of serious injury,differentiate the area with � tlr Right Arm q i minimal or 1It degree burn from those of partial(2"r)or full(3�)thickness burns. III 9%liitire Left Arm A For the purpose of determining Total Body Surface Area(TBSA)of burn,include only RoUpper Posterior Trunk Partial and Full Thickness burns.Report 9% ppGar Anterior Trunk a1�� r��„ rp�r , the observation of other superficial(11t Trunk .,..., degree)burns but do not include those W4�d'i lr�tl"47a° �'( � /q .AkrNr $ "r4 ( rrMlll --' burns in your TBSA estimate. n + Some texts will refer to 4 5 and 6 I ft Entre Anteriof Trunk degree burns.There is significant debate �t regarding the actual value of identifying a burn injury beyond that of the superficial, partial and'rIN� � p h level of f emergent and primary careull thickness burn at least t For our work,all are included in Full w Thickness burns. + Other burn classifications in general r, include:Upper,4on;t Leg 4th referring dermis and involves muscle y 4th to a burn that destroys I' )oLo er Front Leg tissue. / Entire . 5th referring to a burn that destroys dermis,penetrates muscle tissue, �t th and involves tissue around the bone.01 + 6 referring to a burn that destroysI'° I dermis,destroys muscle tissue,and penetrates or destroys bone tissue. p„r M1, Estimate spotty areas of burn by using the size of the patient's palm as 1 % PPw aulmIlls 11cicolrnuuua*ndm:*d II xslrmu II'dcln[M Status, II IIIII ]d II, INa*cllr, II Illmlart, II uuings,AIIbdolru cln, IGi::xtllra*Iluuotlic*s, IGI'.tscllr, and Idm*uulro Green,Yellow and Red In burn severity do not apply to the Start/JumpStart Triage System. CrutocM our Seillouus IGiituuumurms: ..................................................... >5-15%total body sun°ace area(TBSA) 2nd or 3rd degree burns,or 31 degree burns>5% TBSA for any age group, or circumferential burns of extremities, or electrical or lightning injuries, or suspicion of abuse or neglect, or inhalation injury, or chemical burns, or burns of face,hands,perineum, or feet Require direct transport to a Burn Center. Local facility should be utilized only if distance to Burn Center is excessive or critical interventions such as airway management are not available in the field. Burn patients are trauma patients, evaluate for multisystem trauma. Assure whatever has caused the burn is no longer contacting the injury. (Stop the burning process!) Early intubation is required when the patient experiences significant inhalation injuries. Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling. Burn patients are prone to hypothermia—NEVER apply ice or cool the burn. Help maintain normal body temperature. Evaluate the possibility of child abuse with children and burn injuries. Never administer IM pain injections to a burn patient. 3 �IIj°° ° ° IIIIIII 469 Revised 03/01/2023 Head Trauma I Stoury &guns and Syin tole°ns tufts*Ila*Il tllsll • Time of injury • Pain, swelling, bleeding 0 Skull fracture • Mechanism (blunt vs.penetrating) . Altered mental status 0 Brain injury (Concussion, Contusion, • Loss of consciousness . Unconscious Hemorrhage or Laceration) • Bleeding • Respiratory distress/failure 0 Epidural hematoma • Past medical history Vomiting 0 Subdural hematoma Medications 0 Major traumatic mechanism of injury 0 Subarachnoid hemorrhage Evidence for multi-trauma • Seizure 0 Spinal injury • Abuse � Spinal Immobilization Protocol DO NOT ` 1 if indicated Brain Herniation HYPERVENTILATE Adult Multiple Trauma Protocol Unilateral or Bilateral Dilation ofPupils/Posturing Dim if indicated Ventilate 8—10 Breaths per minute to maintain IV Procedure 10 Procedure Hyperventilate 14— 16 Breaths per minutes to maintain EtCO2 35—45 mmHg Altered Mental Status Protocol EtCO2 30—35 mmHg if indicated Seizure Protocol if indicated E Blood Glucose Analysis Procedure Assess Mental Status 1a*oord GCS IIIIIIIIIIIIIIIIIIII NO GCS<_8 YES FT Viulll�illl Monitor and Reassess Gag Reflex g YES NO Intact? "00 Airway Protocol(s) E Supplemental oxygen ul'A.° �iiwm RSI Protocol Maintain Sp02>_94% ® ' if available Maintain EtCO2 Maintain EtCO2 35—45 mmHg 35—45 mmHg m Monitor and Reassess 1111 Airway Protocol(s) if indicated Notify Destination or Contact Medical Control "i�IIIVumil °�I IIII � 470 Revised Head Trauma 03/01/2023 The pharyngeal reflex or gag reflex(also known as a laryngeal spasm) is a reflex contraction of the back of the throat. It is evoked by touching the roof of your mouth,the back of your tongue,the area around your tonsils and the back of your throat. It, along with other aero digestive reflexes such as reflexive pharyngeal swallowing,,prevents something from entering the throat except for normal swallowing, and helps prevent choking.' Stimulation of the gag reflex(head trauma patient)can cause and increase in ICP. Focus should be on maintaining SPO2 2:94% with an EtCO2 between 35—45mmHg. Z. uuiipiuii ' eaiimllls ccouimuuimucu,,mdcd Il;xain,r III' cimlaml StalUs IP,III II 14 i,, II' leaiml.,, III Uings I doiumuiein II' xl.umeixiiu1ics, Ill3aclllk IINeU111m0 GCS liis a Ilkey asscssiuxieil,d foolll liirm IIVmc l.realiuxieil,d of lllmcsc Il aiJerml.s « If GCS < 12 consider air/rapid transport « In areas with short transport times, RSI/Drug-Assisted Intubation is NOT recommended for patients who are spontaneously breathing and who have oxygen saturations of>_ 90% with supplemental oxygen including BIAD/BVM. « Increased intra-cranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Hypotension « usually indicates injury or shock unrelated to the head injury and should be aggressively treated. « An important item to monitor and document is a change in the level of consciousness by serial examination. « Consider Restraints if necessary for patients and/or personal protection per the Restraint Procedure. « Limit IV fluids unless patient is hypotensive. « Concussions are traumatic brain injuries involving any of a number of symptoms including confusion, LOC, vomiting, or headache. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP. 471 Revised Multiple03/01/2023 Trauma hsloiry &gins aind Syixiploixis (Ill...liitc Llll,mureatcumliiing) • Time and mechanism of injury • Pain, swelling • Chest: Tension pneumothorax • Damage to structure or vehicle 0 Deformity, lesions, bleeding Flail chest Location in structure or vehicle . Altered mental status or Pericardial tamponade • Others injured or dead unconscious Open chest wound • Speed and details of MVC 0 Hypotension or shock Hemothorax • Restraints/protective equipment • Arrest • Intra-abdominal bleeding • Past medical history • Pelvis/Femur fracture • Medications • Spine fracture/Cord injury • Head injury (see Head Trauma) • Extremity fracture/Dislocation • HEENT(Airway obstruction) • Hypothermia Assessment oXD SymABC a r Airway Protocol(s) if indicated Slla uunall Ilinuir°muclliullu4aflon II,'3roca*duurcl TI Procedure IO Procedure Cardiac Monitor d III' (1%111uuslicu n I pul GCS Normal Abnormal Iuillllll Repeat Assessment Adult Procedure Rapid Transport to appropriate Splint Suspected Fractures destination using Consider Pelvic Binding I uuirniot Scciunc 111° irne td imiiiiinuautc Control External Hemorrhage I°urGmdc Ctllld Notification �IIIII Monitor and Reassess p„y Head Injury Protocol Transport to appropriate if indicated destination Splint Suspected Fractures Consider Pelvic Binding Control External Hemorrhage Hypotension Shock / Normal Saline Bolus 500 mL IV/to V� Shock Protocol Repeat to effect SBP 2 90 �� Maximum 2 Liters Chest Decompression-Needle P Procedure if indicated Monitor and Reassess Notify es ina ion or Contact Medical Control NEEMENEWWAMMM 472 Revised Multiple03/01/2023 Trauma Code Yellow Trauma Activation • GCS 9-13 • Amputation Proximal to Wrist or Ankle • Paralysis or Sensory Change—Suspected Spinal Injury • Crush to Chest or Pelvis • Two or More Humerus/Femur Fractures • Obvious Open Humerus/Femur Fracture • Vascular Compromise • Burn>10%BSA` IIIII • Ejection from Vehicle • Death of another passenger in vehicle • All Drownings(including CPR in Progress) • Prolonged Extrication • Motorcycle accidents non-ambulatory • Direct Fall From > 15 Feet • Stabbing to neck;chest and abdomen • Isolated GSW to head • Provider Discretion IIIII MINI II ccouim"luuimlusu'mdcdExaa [ uit 11 Status, S<M, I IIEENT, I-I ea t, L uIig,AbdomeIi, ExtreIliffies, F II<, Neuro I rainspoirt Ill esl inal.liioin liis clllm rein Il ased on I.Ilhe c in6lioin of Mims Il aluicunt Sceine l.oiiuxies sllrmoL llld not Ile delllaycd four l iii"occdUiimcs °"l"Ill esc SlIIOL llld Il e Il ciimfoiimiu ied sum uroUlc Wiiein IY ossuill lllc lap Aid trainSp,oirt of 11he Uinslabl lb l.raUiumia I alieint fo f.11lmc aIpprolpiiim ale fa6illll1y uis l.11lmc goall • Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained >_ 90% • Geriatric patients should be evaluated with a high index of suspicion. Often occult injuries are more difficult to recognize and these patients can decompensate unexpectedly and with little warning. • In prolonged extrications or serious trauma, consider air transportation for transport times and the ability to give blood. • Do not overlook the possibility of associated domestic violence or abuse. Illllli 473 Revised Pediatric03/01/2023 Airway Assess Respiratory Rate, Effort, Oxygenation i Supplemental oxygen Goal oxygen saturation Is Airway/Breathing Adequate? Y S >_94% NO ° Basic Maneuvers First Exit to -open airway chin lift/jaw thrust Appropriate Protocol -nasal or oral airway -Bag-valve mask(BVM) Spinal Immobilization Procedure if indicated Consider AMS Protocol Airway Foreign Body rN000, Airway Patent Obstruction Procedure YES Supplemental oxygen Complete Obstruction NO Breathing�o/oxyegdendatloniiiiiiiiiiiii YES EBVM �,Unable to Clear Supp Maintain Oxygen Saturation >_90 % NO YES IIIII��I Monitor/Reassess Supplemental Oxygen Tension l„ Airway Cricothyrotomy if indicated Pneumothorax Needle Procedure � Illll�jlllll See Pearls Section ` YES Exit to Appropriate Protocol i NO Chest Decompression Procedure Jill Unable to Ventilate NO and Oxygenate_90/o BVM/Oxygen o Effecti ve during or after one(1) or more unsuccessful Airway Blind Insertion YES BIAD attempts . FPT Device Procedure Anatomy inconsistent with continued Supplemental oxygen attempts. E BVM Maintain Oxygen Two(2) unsuccessful Consider Sedation Saturation >_90 % attempts by most If B/AD or ETT in place experienced EMT-P. Midazolam 0.1-0.2 mg/kg Ill/IU May repeat in 5 minutes if no Exit to improvement in sedation Pediatric Failed Maximum Total Dose 5mg Airway Protocol Notify Destination or Contact Medical Control F414 Revised Pediatric03/01/2023 Airway luuiy°� ............. Vul�illl °eailI: �Mr ilrli,s Ilorotoin!:cI II�eiii�i atr c Is iefirie:iii as 5 years ars of age or any II�atue n t wKch IIol , ur"ue asiii.ur11..d wfth0ri the, IIII rois6ow uuteurn tsllsa*. Asll a olrne%tlyd(c6olr) our cslpnoglrslplhy Is un ands�tolyd W llr MII uuua*tllrods of ulntsllrsNl�oln IDocruuuua*Iln�t Ira.%ssli�ts:. x Ctontuu ruorus call uroglrsll llyd (IGit t t ) Is urc1%q ulna*d W li IG:3IAID our c1%ndoturscll c1%Ml tslbe% rusa�*:. 4 li t urrm�auuuir��uuuun.i!J Ilrl IIIiCAllft uth ��:n:�ntfiuuuou„us priuullse�Miu�ourru��trd uaauaiu.,u�-ris� f t� 01114), Ii�1I,usMan ii:ii,:h iiu�bi4e to x� I Mau a ��.,:.:� �� u uan:�,:u�uuaos u':� � r�u..uu u�, contuunuua*v otlllr Ilrssllc slivarssd Iine%ssurlircM Ilnstal*sd of uusuuag s Il3 AD ollr IIIlrturllrstliolrn. s� our tlhe% Il urualpsosa*s of tlllrus Ilslrotocoll s secrulre% airway lis v llre%n tlhe% Ipsstoa*nt Its ureca*usuur~ng sIppirolpi1a:al*oxdgal% nstuon and ve% ntoIlstllolrn. u. Vcl% ntll llstllon uratc1%sllhouulld Ural%30 four Ne%onstal*s, 25 four""II oddlkl%irs, 20 four dcllrooll Aga.%, and four Adolia*sca*Il nts, tllra* Irnoliri nM Aduullt ratc1%of 12 aa*IIr Iraalh nuutal*. II'dsuu ntah n s II;`tC 0 Ilia*twe%c*u n 35 and 45 and snood Illrtallaa*Irsal*Il tllllstllolla. + Hyperventilation in deteriorating head trauma should only be done to maintain a pCO2 of 30-35mmHg. + An Airway Evaluation Form will be completed with any BIAD or Intubation procedure. + Paramedics should consider using a BIAD. + Gastric tube placement should be considered in all intubated patients. + Airway Cricothyrotomy Needle Procedure: Indicated as a lifesaving/last resort procedure in pediatric patients<_11 years of age. Very little evidence to support its use and safety. A variety of alternative pediatric airway devices now available, make the use of this procedure rare. Agencies who utilize this procedure must develop a written procedure,establish a training program, maintain equipment and submit procedure and training plan to the State Medical Director/Regional EMS Office. 101' IIIIIII„ 475 Revised Pediatric03/01/2023 Failed Airway Unable to Ventilate and Oxygenate>_90%during or after one(1)or more unsuccessful intubation Call for additional attempts . YES Failed Aiway resources if available Anatomy inconsistent with continued attempts. TWO (2) unsuccessful attempts by EMT-P. Each attempt should include change in approach BVM or equipment Adjunctive Airway Maintains Oxygen NO MORE THAN TWO (2)ATTEMPTS TOTAL Saturation >_90% YES NO CTraumSa'/ gnificant Facial Swelling/Distortion E Place Oral and/or Nasal Airway plll�„ Supplemental oxygen Oxygenation/Ventilation YES E BVM jj,, Adequate Maintain OxygenIIII Saturation z 90% NO IPI Airway BIAD Procedure Continue BVM Supplemental Oxygen lllllliM E SHE I Exit to Appropriate Protocol , lulllll„„ Z III Iu„�ol ';Pwl Airway Cricothyrotoy Needle Supplemental oxygen irway roce ure BVM Procedure NO YES E See Pearls Section Successful Maintain Oxygen Saturation >_90% Supplemental oxygen E BVM Maintain Oxygen Saturation >_90% L-�r Notify es ina ion or Contact Medical Control low °°IIVuumolp uuuuu unroll �, IIIIIII, " Revised Pediatric03/01/2023 Failed Airway lulu, IUIII�I II��ti p�t Ih'°°�nsslrlll �Mr ilrii,s Ilroir MtoiMu��:oN, II�eiii�i atr c us iefirie:iii as 5 years ars of age or any II latueu.'twNuuch IIol , un"ue asiii.urii..d wNthuuru the, IIII rois6ow urteurn tsllsu*. Cspnor°ne%turd(color) or cslp nogrsp by us una ndstory W llr sllll une% prods of unfurllrsWnoir IDocuruuua*unf ure%surllfs. o Contuunuous cslpnogursp by (Il:`tCC ) us sturonglld uru*couuuuuuc1% nda*d W llr IltllAlD our c1% ndoturscll c1%M turllru* urs(*. I Muuu .� �� urn.uuuuw u' lis uuu� y t uniafi uiu��'�uu roi!J Ilrly IIIktA A wuth ��:n:�n tfi uu uou„us priu a �Mpse iu�o urru��try uru,'uiu of f t�u 0111n), ii�1l,us a ii:ii,:hpitabi4e�i:o o ��. r��. , contuunuue%wotllr Ilrssuc sliurwsd ine%ssuuura*s unstu*sd of uusuu ng s Il3 AD oir Ilnturlllrsfiioil. x ou tllru* Il uuurllsose%s of fllrus Ilsurotocoll s secuuura* airway lis wllra*urn tllru* Ilssfoa*nt us ureca*uvung sIl llsuropi1atu*oxdge% nstuon and ve% ntullstuon. x An uuntuullrstuon stfa*urullst us de%fune%d as Ilaassu ng die Ilaryi ngoscolpe% Ilrllsde% oir c1%ndoturs6l c1%M turllrr* Ilssst die tee%dlr our nseirte%d ui into tllrr* amass Ilsssssgu*. 0 Vcl% ntullsfuon uratc1%sllhouulld Ibe%30 four du*ourstu*s, 25 fair 'oddlkl%iirs, 20 four dcllrooll Age%, and fair Ad6c,%sce%i nts, die unoirinMl Aduullf uratc1%of 12 ae%iir uuuuunuute%. II'dsountah n s Il:::ICO2 betwecNin 35 and 45 and sv6d Ilydllua*uva*u fullsWuoiu. • Hyperventilation in deteriorating head trauma should only be done to maintain a pCO2 of 30-35. • It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. • If first intubation attempt fails, make an adjustment and then try again: Different laryngoscope blade; Gum Elastic Bougie; Different ETT size; Change cricoid pressure; Change head positioning. • Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. • Cricoid pressure and BURP maneuver may be used to assist with difficult intubations. They may worsen view in some cases. • Gastric tube placement should be considered in all intubated patients. • It is important to secure the endotracheal tube well and consider a c-collar(even in absence of trauma)to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves/transfers. • Airway CricothyrotomV Needle Procedure: Indicated as a lifesaving/last resort procedure in pediatric patients<_11 years of age. Very little evidence to support its use and safety. A variety of alternative pediatric airway devices now available, make the use of this procedure rare. 101' Illlllli, �' 477 Revised Pediatric03/01/2023 Pairs Control C°III o s l o Irk 7&Ignsn of ri Ip l o uin t ul ffe re Iii t lii a III � + Age + Severity (pain scale) + Per the specific protocol + Location • Quality (sharp, dull, etc.) + Musculoskeletal Duration 0 Radiation • Visceral (abdominal) Severity (1 - 10) + Relation to movement,respiration + Cardiac If child use Wong-Baker faces scale + Increased with palpation of area + Pleural/Respiratory Past medical history • Neurogenic + Medications Renal (colic) Drug allergies Utilize Protocol based on Specific Complaint Assess Moderate Pain Severity Mild - to i,,ti.^ 7Usebination of Pain Scale, Circumstances, Severe MCI, Injury or Illness severity III�I Allow for position of IV Procedure 10 Procedure I� E maximum comfort p Ketorolac 0.5 mg/kg IV/10/IM unless Maximum 30 mg Contraindicated Cardiac Monitor uiplull Consider IV Procedure lu" h if indicated Monitor and Reassess Fentanyl,1 mcg/kg Iv/IM/IN every 5 minutes May repeat 0.5 mcg/kg every 15 minutes.Maximum single dose is 25 mcg,Up to 100 mcg total, p,,t Monitor ETCO2 Monitor and Reassess Every 5 minutes following sedative Monitor and Reassess every 5 minutes Notify Destination or Contact Medical Control r eaiIl 11c*ooirm ine%nded II xsirmu II'dc*ur[M Status,Area of Il3ahm, II14m*uuiro Pain severity (0-10) is a vital sign to be recorded pre and post IV or IM medication delivery and at disposition. + For children, use Wong-Baker faces scale or the FLACC score(see Assessment Pain Procedure) + Vital signs should be obtained pre, 5 minutes post,and at disposition with all pain medications. Contraindications to Narcotic use include hypotension, head injury, or respiratory distress. All patients who receive IM or IV medications must be observed 15 minutes for drug reaction. Ibuprofen/Ketorolac should not be given if there is abdominal pain, history of gastritis, stomach ulcers, fracture, or if patient will require sedation. + Do not administer any PO medications for patients who may need surgical intervention such as open fractures or fracture deformities. Use Numeric(>9 yrs),Wong-Baker faces (0-8 yrs) )as needed to assess pain Consider anti-emetic(s)for nausea and/or vomiting. 478 ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Revised 03/01/2023 Pediatric Asystole PE .......................................................................... History Signs and Symptorns Differential • Events leading to arrest 0 Unresponsive 0 Respiratory failure • Estimated downtime 0 Cardiac Arrest 0 Foreign body • Past medical history 0 Signs of lividity or rigor 0 Hyperkalemia • Medications 0 Infection (croup, epiglotitis) • Existence of terminal illness 0 Hypovolemia (dehydration) Airway obstruction 0 Congenital heart disease 0 Trauma Hypothermia 0 Tension pneurnothorax Suspected abuse-, shaken baby 0 Hypothermia syndrome, pattern of injuries 0 Toxin or medication SIDS 0 Hypoglycernia Acidosis ........................................................................................................................ �111110 Pediatric Pulseless EN HIM Arrest Protocol Criteria for Death No A ANY M�11111 Resuscitation Do not begin Y S Review DNR/MOST Form Return of Resuscitation NO f Spontaneous Follow Begin Continuous CPR Compressions Circulation Deceased Subjects Push Hard(1.5 inches Infant/2 inches in 111111FIM Policy E Children) Push Fast(100/min) HEM, Change Compressors every 2 minutes (Limit changes/pulses checks every 10 seconds) Go to P Cardiac Monitor Post Resuscitation Protocol Follow Rhythm Appropriate AYES Shockable Rhythm Protocol Reversible Causes NO Search for Reversible Causes Hypovolemia Consider Hypoxia Beta Blocker OD IV Procedure 10 Procedure Hydrogen ion (acidosis) Calcium Channel Blocker Epinephrine1:10,000 Hypothermia OD 0.01 mg/kg IWO (max 1mg) Hypo/Hyperkalemia i'11111mm Hypoglycemia (0.1 mL/kg of 1:10,000) Pediatic Toxicology Repeat every 3—5 minutes Tension pneurnothorax Protocol Normal Saline Bolus 10 mL/kg IV/10 Tamponade; cardiac May epeat as needed Maximum 60 mL/kg Toxins E Blood Glucose Analysis Procedure Thrombosis-, pulmonary (PE) Pediatric Diabetic Protocol Thrombosis- coronary as indicated (MI) Consider P Dopamine 10—20 mcg/kg/min IV/10 Consider Chest Decompression-Needle Procedure Notify Destination or Contact ntact Medical Control Pearls In order to be successful in pediatric arrests, a cause must be identified and corrected. Respiratory arrest is a common cause of cardiac arrest. Unlike adults, early airway intervention is critical. In most cases pediatric airways can be managed by basic interventions. If no IV/ 10 access, may use Epinephrine 1:1000, 0.1 mg/kg (0.1 mL/kg) via ETT (Maximum 10 mL). 47�9 Revised 03/01/2023 Pediatric Bradycardia History Signs and Symptorns Differential • Past medical history • Decreased heart rate • Respiratory failure • Foreign body exposure • Delayed capillary refill orcyanosis Foreign body Respiratory distress or arrest • Mottled, cool skin Secretions • Apnea 0 Hypotension or arrest Infection (croup, epiglotitis) • Possible toxic or poison exposure • Altered level of consciousness • Hypovolemia (dehydration) Congenital disease • Congenital heart disease Medication (maternal or infant) 0 Trauma • Tension pneumothorax • Hypothermia • Toxin or medication • Hypoglycemia • Acidosis CCausing ycardia irway Patent ypotension/ Pediatric Airway Protocol(s) MS Oxygenation/Ventilation NOSHum usion/Shock Adequate ;;, YES Identify underlying cause Pediatric AMS Protocol ° Blood Glucose Analysis Procedure ► as indicated IV Procedure 10 Procedure mop Suspected Beta- Cardiac Monitor Blocker or Calcium Channel Blocker Normal Saline Bolus 20mL/kg IV/10 i,,,,,1ZTM Continued Y S Repeat as needed x 3 .01 Poor Perfusion/ Follow Pediatric < Shock Epinephrine 1:10,000 Toxicology 0.01 mg/kg IV/10 Or Protocol Epinephrine 1:1000 0.1 mg/kg via ETT(Max 1 mg) Repeat every 3—5 minutes NO Atropine 0.02 mg/kg IV/10 Minimum is 0.1mg to a Max of 1 mg Repeat in 5 minutes x 1 Consider Exit to _ ea a e Cardiac Pacing Procedure Pediatric Cardiac AYES ®"'� Poor Perfusion/Shock Arrest Protocol NO IF Notify Destination or Contact Medical Control Pearls 11c'coiiniina*III dui*d I,:::::xsirn II'da*III tall Sistrus, II III I'i::ld II, SllrnIII, II IIc:lsirIt, II ur III gs,Albdoirnc:lin IGIltsollr xtireiin tnc:*s, II4a:�*uuiro Use Il:turosefllow.. Uta*u n 'ape% foiir du uug dosage%s ut all 11 llHcMulk- • Infant< 1 year of age • The majority of pediatric arrests are due to airway problems. • Most maternal medications pass through breast milk to the infant. • Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. • Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric patients per the manufacturers guidelines. • Minimum Atropine dose is 0.1 mg IV. 480 Revised 03/01/2023 Pediatric PulmonaryEdema 1 CHF History Sligns/Syrnptorns Differential • Congenital Heart Disease + Infant: Respiratory distress, poor • Congestive heart failure • Chronic Lung Disease feeding, lethargy,weight gain, +/- • Asthma • Congestive heart failure cyanosis 0 Anaphylaxis • Past medical history • Child/Adolescent: Respiratory distress, • Aspiration bilateral rales, apprehension, • Pleural effusion orthopnea,jugular vein distention • Pneumonia (rare), pink, frothy sputum, peripheral • Pulmonary embolus edema,diaphoresis, chest pain • Pericardial tamponade + Hypotension, shock 0 Toxic Exposure Cwith y/Signs/ Airway Patent _ s consistent NO Ventilations adequate NO ►' 'II" Pediatric atory distress Oxygenation adequatekles/rales/wn CHF YES ergic eac ion _ _ Pediatric Anaphylaxis YES ► �� Allergic Reaction Anaphylaxis Protocol NO 12 Lead ECG Procedure E Pulse Oximetry/EtCO2 Cardiac Monitor IV Procedure 10 Procedure if indicated if indicated Position child with head of bed in up-position (25-40°) Flexing hips with support under knees so that they are bent 90' Transport to a Pediatric Specialty Center if available Notify Destination or Contact Medical Control Pearls 0 11a*oou°ninclnda�*d clxai a: 'dcl mall status, 11a*spu......ratory,Cardu.........sc., &<< n, Neu iro Coi ntsot II'ylia*d cM Conturoll a*su lld ui in tllaa*caire of tllua* Ilaaa*d atilt osurd ac IlDstoe nt. Bost di lldireurn W lli CIP,.•IIlI have s congcl nu[M Ilya*suit defect, olllitah n s Ilaairedse Ilasst a°ncld cM Ihustourd. Congenital heart disease varies by age: < 1 month: Tetralogy of Fallot, Transposition of the great arteries, Coarctation of the aorta. 2—6 months:Ventricular septa) defects(VSD),Atrioseptal defects(ASD). Any age: Myocarditis, Pericarditis, SVT, heart blocks. Treatment of Congestive Heart Failure/Pulmonary edema may vary depending on the underlying cause and may include the following with consultation by Medical Control: Fentanyl: 1 mcg/kg IV/10. Max single dose 50 mcg. Nitroglycerin: Dose determined after consultation of Medical Control. Dopamine 10—20 mcg/kg IV/10. Titrate to age specific systolic blood pressure. Do not assume all wheezing is pulmonary, especially in a cardiac child: avoid Albuterol unless strong history of recurrent wheezing secondary to pulmonary etiology (discuss with Medical Control or sending physician) 481 Revised 03/01/2023 Pediatric Pulseless Arres History Signs and Syrnptorns Differential Time of arrest + Unresponsive • Respiratory failure • Medical history . Cardiac arrest Foreign body, Secretions, Infection • Medications (croup, epiglotitis) Possibility of foreign body 0 Hypovolemia (dehydration) Hypothermia • Congenital heart disease • Trauma Tension pneumothorax, cardiac tamponade, pulmonary embolism • Hypothermia • Toxin or medication • Electrolyte abnormalities(Glucose, K) Acidosis /No Resuscitation Do not begin �YES—c!�� w DNR resuscitation NO Follow Deceased Subjects Newly Born/<_31 days old YES---p- """f Exit to Policy Newly Born Protocol NO Exit to �� z 15 years old YES—� ' �� Adult Cardiac Arrest Protocol NO Return of V Spontaneous Begin Continuous CPR Compressions Circulation Push Hard(1.5 inches Infant/2 inches in r,gia Children) Push Fast(>_100/min) 'n. Change Compressors every 2 minutes Go to (Limit changes/pulses checks every 10 seconds) Post Resuscitation Defibrillation Automated Protocol if available NO ALS Available YES Shockable Rhythm Shockable Rhythm Defibrillation Automated NO YES Continue CPR 5 Cycles/2 Minutes Continue CPR i Repeat and reassess 5 Cycles/2 Minutes Follow Repeat and reassess / Follow Pediatric Pediatric Airway VF/VT ® Pediatric Airway Pediatric Protocol(s) °�9 Y Asystole/PEA Protocol Pediatric Tachycardia (s) Pediatric Airway Pediatric Airway Protocols Protocols Notify Destination or FF- Contact Medical Control 482 Per AHA guidelines,when using an AED for a pediatric arrest the best possible procedure is to use pediatric pads,or'a pediatric dose attenuator. If neither are available,it is acceptable per AHA guidelines to use adult pads on pediatric patients. To use the adult;pads,the provider should place the pads anterior and posterior on the patient. pearls 11cicoinine%nded II xsirmu: II'dcln[M Status fforts sllhouulld Ilea%durecte%d at Ilu gllh pumsllutp and conflinuuoums couuull re%ssuons W di Ilnuuuote%d unte%inruulpflons and a*sirup de%f lluu,ullllstuon wWmeni liri�u ion ate�J Co mprii..ss t i/,I ariitedm Mr..lksosta*u1oir dusumua�*ta*ir of cllhest, in Infants 1.5 uncllhes and in 6hHdura*n 2 unclhes:. ConsWeir a*surllp IIO IIallsca ine%nt of sssul4bk1%and f our dnffocuulK IIV scce%ss a ntucull ate%d. DO II40 III V ILIA': If no advanced su,u wsp(IItIIVII'a, III u,s ui in Ilalhsca*, courull ura*ssnon to sa*untullaflon urstno Is,fd':2. If sdssunca*d snuwsp uun Ilallsca*,sa*untullsta*d 10 IIbire%stllms Il a`u" uuun III uuta*wn[III Con tnunuuouas, uu III u III ta*nruruullate%d couuullsra*ssuouas. • Do not interrupt compressions to place endotracheal tube.Consider BIAD first to limit interruptions. • Airway is a more important intervention in pediatric arrests. This should be accomplished quickly with BVM or supraglottic device. Patient survival is often dependent on proper ventilation and oxygenation/Airway Interventions. • Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. Consider Team Focused Approach assigning responders to predetermined tasks. • Team Focused Approach/Pit-Crew Approach. Refer to optional protocol or development of local agency protocol. • Reassess and document endotracheal tube placement and EtCO2 frequently,after every move, and at transfer of care. • Monophasic and Biphasic waveform defibrillators should use the same energy levels 2 joules/kg and increase to 4 joules/kg on subsequent shocks. • In order to be successful in pediatric arrests, a cause must be identified and corrected. 483 Revised 03/01/2023 Pediatric Tachycardia History Signs and Syrnptorns Differential + > Past medical history Heart Rate: Child 180/bpm 0 Heart disease(Congenital) + Medications or Toxic Ingestion Infant>220/bpm + Hypo/Hyperthermia (Aminophylline, Diet pills, + Pallor or Cyanosis 0 Hypovolemia or Anemia Thyroid supplements, + Diaphoresis 0 Electrolyte imbalance Decongestants, Digoxin) 0 Tachypnea + Anxiety/Pain/Emotional stress + Drugs(nicotine, cocaine) 0 Vomiting + Fever/Infection/Sepsis + Congenital Heart Disease + Hypotension 0 Hypoxia Respiratory Distress + Altered Level of Consciousness + Hypoglycemia + Syncope or Near Syncope + Pulmonary Congestion + Medication/Toxin/Drugs (see HX) + Syncope + Pulmonary embolus + Trauma Tension Pneumothorax Unstable/Serious Signs and Symptoms Probable Sinus Tachycardia HR Typically > 180 Child YES NO HR Typically >220 Infant NO Cardioversion Procedure E 12 Lead ECG Procedure IV Procedure 10 Procedure 5VT/VT'0.5-1 J/kg May repeat if needed and increase Cardiac Monitor dose with subsequent shacks 2 J/kg Consider Sedation pre-shuck YES Midazolam 0.1-0.2 mg/kg QRS>_0.90 seconds IV/10 May repeat if needed Maximum 5 mg Y S 0.2 mg/kg IN Maximum 2 mg Probable Sinus Probable SVT Exit to Tachycardia ®'' 'Appropriate Protocol Vagal Maneuvers Consider Identify and Treat Adenosine Underlying Cause Adenosine P0.1 m /kg IV/10 Maximum 6 mg Single lead ECG able to 4 0.1 mg/kglV/10 Maximum 6 mg May repeat diagnose and treat Exit to Adenosine arrhythmia Appropriate 0.2 mg/kg IV/10 Protocol Maximum 12 mg If no respcanse 12 Lead ECG not Amiodarone necessary to diagnose 5 mg/kiz IV/lQ and treat, but preferred Over 20 Minutes when patient is stable. If no response Maximum 150 MR Amiodarone P 5 mg/kg Ill/ID Over 20 Minutes INY M�I Maximum 150 mg Pulseless E Magnesium luul'©e Rhythm Converts 12 Lead ECG Procedure mg/kg / Over 10 minutes Go to Maximum 2 g Pediatric Pulseless —11 Arrest Protocol Notify Destination or Contact Medical Control 484 Revised ,� Tachycardia03/01/2023 eduric +" Pearls ccouimuuimucu,,mdcd Il;xaiumur Ill eumlaml Wl.Us Ill uium, IP' e6k Ill....Lmumg, II',Ileauri.,, Xodoixiein, 3aclk, II xl.reiumuiu1Jes, IY' eUuro Serious Signs and Symptoms: Respiratory distress/failure. Signs of poor perfusion with or without hypotension. AMS Sudden collapse with rapid, weak pulse • Narrow Complex Tachycardia I<_ 0.09 seconds): Sinus tachycardia: P waves present. Variable R-R waves. Infants usually <220 beats/minute. Children usually < 180 beats/minute. SVT: > 90 % of children with SVT will have a narrow QRS (50.09 seconds.) P waves absent or abnormal. R-R waves not variable. Usually abrupt onset. Infants usually>220 beats/minute. Children usually> 180 beats/ minute. Atrial Flutter/ Fibrillation • Wide Complex Tachycardia I>_ 0.09 seconds): SVT with aberrancy. VT: Uncommon in children. Rates may vary from near normal to >200/minute. Most children with VT have underlying heart disease/cardiac surgery/long QT syndrome/cardiomyopathy. • Torsades de Pointes/Polymorphic(multiple shaped) Tachycardia: Rate is typically 150 to 250 beats/minute. Associated with long QT syndrome, hypomagnesemia, hypokalemia, many cardiac drugs. May quickly deteriorate to VT. • Vaaal Maneuvers: Breath holding. Blowing a glove into a balloon. Have child blow out"birthday candles" or through an obstructed straw. Infants: May put a bag of ice water over the upper half of the face careful not to occlude the airway. • Separating the child from the caregiver may worsen the child's clinical condition. * Pediatric paddles should be used in children < 10 kg or Broselow-Luten color Purple if available. Monitor for respiratory depression and hypotension associated with the use of Diazepam or Midazolam. • Continuous pulse oximetry is required for all SVT Patients if available. • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. • Generally, the maximum sinus tachycardia rate is 220 BPM —the patient's age in years. 485 Revised Pediatric Ventricular Fibrillation 03/01/2023 Pulseless Ventricular Tachycardia History Signs and Syrnptorns Differential • Events leading to arrest • Unresponsive • Respiratory failure/Airway obstruction • Estimated downtime • Cardiac Arrest • Hyper/hypokalemia • Past medical history • Hypovolemia • Medications Hypothermia • Existence of terminal illness HypoglycemiaAcidosis • Airway obstruction • Tension pneumothorax • Hypothermia . Tamponade Toxin or medication Thrombosis: Coronary/Pulmonary Embolism Congenital heart disease Pediatric Pulseless Begin Continuous CPR Compressions Arrest Protocol Push Hard(1.5 inches Infant/2 inches in E Children) Push Fast(>_100/min) Change Compressors every 2 minutes Defibrillation Manual (Limit changes/pulses checks every 10 seconds) Procedure 2 Joules/kg piimy 1,101 Pediatric Airway Protocol(s) IV Procedure 10 Procedure Epinephrine(1:10,000 ) 0.01-0.1 mg/kg, IV/ 10 Maximum 1 mg each dose Repeat every 3 to 5 minutes Defibrillate Manual Procedure 4 Joules/kg III Begin Continuous CPR Compressions Return of Push Hard. Push Fast(>_100/min) Change Compressors every 2 minutes Spontaneous (Limit changes/pulses checks every 10 seconds) Circulation E If Rhythm Refractory a!''s Continue CPR and give Agency specific Anti- arrhythmics/Epinephrine during Go to compressions. Post Resuscitation Continue CPR up to point where you are ready Protocol to defibrillate with device charged. Repeat pattern during resuscitation. Amiodarone 5 mg/kg IV/10 Torsades de pointes Maximum dose 300 mg Magnesium Sulfate Repeat every 5 minutes 40 m k IV Persistent VF/VT �/ g /10 Maximum dose 150 mg May repeat every After second defibrillation Maximum total dose 15 mg/kg eve 5 minutes may increase energy in Defibrillate Manual Procedure Maximum 2 g increments of 2 Joules/kg not to exceed 10 Joules/kg Maximum Magnesium Sulfate 40 mg/kg IV/10 May repeat every 5 minutes Maximum 2 g Notify Destination or Contact Medical Control 486 Revised Pediatric Ventricular Fibrillation 03/01/2023 Pulseless Ventricular Tachycardia ___w--w_________________________________________________________________________________________________________________ Pearlls ffourl.s sllPmormllld be 61recled at Illmliigll!m IgUallliiily aind Coll i.lii III:WoUs c01111iull uressliioins vvliil.11lm IlluiiuruiuIled aind ermurllly defliillfurliillllll ml.liiou,:m wl4mein Viin6cal.ed::: Coiuruillruress f/d ainteurliiour Ilrosl.euriuour dliiaixiiel.eur of clllmesf,: liiin liiumfau,:,ml.s f:::d liiu,: 6:ies aind liiin clllmuillldureum 2 iiiu,:mclllmes::: Coumsliideur ermurllly Il0 Il lllaceiu ieumf uif avamIillrmllfllle aind /our Offiiicrmllll. II'V access aiifl.liiciiilpalod::: l0 IP'401 lII'IIL.: ""l II f no rmdvrmumced rmiiiurvmmrmy III lll': 1,,: II l 'l"" liiiim Ilrlllrmce,,: couimullwmessliiou,:m to veumfuilllrml.liioum urrml.liio liis dd:2::: II'f advrminced rmiiiuiway liiu,:m Ilrlllrmce, veuml.liilllale 8. fd Ilfrea l]hs Ilreur iuri.ulliiu,:Wle wrIillh Coll:mluiiiWoUs, rmumliiu,:mfeurur mll l.ed coiuxi Ipressliiorms::: • Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. Airway is a more important intervention in pediatric arrests. This should be accomplished quickly with BVM or supraglottic device. Patient survival is often dependent on proper ventilation and oxygenation /Airway Interventions • In order to be successful in pediatric arrests, a cause must be identified and corrected. • Respiratory arrest is a common cause of cardiac arrest. Unlike adults, early ventilation intervention is critical. • In most cases pediatric airways can be managed by basic interventions. • Reassess and document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. Ensure RRT confirms patent airway. • Monophasic and Biphasic waveform defibrillators should use the same energy levels 2 joules/kg and increase to 4 joules/kg on subsequent shocks. • In order to be successful in pediatric arrests, a cause must be identified and corrected. 487 Revised 03/01/2023 Pediatric Post Resuscitation History Sligns/Syrnptorns Differential Respiratory arrest • Return of pulse • Continue to address specific differentials Cardiac arrest associated with the original dysrhythmia Repeat Primary Assessment Arrhythmias are common Optimize Ventilation and Oxygenation Hypotension and usually self limiting • Maintain Sp02>_94% Age Based after ROSC 0 Advanced airway if indicated E 0 ETCO2 ideally 35—45 mm Hg 0—28 Days niihlil • Respiratory Rate 8—10 <60 mmHg Remove Impedence Threshold Device If Arrhythmia Persists DO Iq0 II i F "I I E Iq II II L. III: 1 Month to 1 Year follow Rhythm < 70 mmHg Appropriate Protocol Monitor Vital Signs/Reassess E 12 Lead ECG Procedure 1 to 10 Years < 70+ (2 x age)mmHg IV Procedure IO Procedure 11 Years and older Cardiac Monitor <90+ (2 x age)mmHg Normal Saline Bolus 10 mL/kg IV/ID YES Hypotension May repeat to 60 mL/kg Age based if lungs remain clear NO Dopamine ' Pediatric P 10—20 mcg/kg/min IV/ID Blood Glucose fYES� Diabetic Titrate to SBP age appropriate <_69 or>_250 Protocol Pediatic Bradycardia +YES Symptomatic Protocol Bradycardia Pediatic Symptomatic YES Tachycardia Tachycardia � Protocol o O er Continue Antiarrhythmic Amiodarone 5 mg/kg IV/10 YES Defibrillation and NO Utilized Infuse over 10 minutes NO Refer to Appropriate Pediatric Antiarrhythmic Arrhythmia Protocol Consider Sedation/Paralysis Use only with definitive airway in place Versed 0.1—0.2 mg/kg IV/IU May repeat in 3-5 minutes as needed And,/Or Fentan l 1 mcg/kg IV/10 bolus May repeat 1 mcg/ g every 20 minutes As needed Maximum 200 mcg Notify Destination or Contact Medical Control 488 Revised 03/01/2023 Pediatric Past Resuscitation Pea rlls lIcicoumuuuue%nded II xsirmu II'dc:in[M Status, II14clehr' dlkhl' Il. ungs, Ilh, k*sirt,Nidoumuclin, II xtirc�*uuflflcls, IlNeuuiro • Hyperventilation is a significant cause of hypotension/recurrence of cardiac arrest in post resuscitation phase and must be avoided. • Appropriate post-resuscitation management may best be planned in consultation with medical control. 489 Revised 03/01/2023 Pediatric Allergic Reactio. ...................................................................................................................................................................................... aood oIIffereooliIalI • Onset and location • Itching or hives . Urticaria (rash only) • Insect sting or bite • Coughing/wheezing or respiratory + Anaphylaxis(systemic effect) • Food allergy/exposure distress . Shock(vascular effect) • Medication allergy/exposure 0 Chest or throat constriction Angioedema (drug induced) • New clothing, soap, detergent • Difficulty swallowing + Aspiration/Airway obstruction • Past medical history/reactions • Hypotension or shock Vasovagal event • Medication history • Edema • Asthma/COPD/CHF ....... ........ ........ ........ ........ ° °.... MILD Assess 7kgEpi RE Symptom Severity MODERATE Epiine 1:1000 njector Monitor and Reassess E >_30 klt Epi Pen IM E Monitor for Worsening Epinephrine 1:1000 <30 Pen Jr IM Signs and Symptoms Auto-Injector ailable E >_30 kg Adult Epi Pen IM <30 kg Epi Pen Jr IM if available Epinephrine 1:1000 IV Procedure 0.01 mg/kg IM if indicated Epinephrine 1:1000 P Maximum 0.5 mg 0.15 mg IM Repeat in 5 minutes „u Diphenhydramine Albuterol Nebulizer if no improvement 1 mg/kg IV/IM/10 Or II ":2.5—5 m x 1.25 (Airway Pediiaicatedtocol(s)if � mg Repeat as needed X2 If IV Procedure IO Procedure III i icated Diphenhydramine 1 mg/kgIV/IM/10 if not already given PO Epinephrine 1:1000 Albuterol Nebulizer �uuu 0.01 mg/kglM 2.5-5m Maximum 0.5 mg g ° +/- 5 mg w Repeat in 5 minutes if no P Ipratropium 0. n improvement OR Igl��l r Xopenex 1.25 mg Repeat as needed x illlllll IV Procedure 3 if indicated Normal Saline Bolus ��" Diphenhydramine P 1 mg/kg IV/IM/10 20mL/kgIV/10 if not already given PO Repeat as needed to effect age, appropriate SBP x, Albuterol Nebulizer Maximum 60 mL/kg 2.5—5 mg Methylprednisolone +/-Ipratropium 0.5 mg P 2 mg/kg IV Repeat as needed x 3 Maximu dose 125 mg if indicated Cardiac Monitoring IF NOT IMPROVING 2 IV P Indicated for Moderate Methyl Indicated Epinephrine d Maximum dos ` and Severe Reactions dose 12S mg 1:10,000IV/IQ See Pearls Instructions Notity Destination or Contact Medical Control Mi IIf Mi �1 Mi K 490 Revised Pediatric Allergic Reaction� 03/01/2023 uu,u, �m �m a� JnJ, lIcicoim ine%nde II xa irmm: II' lcln[M Status,s, &<l , II Ilia* irt:, IL..ungs na pllhym a As Is an a tc1%and Ilaote%nUMl Ila*iIll M ummuallflsyst%in a lkl%irgic re%acfloil. auu na*II II 1 uu na* Is illua*diirug of Ill 6ce%and illua* flirst diirugthat slhoWd Ilbe% a aiummon stein% ui in uuia*a na llaallhym axis(II'Aode%ira te*U Sa*vein S a°mmIlitoli ms.) �IV U II II' 3u neIl lllmr Ie% Ii:1 U,00(0,01 ung llr D Il llr (inax I in ) ui in illma* Ileum scam a*of&Il o6k. Seve%irM doss ng re4i ma*uns auxust and slhoWd be aia*ta*urummonam by Il cM ummau6cM mire* i mur. Symptom Severity Classification: Mild symptoms: Flushing, hives, itching,erythema with normal blood pressure and perfusion. Moderate symptoms: Flushing, hives, itching,erythema plus respiratory(wheezing,dyspnea, hypoxia) or gastrointestinal symptoms (nausea,vomiting,abdominal pain)with normal blood pressure and perfusion. Severe symptoms: Flushing, hives, itching,erythema plus respiratory(wheezing, dyspnea, hypoxia) or gastrointestinal symptoms (nausea,vomiting,abdominal pain)with hypotension and poor perfusion. • Allergic reactions may occur with only respiratory and gastrointestinal symptoms and have no rash/skin involvement. • Angioedema is seen in moderate to severe reactions and is swelling involving the face, lips or airway structures.This can also be seen in patients taking blood pressure medications like Prinivil/Zestril (lisinopril)-typically those ending in -i I. Fluids and Medication titrated to maintain a SBP >70 +(age in years x 2)mmHg. EMT-B may assist in administration of Auto-injector if prescribed to the patient. Patients with moderate and severe reactions should receive a 12 lead ECG and should be continually monitored, but this should NOT delay administration of epinephrine. • The shorter the onset from symptoms to contact,the more severe the reaction. The shorter the onset from exposure to symptoms the more severe the reaction. ��yyy old J2UP u'UY U0�UUIUIU�JUJUJ��'"I Fri,pwuuu 491 Revised 03/01/2023 Pediatric Altered Mental Status .................. °n;�Igiilla; slrou °Dzylrohllt arlloh°��, )IIII'ffeoualIlJlall • Past medical history • Decrease in mentation • Hypoxia • Medications • Change in baseline mentation • CNS(trauma,stroke, seizure, infection) • Recent illness • Decrease in Blood sugar • Thyroid (hyper/hypo) • Irritability • Cool, diaphoretic skin • Shock(septic-infection, metabolic,traumatic) • Lethargy • Increase in Blood sugar • Diabetes(hyper/hypoglycemia) • Changes in feeding/sleeping • Warm, dry, skin, fruity breath, • Toxicological • Diabetes Kussmaul respirations, signs of • Acidosis/Alkalosis • Potential ingestion dehydration • Environmental exposure • Trauma • Electrolyte abnormatilities • Psychiatric disorder Pediatric Airway Protocol(s) mildil"' if indicated Blood Glucose Exit to E Blood Glucose Analysis Procedure .4 m < 69 or>_250 _*_YES--il won Pediatric Diabetic IV Procedure 10 Procedure Protocol 1111111T9 Spinal Immobilization Protocol '20 °°°'"' if indicated IMP; Signs of Poor Exit to YES I- "'I"' Pediatric Hypotension/Shock �nr perfusion �,mu Protocol III�� NO Exit to Signs of OD TOXICOIOgy YES ilumggg Pediatric E111111.,, Overdose/Toxic Ingestion related g �U Protocol NO a, w11b Signs of Exit to YES 1- 119 Hypo/o H Yp erthremia I Hypo/Hyperthermia If Protocol<: � NO Exit to E 12 Lead ECG Procedure Cardiac Monitor YES Appropriate Pediatric P Cardiac/Arrhythmia Protocol as indicated Notify Destination or Contact Medical Control II"e<„y II 11cicolrm ine%ndm:*d II xslrmu II'dcln[M Status, II IIIII ]d II, dllrl�um, II Ilklart, II umlrngs,Allidolrmua*u , IGI'.tsollr, 11::x1lra*Iluuotnc�*s, II14a�*rulro 3sd calls*tW4 stte%i ntllon to thus* IIhe%ad e% sure tour sugns of IlullrWsllilg ollr otlleir Injury. ry. Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose. Consider alcohol, prescription drugs, illicit drugs and Over the Counter preparations as a potential etiology. Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure. I�I i V�,�No°°•.riruowoo .' """iii�"^I�OOD,VU JkNN v„Y�f 1f1fUVU0��11!11DJU,JI��JUJJv'�"°° �li"" v°r0�;�' .,,, 492 Revised 03/01/2023 Pediatric Diabeti............... ............................. IIlHISItoir"y airo� °Dz irohll a iioha�, � IlioII'ffeoeooItiIall • Past medical history 0 Altered mental status + Alcohol/drug use • Medications • Combative/irritable + Toxic ingestion • Recent blood glucose check 0 Diaphoresis Trauma; head injury • Last meal • Seizures Seizure • Abdominal pain + CVA • Nausea/vomiting Altered baseline mental status. • Weakness • Dehydration ,, • Deep/rapid breathing Blood Glucose Analysis Blood glucose 569 mg/dL Pediatric E Procedure Symptomatic with Altered Mental Status NDii//iOAccess; Protocol P IV Procedure 10 Procedure Awake,alert and able to tolerate oral if indicated Cardiac Monitor E agent;Give oral glucose solution ` �, if indicated Repeat every 15 minutes as needed to Deep Blond glucose>69 mg/dl. Blood Sugar Blood Sugar Blood Sugar <_69 mg/dL 70—249 mg/dL >_250 mg/dL Awake and alert NO - Dehydration with but symptomatic Monitor Blood no evidence of Glucosei YES q. 15 minutes CHF/Fluid Overload Consider Exit to Appropriate E Oral Glucose Solution Protocol If age appropriate p1111190 Normal Saline Bolus r UllU • °°° 10 ml/kg IV/10 h Repeat as needed to effect age appropriate SBra Maximum 60 mL/kg D1U 25gm/250mi Mix I IIIIIII For,patients under'50kg give 5mllkg Titrate,to effect vat For patients over 50kg Titrate'to effect Repeat Dextrose per appropriate treatment arm Every 5 minutes Until Blood Glucose 70 mg/dL or greater Notify Destination or Contact Medical Control 11111111rcrcrcmu Nui�»i��%y0�1i��ii��ii�� 493 I o f uNr IIIIIIIU Illlu 711iiiiIIIIIIII, �m R III�� Iw k� x� ccouimuuimucul,mdcd Il; Amin, IIIMeiifl ml i.alUSl, IP,III III I14 LI, Illkuiin, II' leaimi.l, III Uingsl, Xodoixiein, Il;lIacllk, Il 11 lreim.uilIJies, INeUllimo • Do not administer oral glucose to patients that are not able to swallow or protect their airway. • Contact medical control for advice. • Quality control checks should be maintained per manufacturers recommendation for all glucometers. • Patient Refusal: Adult caregiver must be present with pediatric patient. Blood sugar must be 70 or greater and patient has the ability to eat (availability of food)with responders on scene. Patient must have known history of diabetes and not be taking any oral diabetic agents. Otherwise contact medical control. 494 ti Revised Pediatric Hypotension / Shock 03/01/2023 .............. ........................................................................................................................................................................................ II IhIsltoii"Iy ay.ii"Id II Iff e re II II It II aI • Blood loss 0 Restlessness, confusion,weakness • Shock • Fluid loss 0 Dizziness Hypovolemic • Vomiting 0 Tachycardia Cardiogenic • Diarrhea 0 Hypotension (Late sign) Septic • Fever * Pale, cool, clammy skin Neurogenic • Infection 0 Delayed capillary refill Anaphylactic 0 Dark-tarry stools • Trauma • Infection Dehydration Congenital heart disease A,• Medication or Toxin ................................................................................................................................................................................................................................ Hypotension Hypotension --0' E Blood Glucose Analysis Procedure Pediatric Age Specific VS Diabetic Protocol S P P IV Procedure 10 Procedure BP< 70+2xAge if indicated Poor perfusion Shock P Cardiac Monitor 11111IRM Pediatric Airway Protocol(s) 9�1m oil I if indicated History, Exam and Circumstances Suggest C Type of Shock 7 Hypovolem Ic Cardiogenic Distributive Obstructive Spinal Immobilization Appropriate Pediatric Spinal Immobilization Spinal Immobilization Procedure Arrhythmia Protocol Procedure Procedure if indicated as indicated if indicted if indicted Normal Saline Normal Saline — Normal Saline Bolus 20 mL/kg IV/10 Normal Saline Bolus Bolus 20 mL/kg IV'/10 Bolus 20 mL/kg IV/10 Repeat to effect P 5-10 V I 10 mL/kg Repeat to effect Repeat to effect P Age appropriate Maximum P Age appropriate P Age appropriate SBP 2:70+(2 x Age in SBP 2:70+(2 x Age in SBP 2:70+(2 x Age in I" i_0 mL/kg yea rs) yea rs) yea rs) Maximum 60 mL/kg Maximum 60 mL/kg Maximum 60 mL/kg rauma NO rauma Or Y S Anaphylaxis 0 Wound Care E Y S eNO Trauma E Procedures as indicated Y S Control Hemorrhage 1111111 1 oil Exit to T Appropriate Pediatric Exit to :> T Protocol Pediatric Exit to 1111111010 T, Multiple Pediatric 11111119 W3 Multiple Trauma Protocol Protocol Notity uesAination or Contact Medical Control 495 Revised Hypotension03/01/2023 Shock „ Vi�uu w� Iliilll 14 °w ,ono w ................................................................................................................................................................................................................................................................................................................................................................. 11cicoirm ine%ndm:*d II xairmu: II'dcln[ 11 Status, dll<un, II Ilk art:, II.umngs:,Albdoirncli , IGI'.tacllr, II xtirc�*uuuotnc�*s:, IINcluuiro owe%st Ilullood Mane%ssuuura* by age*; < 31 dads: 60 unimull Illg. 31 dads to I du*au 7"0 uruuuull lllg. Cueate%iir this n I dm*an "'t"d w (2 x Aga.* in da*airs). • Consider all possible causes of shock and treat per appropriate protocol. Majority of decompensation in pediatrics is airway related. • Decreasing heart rate and hypotension occur late in children and are signs of imminent cardiac arrest. • Shock may be present with a normal blood pressure initially. • Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation. • Consider all possible causes of shock and treat per appropriate protocol. • Hypovolemic Shock; Hemorrhage,trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding. • Cardiogenic Shock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventrical/septum/valve/toxins. • Distributive Shock: Sepsis Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins • Obstructive Shock: Pericardial tamponade. Pulmonary embolus. Tension pneumothorax. Signs may include hypotension with distended neck veins,tachycardia, unilateral decreased breath sounds or muffled heart sounds. • Acute Adrenal Insufficiency: State where body cannot produce enough steroids(glucocorticoids/mineralocorticoids.) May have primary adrenal disease or more commonly have stopped a steroid like prednisone. Usually hypotensive with nausea, vomiting,dehydration and/or abdominal pain. If suspected, EMT-P should give Methylprednisolone 2 mg/kg IV/10 or ��)", Dexamethasone 0.3 mg/kg(Maximum 10 mg) IV/10. Use agency-specific steroid. • Airway Cricothyrotomy Needle Procedure: Indicated as a lifesaving/last resort procedure in pediatric patients<_11 years of age. Very little evidence to support its use and safety. A variety of alternative pediatric airway devices now available make the use of this procedure rare. uuuuuu II i X uuu rcrcrcmu Uy pp Jll XX IIII � �9 r r r r a 496 Revised Pediatric Overdose / Toxic In estion 03/01/2023 g II Ihisitolr"y girl °Dzylrohlltllarlioh°��, � Il ullferei oIliall • Ingestion or suspected ingestion • Mental status changes • Tricyclic antidepressants of potentially toxic substance • Hypotension/hypertension « Acetaminophen • Substance ingested, route, • Decreased respiratory rate • Depressants quantity 0 Tachycardia, dysrhythmias • Stimulants • Time of Ingestion is important • Seizures • Anticholinergic • Reason (suicidal, accidental, 0 S. L. U. D.G. E. M. Cardiac medications criminal) Solvents,Alcohols, Cleaning agents « Available medications in home • Insecticides(organophosphates) Past medical history, medications, past psychiatric history 1. Scene Adequate Respirations/ NOS P Naloxone 0.1 mg/kg IN Safe YES Oxygenation/Ventilation f� Maximum 2 mg NO Naloxone 0.1;mg/kg IV/10/ y YES IN/IM/ETT T Naloxone is titrated to effect Call for help/additional E 12 Lead ECG Procedure adequate ventilation and resources oxygenation Stage until scene safe P Cardiac Monitor NOT GIVEN TO RESTORE CONSCIOUSNESS P IV Procedure 10 Procedure Blood Glucose Appropriate Pediatric E fYES Altered Mental Status 9""'�I� Airway Protocol s Analysis Procedure •1U y ( ) as indicated ilf r Appropriate Hypotension Specific sion ,n Pediatric ShockProtocolon/ Pediatric Diabetic/AMS/ YES Behavioral Protocol(s) as indicatedi 11 Potential Cause Serious Signs/Symptoms w JiUUU ->T Beta Blocker Calcium Channel Blocker Tricyclic Cyanide Organophosphate OD OD Antidepressant OD Carbon Monoxide OD IIIIIII QRS Atropine Calcium Chloride z 0.09 sec 0.02-0.05 mg/kg IVI Exif'to P 60 mg/kg IV/to NO IM/10 Carbon Over 10 minutes Y S Repeat every 5 Monoxide minutes until Cyanide Protocol wi symptoms resolve «� n Sodium Bicarbonate Dopamine 1 mEq/kg IV/to 10-20 mcg/kg/min IV/IO P Maximum 50 mEq' Repeat 0.5 mEq/ If no improvement kg in 10 minutes if eded: Cardiac External Pacing QRS remains> Florida Poison Procedure for Severe Cases 0.09 seconds Control 1-800-222-1222 Notify Destination or No. Contact Medical Control �� oo,Viuy:+u axmmg�..-"mII pmouyUy�»uweAy�amvaCp ' „nU' ., Mi IIf Mi p1Diw�Mi �m»Iy d��'„m 4Q7 Revised Pediatric Overdose / Toxic Ingestion 03/01/2023 g Jill ' Ill�l Salivation Lacrimation Urination;increased loss of control Defecation(Diarrhea,GI Upset;Abdominal pain/cramping, > mesis,Muscle Twitching tuuu "lu IIIIIII Illh�y 14 P" a^ .. ......ii, 11cicolrnincl%ndml*d II:xslrmu II'dcln[M Status, &Jd , II III d"III", II Illa�*slrt, II umings,Albdolrnclin, IG::x1ra*Iluuotic1%s, IINcl%uulro • Do not rely on patient history of ingestion,especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. Bring bottles, contents,emesis to ED. • Age specific blood pressure 0—28 days >60 mmHg, 1 month -1 year>70 mmHg, 1 -10 years> 70+(2 x age)mmHg and 11 years and older>90 mmHg. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. • Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure • Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal dysfunction, liver failure, and or cerebral edema among other things can take place later. * Depressants: decreased HR,decreased BP, decreased temperature, decreased respirations, non-specific pupils Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures • Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes • Cardiac Medications: dysrhythmias and mental status changes • Solvents: nausea, coughing, vomiting, and mental status changes Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils Consider restraints if necessary for patients and/or personal protection per the Restraint Procedure. • Nerve Agent Antidote kits contain 2 mg of Atropine and 600 mg of pralidoxime in an autoinjector for self administration or patient care. These kits may be available as part of the domestic preparedness for Weapons of Mass Destruction. Consider contacting the State of Florida Poison Control Center for guidance. yyyuytyyyy ar a NG� J777 D»�� YY�O �� )U1JJ uuu �ussua�nliUur �� IIIIIIIIIIIIIII�I� �IIIIIIIIIIIIIIIII�I�IIIIIIII�� IIIIII��IIIIIII��IIIII��IIIIIII��I�IIIIIIIIIII 498 Revised 03/01/2023 Pediatric Respiratory Distress �I ly S I g " ,rrl d, Syiin oiin s DN'�ffe I r Iruwal • Time of onset 0 Wheezing/Stridor/Crackles/ Rales • Asthma/Reactive Airway Disease « Possibility of foreign body « Nasal Flaring/Retractions/Grunting « Aspiration « Past Medical History • Increased Heart Rate 0 Foreign body • Medications • AMS 0 Upper or lower airway infection « Fever/Illness • Anxiety • Congenital heart disease • Sick Contacts 0 Attentiveness/Distractability • OD/Toxic ingestion/CHF « History of trauma « Cyanosis • Anaphylaxis • History/possibility of choking * Poor feeding 0 Trauma Ingestion/OD « JVD/Frothy Sputum Congenital heart disease « Hypotension :re story/Signs/ Syptoms consistent �• Pediatric Airway withspiratory distress NOS Ventilations adequate �NO� „-,," Protocol(s) withheezing or stridor Oxygenation adequate YES ergic eac ion _ _ Pediatric E 12 Lead ECG Procedure NO Anaphylaxis YES II "1I9,f Allergic Reaction IV Procedure 10 Procedure Anaphylaxis Protocol if indicated if indicated Cardiac Monitor WHEEZING Lung Exam Jill STRIDOR Signs/Symptoms NO eo Age z 12 months YES Epinephrine 1:1000 Nebuiizer Imgin2ml.NS i <LEpisodef� Whee YES May repeat 1 Albuterol Nebulizer NO 2.5 mg OR Worsening NO 1 Albuterol Nebulizer P GI�� .......Xopenex 1.25 mg 2.5 mg +/-Ipratopium 0.5 mg YES OR Repeat as needed x 3 I Methyl-prednisolone l'il":�t��Xopenex 1.25 mg Albuterol Nebulizer +/_Ipratopium 0.5 mg P 2 mg/kg IV/10 2.5 mg Repeat as needed x 3 Methyl- Maximum 125 mg IIIIIIII OR prednisolone � P X Xopenex 1.25 mg 2 mg/kg IV/10 +/-Ipratopium 0.5 mg Maximum 125 mg Repeat as needed x 3 Worsening Epinephrine 1:1000 " 0.01 ring/kglM Methyl- YES YES Maximum 0.3 mg prednisolone Epinephrine NO Worsening 2 mg/kg IU/fQ 1;1000 Pediatric Maximum 125 mg Nebulizer Airway Protocol(s) 1 mg in 2 mL NS as indicated Pediatric Airway Protocol(s) Pediatric Airway as indicated 111°�'� Protocol(s) lli1" 1 0 Noti Destination or as indicated'j, fY Contact Medical Control Magnesium sulfate 40 mg/kg IV/14 Over 20 minutes °""IIIOD U JkNN ""rif IIIIVU 11AIDJU, JU1JJ'""" i '"'"" Mi II Mi UfDulla�Mi »Iy �i��, 499 Revised 03/01/2023 Pediatric Respiratory Distress �m �m a� lRcicoirniincl%nded II xsirn II'dcln[sll Status, II II1 ::ld II, dllrnill, IINa*clk, II Illa*sirt:, IL. urngs:,Allidoirn en, II::xtira*uauotnes, Na�*ruiro teems uun IlRcl%d II'a*xt aura* IlyaW Ilsa*urtoirina nce% uric*ssuua*s uusc*d to a*vMuusta* Ilsurotoc6 cou°uupllHa nca*and csura*. l3uullsa*oxuouua*try sllrouulld Ilan% a°nonRora*d contuunuuouuslly ui in tllra* Ilcstoa*unt Wdi re%spurstory dusts%ss. • Consider IV access when Pulse oximetry remains<_92% after first beta agonist treatment. • Do not force a child into a position,allow them to assume position of comfort. They will protect their airway by their body position. • The most important component of respiratory distress is airway control. • Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respond to beta-agonists. Consider Epinephrine if patient< 18 months and not responding to initial beta-agonist treatment. • Croup typically affects children <2 years of age. It is viral, possible fever, gradual onset, no drooling is noted. • Epiglottitis typically affects children >2 years of age. It is bacterial,with fever, rapid onset, possible stridor, patient wants to sit up to keep airway open,drooling is common.Airway manipulation may worsen the condition. • In patients using Ievalbuterol(Xopenex)you may use Albuterol for the first treatment then use the patient's supply for repeat nebulizers or agency's supply. 500 Revised 03/01/2023 Pediatric Seizura ................................................................................................................... ..................... ........................................................................................................................................................................................................................ Il a°� of y °n;�IgiiI sirou °Dzyir'ohlLtUariiohU�U, oIIfereiio hall Fever . Fever; hot, dry skin • Febrile seizure • Sick contacts • Seizure activity . Infection Prior history of seizures « Incontinence . Head trauma • Medication compliance 0 Tongue trauma . Medication or Toxin • Recent head trauma • Rash . Hypoxia or Respiratory failure • Whole body vs unilateral seizure « Nuchal rigidity Hypoglycemia activity 0 Altered mental status 0 Metabolic abnormality/acidosis • Duration, Single/multiple • Tumor Congenital Abnormality NO Active Seizure YES Activity ..........>— 111111IM11 Pediatric Airway Protocol(s) 1,Iooa9 Gkx arse:,Analysis I"i orn.edu i,e ®t1 as indicated Spinal Immobilization Procedure Pediatric Diabetic Protocol wla�ra�d a_�luan;ose AnaIysIs "ia�ra::edu ie E if indicated if indicated Spinal Immobilization Procedure Loosen any constrictive clothing P"1112TM E if indicated „u Protect patient Loosen any constrictive clothing IV Procedure Protect patient if indicated IV Procedure 10 Procedure P Cardiac Monitor Ill�l if indicated „1W Midazolam 0. —0.2 mg/kg IV/IM/ t Fill llU Consider 10/IN � Pediatric P °^ Altered Mental ; MA dose of 10 MCa „ Status Protocol , Awake,Alert if indicated —NOS mwwi � Normal Mental Status � y 14 Or Cardiac Monitor YES Postictal State IN Montior and Reassess Monitor and Reassess Status Epilepticus YES Notify Destination or Active Seizure in Known or Suspected Contact Medical Control Pregnancy >20 Weeks Exit to Obstetrical Emergency Protocol II"U,<<„y 0 11cicoirnuaua*nded xsirmu 'dcln[M Status, klart, I uru gs, xtira�*uauotua�*s, 14a*uriro teems uun Il1cld II',ext aura* Ikey Ilsa*urtoirina nce urua*ssuuires used to evMuuate Ilsurotocd cou°uuplha nce and caire Midazolam 0.2 mg/kg (Maximum 10 mg) IM is effective in termination of seizures. Do not delay IM administration with difficult IV or 10 access. IM Preferred over 10. Addressing the ABCs and verifying blood glucose is as important as stopping the seizure. Be prepared to assist ventilations especially if a benzodiazepine is used.Avoiding hypoxemia is extremely important. • In an infant, a seizure may be the only evidence of a closed head injury. Status epilepticus is defined as two or more consecutive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control,treatment, and transport. Assess possibility of occult trauma and substance abuse,overdose or ingestion/toxins and fever. JNNN P�yyaau0�Il1UlUl�UvU,UlUJII)'��' � � 501 Revised Pediatric Vomiting / Diarr 03/01/2023 he6 . .................................................................................................................................................................. ..........................................................................................................................................................................................-,""I'll"........... airld i iff e re iro It i a i • Age 6 Pain • CNS(Increased pressure, headache,tumor, • Time of last meal 0 Distension trauma or hemorrhage) • Last bowel movement/emesis 0 Constipation • Drugs • Improvement or worsening with & Diarrhea • Appendicitis food or activity 6 Anorexia • Gastroenteritis • Other sick contacts 0 Fever • GI or Renal disorders Past Medical History 0 Cough, Diabetic Ketoacidosis 0 Past Surgical History 0 Dysuria Infections(pneumonia, influenza) 0 Medications • Electrolyte abnormalities 6 Travel history 0 Bloody Emesis or diarrhea ................................................................................................................................................................................................. ..............."I'l""I'll""I'll'll""I'll""I'll",'ll""I'll""I'll'll""I'll""I'll""I'll""I'll",'ll""I'll""I'll",'ll""I'll""I'l'll""I'l,"",',,"",',,""I',l",lI............. Blood Glucose Analysis Pediatric E Diabetic Protocol Procedure NUE if indicated Serious Signs/Symptoms: rNO Hypotension, Poor —YES Jill" perfusion TZ Ondansetron IV Procedure loProcedure P 0.15 mg/kg IV/10 Normal Saline 611111 Maximum dose 4mg Bolus 20 mL/kg IV/10 P Repeat to effect Pediatric Age appropriate Abdominal Pain Pain Control SBP�:70+2 x Age Protocol Maximum 60 mill if indicated Ondansetron NO P 0.15 mg/kg IV/10 Maximum dose 4mg Improving YES --YES Improving NO NO X11 IV Procedure Exit to if indicated Pediatric P �.flHypotension/Shock Normal Saline Bolus Protocol 10 mL/kg IV/10 Notify Destination or Contact Medical Control II e a ar ; in,rr IIMeinla�l SWIUS, &(uJllh I I I14 I II"4 e c k, leairl, I U1111gS, Xodoixiein, 3aclk, I xlreixilltles, INeU111imo Heart Rate: One of the first clinical signs of dehydration, almost always, is increased heart rate. Tachycardia increases as dehydration becomes more severe. If heart rate is close to normal it is unlikely the patient is significantly dehydrated. Age specific blood pressure 0—28 days > 60 mmHg, 1 month -1 year> 70 mmHg, 1 -10 years > 70 + (2 x age) mmHg and 11 years and older>90 mmHg. Beware of vomiting in children. Pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures)all often present with vomiting. 502 Revised 03/01/2023 Pediatric Head Trauma] History Signs and Symptoms Differential • Time of injury • Pain, swelling, bleeding • Skull fracture • Mechanism (blunt vs.penetrating) • Altered mental status • Brain injury (Concussion, Contusion, • Loss of consciousness . Unconscious Hemorrhage) • Bleeding • Respiratory distress/failure • Epidural hematoma • Past medical history • Vomiting • Subdural hematoma • Medications • Major traumatic mechanism of • Subarachnoid hemorrhage • Evidence for multi-trauma injury . Spinal injury • Seizure + Abuse QbtaVn and II''uta*cord GCS Spinal Immobilization Procedure if indicated IV Procedure 10 Procedure if indicated if indicated Pediatric E Blood Glucose Analysis Procedure Noµ�� AMS/Diabetic °� Protocol as indicated Pediatric � Multiple Trauma NO Isolated Head ® Protocol :> Trauma YES � Pediatric ENO Adequate Ventilation/ V Airway Protocol Oxygenation YES Hypotension Pediatric < 70+ (2 x Age) YES NMultiple Trauma is C(SBP oor Perfusion/Shock Protocol NO Seizure Activity YES-----► Pediatric ®.1,1 Seizure Protocol NO Notify Destination or FF- Contact Medical Control Pearls lute%coirm ine%ndm:*d II aim II'dcln[M Status, II IIIII ]14II, IIIllmlart, II uuu gs,N douuua*un, IGi:: tura*uuflflc*s, IGI'.tadk, II14c�*uuiro GCS us s Ike%y Il a*u toururusnce% a°ne%asuuuru* uusm*d to c1%vMuusta* Ilsurotocd couuull lha nce%and caire If GCS < 12 consider air/rapid transport and if GCS <9 intubation should be anticipated. Hyperventilate the patient only if evidence of herniation (blown pupil, decorticate/decerebrate posturing, bradycardia, decreasing GCS). If hyperventilation is needed (35/minute for infants<1 year and 25/minute for children>1 year) EtCO2 should be maintained between 30 -35 mmHg. • Increased intracranial pressure(ICP) may cause hypertension and bradycardia (Cushing's Response). Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively. . An important item to monitor and document is a change in the level of consciousness by serial examination. Concussions are traumatic brain injuries involving any of a number of symptoms including confusion, LOC, vomiting, or headache.Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP. Fluid resuscitation should be titrated to maintain at least a systolic BP of> 70+ (2 x the age in years)for patients< 11 years old. 503 di A INS History Signs and Symptoms Differential • Time and mechanism of injury • Pain, swelling • Chest: Tension pneumothorax • Damage to structure or vehicle 0 Deformity, lesions, bleeding Flail chest, Hemothorax • Location in structure or vehicle « Altered mental status or Pericardial tamponade • Others injured or dead unconscious Open chest wound Speed and details of MVC • Hypotension or shock • Intra-abdominal bleeding • Restraints/protective • Arrest • Pelvis/Femur/Spine fracture, cord injury equipment • Head injury (see Head Trauma) • Past medical history 0 Extremity fracture/Dislocation • Medications 0 HEENT(Airway obstruction) « Hypothermia into Pediatric Airway Protocol(s) if indicated Slpu nM Iluaair°aadiflluuatoon 14 roca*du rcl Elv rocedure IO Procedure pp Cardiac Monitor Assems VS Normal (1%11'fuasliou�n f Abnormal GCS Repeat Pediatric Assessment Rapid,Transport to appropriate Splint Suspected Fractures destination Consider Pelvic Binding Limit coins Flir mo 10 iimi°lin ujes Control External Hemorrhage IDr ymde III au ly Notification r---Mo and Reassess �• Pediatric Head Injury Protocol 6 if if indicated Transport to appropriate Splint Suspected Fractures destination E Consider Pelvic Binding Control External Hemorrhage Pediatric Normal Saline Hypotension/ Bolus 20 mL/kg IV/IU Shock Protocol Repeat to effect Age appropriate as indicated SBP?70+(2 x Age in years) RUT01 Maximum 60 mL/kg Chest Decompression-Needle Procedure if indicated Notify Destination or Monitor and Reassess Contact Medical Control Pearls Sce ne%tuurmaNs sllhoWd not be dellaye%d for Ilaroce%du re%s II these%sllhoWd be IlsaNurfou i ned aNu n urou te%v he%urn Iluossullbk1% Ik°talpW traunslpourf of Uhe% uanstalikl%,turaluina Ilsafle% nt to Uhe% all lluurolpirr ate% fadul ty us Uhe%adoM. • Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained >_90% • Age specific blood pressure 0—28 days> 60 mmHg, 1 month- 1 year>70 mmHg, 1 - 10 years>70+ (2 x age)mmHg and 11 years and older>90 mmHg. * Consider Chest Decompression with signs of shock and injury to torso and evidence of tension pneumothorax. • Severe bleeding from an extremity, not rapidly controlled with direct pressure, may necessitate the application of a tourniquet. • Do not overlook the possibility of child abuse. 504 Revised 03/01/2023 Pediatric Thermal Burn History Signs and Symptoms Differential + Type of exposure(heat,gas,chemical) . Burns,pain,swelling + Superficial(11 Degree)red-painful(Don't include in TBSA) Inhalation injury . Dizziness Partial Thickness(2nd Degree)blistering + Time of Injury + Loss of consciousness + Full Thickness(3rd Degree)painless/charred or leathery skin Past medical history and Medications Hypotension/shock Thermal Other trauma + Airway compromise/distress . Chemical—Electrical Loss of Consciousness could be indicated by + Tetanus/Immunization status hoarseness/wheezing ----------------------------------------------------------- Assess Burn/Concomitant Injury Severity Minor Burn Serious Burn iii n 5-'15%TBSA 2"d/3rd Degree Burn p <5%TBSA 2"d/3rd Degree Burn Suspected inhalation injury or requiring No inhalation injury, Not Intubated, intubation for airway stabilization Nor 4 orG ea Hypotension or GCS 13 or Less GCS 14 or Greater (When reasonably accessible, transport to a Burn Center) Remove Rings, Bracelets/ E Constricting Items E Remove Rings, Bracelets/Constricting Items Dry Clean Sheet or Dressings Dry Clean Sheet or Dressings M Pediatric Multiple Trauma Protocol �11111". Pediatric Multiple Trauma Protocol ",,,,,; if indicated WW if indicated Pediatric Airway Protocol(s) Pediatric Airway Protocol(s) Illllll710 IIIIIII�Aa ";,,,,, as indicated as indicated IV Procedure IV Procedure if indicated Consider 2 IV sites if greater than 15 %TBSA Normal Saline Normal Saline 0.25 mL/kg(x% TBSA)/hr 0.25 mL/kg(x% TBSA)/hr for up to the first 8 hours. for up to the first 8 hours. (More (More info below) ,. Lactated Ringers p'��I°:�r��Lactated Ringers if s if available P 10 Procedure if indicated Pediatric Pain Control Protocol Pediatric Pain Control Protocol �iI1V if indicated ® if indicated Carbon _ Monoxide/ Cyanide Exposure YES I►, Cyanide AYES Protocol Cyanide Exposure r7, IN �� FTTransport Facility of Choice Rapid,Transport to appropriate destination Notify Deshination or Contact Medical Control 1. Lactated Ringers pref6rred over Normal Saline. Use if available,if not changelover once available. 2. Formula example:an 80 kg(196 lbs.)patient with 50% TBSA will need 1000 cc of fluid per hour. 505 Revised 03/01/2023 Pediatric Thermal Burn b��tr,�o)�ur1a� �` "� V Llll ofII" lin s + Seldom do you find a complete isolated body part that is injured as described in the Rule of Nines. . More likely, it will be portions of one area, portions of f'su,V'It another, and an approximation will be needed. For the purpose of determining the extent of serious injury, differentiate the area with minimal or 15t degree burn from those of partial (2"d)or full (3 d)thickness ro- burns. �� o �� '� �( • For the purpose of determining Total Body Surface �, Area (TBSA)of burn, include only Partial and Full , 1 � o f3 Thickness burns. Report the observation of other J �� rv� r superficial (1st degree) burns but do not include those , i' ��r I`� �� iPupr1so;iwiiii°rho i` (,raj i�"„ �� ym44 '1`` burns in your TBSA estimate. Gi1ft,31 Some texts will refer to 4« 5«and 6«degree burns. There is significant debate regarding the actual value 1 of identifying a burn injury beyond that of the superficial, partial and full thickness burn at least at the level of emergent and primary care. For our work, all are included in Full Thickness burns. Other burn classifications in general include: �I�f� tIfitw/, + 4th referring to a burn that destroys the dermis and involves muscle tissue. V101411JIVO 1�r,„If iM uextywoim,fiff qi 1 ,BSAi OcicoA by 1"Iff0f0h 0 5th referring to a burn that destroys dermis, penetrates muscle tissue, and involves tissue t around the bone. I t I � I f I t . 6« referring to a burn that destroys dermis, Body Paidestroys muscle tissue, and penetrates or I Ufr 1 9 1�1 &i G{�� I�� r Il�� 4�lgr destroys bone tissue. Estimate spotty areas of burn by using the size of the patient's palm as 1 % Pearls lIcicoirnuuua*ndm:*d II xsirmu II'dcln[M Status, II III II ]14II, INedk, II IIklart, II uungs,AIbdoirncln, IGi::xlura*uuuoli�m•*s, IGI'.tsollr, and Idm*uuiro Green,Yellow and Red in burn severity do not apply to the Start/JumpStart Triage System. CroluoM oir Sa*ruouus II tuuumurms: .............................................. ......................................................................................... >5-15%total body surface area(TBSA) 211 or 311 degree burns,or 31 degree burns>5% TBSA for any age group, or circumferential burns of extremities, or electrical or lightning injuries, or suspicion of abuse or neglect, or inhalation injury, or chemical burns, or burns of face,hands,perineum, or feet, or any burn requiring hospitalization. Require direct transport to a Burn Center. Local facility should be utilized only if distance to Burn Center is excessive or critical interventions such as airway management are not available in the field. Burn patients are trauma patients, evaluate for multisystem trauma. Assure whatever has caused the burn is no longer contacting the injury. (Stop the burning process!) Early intubation is required when the patient experiences significant inhalation injuries. Circumferential burns to extremities are dangerous due to potential vascular compromise secondary to soft tissue swelling. Burn patients are prone to hypothermia - never apply ice or cool the burn. Maintain normal body temperature. Evaluate the possibility of child abuse with children and burn injuries. Never administer IM pain injections to a burn patient. 60 506 Revised 202 03/01/2023 START/ JumpStart Triage < >-YES film NO Position Upper Airway Breathing -NO No Results in YES Spontaneous < Breathing NO Jult Pulse NO DECEASED YES Ylis <Breathing NO YES Adult< 30 minute No palpable Pulse (Pediatric) Obeys Commands YES DELAYED Adult Status Appropriate to AVPU Pediatric 0 beys * Capillary refill can be altered by many factors including skin temperature. Age-appropriate heart rate may also be * used in triage decisions. ntitinron�n��i„„� �iiiiIIIIIIIIIIIIIIII�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�III��III�IIIIIII�IIIIIIIII�IIIIIII�I�IIIIIIIIII�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�I�P° r, Revised 03/01/2023 Fever 1 Infection Control -------------------------------------------- ............................................. histoiry Sou„tlrm arxi, Sy nqp toonnr Iliuutta�nura�nntuuJnl • Age • Warm • Infections/Sepsis • Duration of fever 0 Flushed Cancer/Tumors/Lymphomas • Severity of fever • Sweaty • Medication or drug reaction • Past medical history • Chills/Rigors • Connective tissue disease • Medications Asso6ur1m;vd „yii,nru,,iioinrm • Arthritis • Immunocompromised (transplant, ivy ivrca4u Ize s ou irc e), • Vasculitis HIV,diabetes, cancer) • myalgias, cough, chest pain, . Hyperthyroidism • Environmental exposure headache, dysuria, abdominal pain, . Heat Stroke • Last acetaminophen or ibuprofen mental status changes, rash Meningitis Contact, Droplet, and Airborne Precautions Temperature Measurement Procedure ilu E if available UUUUUUiu IV Procedure 10 Procedure If indicated If indicated I�J�II TemperatuDF ------NES t,Y ,-NO---CGreater than 1 B' (38 C) Consider Differential: u�l Exit to PossibleSepsis,Seizures,etc Appropriate Protocol Pediatric pstis;umtr can deteriorate quicW of a UUUU Exit to Appropriate Protocol �a ;rx a a Ir 1I 11cicoirm ine%ndm:*d II:xairmu II'da*uctall Status, dllruuc, II III d"III", IINcldk, II Ilkl%airt, IL. a ngs,Albdoirne%n, IGI'.tadk, II x1irc�*uuflUc1s, IlNe uiro • Proper assessment and early intervention for sepsis is a key to decreased mortality. Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature. • Patients with a history of liver failure should not receive acetaminophen. • Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB 02 mask for the patient. This level of precaution should be utilized when influenza, meningitis, mumps,streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected.A patient with a potentially infectious rash should be treated with droplet precautions. • Airborne precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster(shingles), or other illnesses spread by contact are suspected. • All-hazard precautions include standard PPE plus airborne precautions plus contact precautions. This level of precaution is utilized during the initial phase of an outbreak when the etiology of the infection is unknown or when the causative agent is found to be highly contagious (e.g. SARS). • Rehydration with fluids increases the patient's ability to sweat and improves heat loss. • All patients should have drug allergies documented prior to administering pain medications. • Allergies to NSAIDs (non-steroidal anti-inflammatory medications)are a contraindication to Ibuprofen. • NSAIDs should not be used in the setting of environmental heat emergencies. • Do not give aspirin to a child. a u i �ri uii t t INN Illllllllllllliuil 508 Revised Police Custody03/01/2023 ......................................... Histoiry S u g iros auo(N uu��IUroua;�uu�� fft,,ir ir°LVi I • Traumatic Injury • External signs of trauma • Agitated Delirium Secondary to • Drug Abuse • Palpitations Psychiatric Illness • Cardiac History • Shortness of breath • Agitated Delirium Secondary to • History of Asthma 0 Wheezing Substance Abuse • Psychiatric History • Altered Mental Status Traumatic Injury • Intoxication/Substance Abuse 0 Closed Head Injury • Asthma Exacerbation • Cardiac Dysrhythmia Exit to Evidence of Traumatic Injury or Appropriate Protocol(s) EYES Medicallllness? • ' NO III II III III III SII III' Y Use of Pepper Spray or Taser? >— NOI AS III Irrigate face/eyes CTIaser nificant Injury/ Remove entry point NO contaminated clothing YES �uIIIIVk Asthma Wound Care-Taser Probe VUUUUUIu NO /COPD NO Removal Procedure �h^M Wheezing History Wound Care Procedure(s) as indicated YES Multiple Trauma Protocol if indicated YES Observe 20 Minutes NO Dyspnea or Cardiac History Wheezing? NO— Chest pain/ YES U Palpitations/ Exit to Dyspnea �n Appropriate o� Respiratory Distress Protocol(s) VUUUU M Excited Delerium Syndrome YES • IUUb, .I_5 UwV NO Restraint Procedure if indicated Exit to Behavioral Protocol Or Appropriate Protocol •u� Notify Destination or Contact Medical Control u a�i uu � iui NuuiAiuu Nu i i Nu a ivu N u � n I 509 WIl�u�, 4114 I" 4114 J?�nVNY ��I uq IIIIINM NUUUUU@ pY 6mppu�, INJIIII iYk iY lu�n 16;MG ik UUUUU Illlh�" w ;rxU' aIrIIs P)a1Jllei1d does not to Ile Uum II'olll cc cUwUsl.ody oul" mUundsulm alllmlllmcst 10 UwUlllllll ze I.IIImUs Ill Illmolocolll :IMS shoOd k)inn'uUUIate c U lith Ilocacl IIcaw eiAourvcm;uU ent agendes couglcm.urvnliigg )afients req uliiJigg II:II`S aigd II...a uUUUUurv�;m;uUum uUl un'iUuIIQcIIUeou sly Agendes shoOd work together IUm ft)rn'iOate c 6spo lifioliq in the Ibest interest UUU the p)cl ent Patients restrained by law enforcement devices must be transported accompanied by a law enforcement officer in the patient compartment who is capable of removing the devices.When rescuers have utilized restraints in accordance with Restraint Procedure, the law enforcement agent may follow behind the ambulance during transport. The patient may not be handcuffed to the stretcher, they must be handcuffed in front. « The responsibility for patient care rests with the highest authorized medical provider on scene. If an asthmatic patient is exposed to pepper spray and released to law enforcement, all parties should be advised to immediately contact EMS if wheezing/difficulty breathing occurs. All patients in police custody retain the right to participate in decision making regarding their care and may request care of EMS. If extremity/chemical/law enforcement restraints are applied, follow Restraint Procedure. Consider Haldol for patients with history of psychosis or a benzodiazepine for patients with presumed substance abuse. All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. Excited Delirium Syndrome: Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent/bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Most commonly seen in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may also contribute to the condition. • If patient is suspected of suffering from agitated delirium and suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early. • Do not position or transport any restrained patient is such a way that could impact the patients respiratory or circulatory status. ri 0 M 0I IIII NN �N h0 11 N N I tIN N llllllllil 510 Revised Emergencies Involving 03/01/2023 Indwelling Central Lines Uostoir &gird s arxN Syrnll,rot ronns iffE,rlra,IrfloJ U + Central Venous Catheter Type « External catheter dislodgement + Fever Tunneled Catheter « Complete catheter dislodgement 0 Hemorrhage (Broviac/Hickman) « Damaged catheter « Reactions from home nutrient or medication « PICC(peripherally inserted « Bleeding at catheter site Respiratory distress central catheter « Internal bleeding . Shock • Implanted catheter . Blood clot (Mediport/Hickman) Air embolus « Occlusion of line « Erythema,warmth or drainage Complete or partial dislodge about catheter site indicating « Complete or partial disruption infection Airway, Breathing or to Circulation Problem �YES� I R Appropriatetprotocol(s) NO Clamp catheter proximal to disruption �ageeter YES May use hemostat wrapped in gauze Stop infusion if ongoing NO a IVu UUUUuuiu Catheter com letel or Apply direct pressure around catheter p y YES partially dislodged Stop infusion if ongoing NO a;' IpJ�lll Hemorrhage at catheter YES Apply direct pressure around catheter site pp y p NO Suspect Air Embolus Tachypnea, Dyspnea, YES Place on left side in head down P„ Chest Pain position ;, Stop infusion if ongoing � VUUUU NO Clamp catheterh�b" On oin infusion YES Continue infusion wk� g gP Do not exceed 20 mL/kg Notify Destination or Contact Medical Control Always talk to family/caregivers as they have specific knowledge and skills. « Use strict sterile technique when accessing /manipulating an indwelling catheter. « Do not place a tourniquet or BP cuff on the same side where a PICC line is located. Do not attempt to force catheter open if occlusion evident. « Some infusions may be detrimental to stop. Ask family or caregiver if it is appropriate to stop or change infusion. Cardiac arrest: Access central catheter and utilize if functioning properly. « Hyperalimentation infusions (IV nutrition): If stopped for any reason monitor for hypoglycemia. N u n u v nn Ilu r �i Nri rims NN I INN 511 Revised Respiratory Distress 03/01/2023 With a Tracheostomy Tub ii4��r toiry � &girm ar°x'l yr�'�q,,A.o n'mr + Birth defect(tracheal atresia, • Nasal flaring • Allergic reaction tracheomalacia, craniofacial + Chest wall retractions(with or • Asthma abnormalities) without abnormal breath sounds) + Aspiration Surgical complications • Attempts to cough • Septicemia (accidental damage to phrenic • Copious secretions noted coming + Foreign body nerve) out of the tube 0 Infection • Trauma (post-traumatic brain or • Faint breath sounds on both sides 0 Congenital heart disease spinal cord injury) of chest despite significant • Medication or toxin • Medical condition (bronchial or respiratory effort Trauma pulmonary dysplasia, muscular + AMS dystrophy) Cyanosis rac eso omy _ rac eso only _ Allow Caregiverto insert Tube in place NO Tube available YES Tracheostomy Tube Or YES NO :> Place Tracheostomy Tube/ Appropriately sized ETT into stoma Place Appropriately sized endotracheal tube into stoma Obturator Removed NOS, P I Remove Obturator UUUUUUiu YES Continued Inner Cannula > Remove Inner Cannula Respiratory Distress NO in place YES P (Double lumen) Suction Tracheostomy Tube Y S NO Remove Speaking Valve Speaking Valve Remove Decannulation plug Decannulation plug N Removed Suction Tracheostomy Tube YES "lf"" Suction Tracheostomy Tube VUUUU Illlh�° Exit to �Ib Continued 4TAssist Ventilations via r. Appropriate Pediatric <�; piratory Distress YES Tracheostomy Tube/ETT .''ll1 Respiratory Distress kC Protocol(s) kh a� NO Monitor and Reassess Notify Destination or Contact Medical Control Always talk to family/caregivers as they have specific knowledge and skills. Use patients equipment if available and functioning properly. • Estimate suction catheter size by doubling the inner tracheostomy tube diameter and rounding down. Suction depth:Ask family/caregiver. No more than 3 to 6 cm typically. Instill 2—3 mL of NS before suctioning. • Do not suction more than 10 seconds each attempt and pre-oxygenate before and between attempts. • DO NOT force suction catheter. If unable to pass,then tracheostomy tube should be changed. Always deflate tracheal tube cuff before removal. Continual pulse oximetry and EtCO2 monitoring if available. DOPE: Displaced tracheostomy tube/ETT, Obstructed tracheostomy tube/ETT, Pneumothorax and Equipment failure. l a I I lu I u i i N ri iii u N N i INN IIp �IIpI i .� k I 1 .I ilia, I II I w 512 Revised Emergencies 03/01/2023 Involving Ventilators iustoir &girm ar°xl yr�,q,ttorn,mr � II a a�ra�uoiurJ�� + Birth defect(tracheal atresia, + Transport requiring maintenance + Disruption of oxygen source tracheomalacia, craniofacial of a mechanical ventilator + Dislodged or obstructed tracheostomy tube abnormalities) . Power or equipment failure at 0 Detached or disrupted ventilator circuit + Surgical complications(damage residence 0 Cardiac arrest to phrenic nerve) + Increased oxygen requirement/demand + Trauma (post-traumatic brain or + Ventilator failure spinal cord injury) + Medical condition (bronchopulmonary dysplasia, muscular dystrophy) <];f� with Airway, — NO r Oxygengation YES 7Ak nation saturation >_ 94% egiver: The baseline YES Problem with Circulation/ YES saturation for patient) Other problems ��f�RRR Or ui Oxygenation 35—45 mmHg NO Exit to NO AppropriateRrotocol(s) 11H IWI All. 09 lie WHAL CDetached Oxygen Source ��"' Detached Ventilator Circuit YES► Correct cause �Il��i NO llk, Dislodged Tracheostomy Tube/ETT �IoiUl Y S Respiratory Distress NO with a Tracheostomy Tube Jul Y S Protocol Obstructed Tracheostomy Tube/ETT NO lull �I�h 7andsmPTaintain ort on patients ventilator Cause corrected YES P ��o current settings NO 1 Remove patient from ventilator and manually ventilate with BVM Notify Destination or Contact Medical Control p..rElairIs Always talk to family/caregivers as they have specific knowledge and skills. Always use patient's equipment if available and functioning properly. Continuous pulse oximetry and EtCO2 monitoring must be utilized during assessment and transport. DOPE: Displaced tracheostomy tube/ETT, Obstructed tracheostomy tube/ETT, Pneumothorax and Equipment failure. Unable to correct ventilator problem: Remove patient from ventilator and manually ventilate with BVM. Take patient's ventilator to hospital even if not functioning properly. Typical alarms: Low Pressure/Apnea: Loose or disconnected circuit, leak in circuit or around tracheostomy site. Low Power: Internal battery depleted. High Pressure: Plugged/obstructed airway or circuit. k °" uuwnvnu n uwn lo�unq I�u o, 1 11 I I u N ri r iii u H N i I 513 � ,..,.. RevisedBites and Envenomations' 03/0101/2023 20 ...................................................................................................................................................................... 1,0 i D iif • Type of bite/sting • Rash, skin break,wound • Animal bite • Description or bring creature/ photo • Pain, soft tissue swelling, redness Human bite with patient for identification • Blood oozing from the bite wound • Snake bite (poisonous) + Time, location, size of bite/sting I e Evidence of infection • Spider bite(poisonous) • Previous reaction to bite/sting • Shortness of breath,wheezing + Insect sting/bite(bee,wasp, ant,tick) • Domestic vs. Wild 0 Allergic reaction, hives, itching Infection risk • Tetanus and Rabies risk 0 Hypotension or shock • Rabies risk • Immunocompromised patient • Tetanus risk YES General Wound Care Procedure If Needed Scene IV Procedure 10 Procedure Safe Florida Poison Control P if indicated if indicated NO 1-800-222-1222 l T Hypotension/Shock LHy'opoteln us njury/ �uum111 Protocol Call for help/additional <__ YESt„ sion ®�� Appropriate resources Trauma Protocols Stage until scene safe g NO Ale r / Allergic Reaction gy YES P""'� Anaphylaxis Ana h IaXIS •uuur'r p y Protocol NO Appropriate �YES� Moderate/Severe i ®�°°°fl Pain Protocol Pain Identification of Animal Spider Bite Snake Bite Dog/Cat �1 ON Bee/Wasp Sting Human Bite i Immobilize Injury j Immobilize Injury Immobilize Injury j Elevate wound locations Elevate wound location if able 11111111rk Extremity Trauma Protocol if able ' if indicated Remove any constricting Apply Ice Packs clothing/bands Remove any constricting clothing/ DO NOT APPLY ICE Transport ;;//j bands/jewelry j Remove all jewelry NO Midazolam 2.5—5.0 mg IV/10 from affected extremity Y S " Over 2 to 3 minutes Midazolam 1 to 2 mg INIL Mark Margin of Swelling Midazolam 5 mg IM Redness and Time Animal bites: P Maximum 5 mg Contact and Pediatric Document Midazolam 0.1-0.2 miUkiz IV'/t(? LT contact Over 2 to 3 minutes Midazolam 0.2 mg/kg mg/kg IN with Animal Maximum 2:ing Control --Notity Destmation or Officer Contact Medical Control r o io it iii ii 1 � J 11 i 5 14 Revised 03/01/2023 Bites and Envenomations RM P e a r I 1,,,,,,xain,r� Meiifla�� SIMUS, Sk�Ill. "x1rein,iiiiiies ocalJoin Of IllljUiry),, aind a coixip��ele Nec�k, U III I g �eairl. Xodoixiein, 3a6k, aind NeUiro exaixii ��f sysleiivi�Ic effects aire noted • Human bites have higher infection rates than animal bites due to normal mouth bacteria. • Carnivore bites are much more likely to become infected and all have risk of Rabies exposure. • Cat bites may progress to infection rapidly due to a specific bacteria (Pasteurella multicoda). • Poisonous snakes in this area are generally of the pit viper family: rattlesnake and copperhead. • Coral snake bites are rare: Very little pain but very toxic. "Red on yellow- kill a fellow, red on black-venom lack." • Amount of envenornation is variable, generally worse with larger snakes and early in spring. If no pain or swelling, envenornation is unlikely. About 25 % of snake bites are "dry" bites. • Black Widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may develop (spider is black with red hourglass on belly). • Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle shape on back). • Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound. • Immunocompromised patients are at an increased risk for infection: diabetes, chemotherapy, transplant patients. • Consider contacting the Florida Poison Control Center for guidance (1-800-222-1222). Revised 03/01/2023 Carbon Monoxide I Cyanide! ..............."I'l""I'll""I'll'll""I'll""I'll",'ll""I'll""I'll'll""I'll""I'll""I'll""I'll",'ll""I'll""I'llI.................................................................................................................................................................................... I"I I""""'A"0"Y S I S ,J • Smoke inhalation 9 AMS + Diabetic related « Ingestion of cyanide • Malaise,weakness, flu like illness Infection • Eating large quantity of fruit pits I • Dyspnea • MI • Industrial exposure • GI Symptoms; N/V; cramping • Anaphylaxis • Trauma I • Dizziness 0 Renal failure/dialysis problem • Reason: Suicide, criminal, • Seizures • Head injury/trauma accidental 0 Syncope • Co-ingestant or exposures • Past Medical History • Reddened skin • Time/Duration of exposure • Chest pain Immediately Remove from Exposure Appropriate ��1111111011 Diabetic Protocol E Hi h Flow Ox en •��110-1 9 Y9 if indicated Blood Glucose Analysis Procedure Spinal Immobilization Protocol 1��,��, Appropriate )1 PAM 1:.III ruuuuum Trauma PfOt0001(S) if indicated if indicated E 12 Lead ECG Procedure / P IV Procedure 10 Procedure %i Cardiac Monitor Continue Care Adequate Continue High Flow Oxygenation Ventilation YES Oxygen Monitor and Reasses NO j E..Appropriate Airway Protocol(s) as indicated High Suspicion II��,',m Hydroxocobalamin 70 mg/kg of Cyanide YES IV/10 Maximum 5 gm if available NO jJ SBP<90 Appropriate Age Specific VS YES 1°' Hypotension/Shock SBP< 70+(2 x Age in years) ; Protocol Poor Perfusion NO Continue Care %-- Continue High Flow Oxygen Monitor and Reasses Notify Destination or Contact Medical Control ccouimuuimucu,,mdcd cxaixi IY eUllimo Slll uium, II Illeai 1, III ruumg%, Xodoixiein, II x1rein,iiiJes Sccine safely uis Il rmloui liil.y Use CO iumuiou,fliii.ouimuiung dsviiicc„ Il cuim CO III'dou,,fliiiouimiiiing II)uimoccdUire„ liif avauiWl lllc Consider CO and Cyanide with any product of combustion • Normal environmental CO level does not exclude CO poisoning. Symptoms present with lower CO levels in pregnancy, children and the elderly. „ Continue high flow oxygen regardless of pulse ox readings. � r J r 1 5 6 Revised 03/01/2023 Drowning 1 Submersion Injury ...................................................................................................................................................................................................................................................................................................... ;.Jry , • Submersion in water regardless • Unresponsive • Trauma of depth • Mental status changes • Pre-existing medical problem • Possible history of trauma ie: Decreased or absent vital signs • Pressure injury (diving) diving board • Vomiting 0 Barotrauma • Duration of immersion • Coughing, Wheezing, Rales, • Decompression sickness • Temperature of water or Rhonci,Stridor • Post-immersion syndrome possibility of hypothermia • Apnea • Degree of water contamination .............................................. _.............. Spinal Immobilization Procedure 111111�0 Consider if indicated " :_)q Hypothermia Protocol if indicated Mental Status Exam Z Awake and Alert Awake but with AMS Unresponsive j IR Age Apl5ropriate % Remove wet clothing °w;,� Airway Protocol(s) YES Pulse Dry/Warm Patient as indicated % i i Monitor and Reassess Age Appropriate NO k'� Altered Mental Status Protocol Encourage transport as indicated � and evaluation even if Remove wet clothing Exit to / asymptomatic E Dry/Warm Patient Age Appropriate Asymptomatic near- Cardiac/Pulseless "RE", P IV Procedure 10 Procedure r drowning victims Arrest and/or should be observed 4 P Cardiac Monitor Arrhythmia to 6 hours for Protocol(s) development of symptoms Dyspnea/ Wheezing %! IV Procedure Y S if indicated /r,, ,,,,, Cardiac Monitor NO if indicated i Age g Appropriate Dyspnea/ Respiratory j Wheezing YES Distress Protocol(s) NO Monitor and Reassess Notity uesAination or Contact Medical Control 11cicoinine% nda*d II ai II rauina Survey, IG,Ilklad, IINcldk, fflhest,AIbdoinclin, II,3cflvus, Il:tsolk, Il: tirelyflfles, Sll<uun, IlNeu iro unsuuu a*soaNIC?safe%td. IDirow nhi ng us s Ile*sdong cause%of de%a lli ai not ng v oulld be ure%scu e%irs. Allow all 11 urollsurlistafid toys ne%d and oa*urtof c1%d ura*souse%irs to ure%i aosa*snothns furoin aura%as of da nga*ur. W lla oolld vista%ir no to ne% Ilouaaot ura*suas6tatc1%sllll I lhesa* Ilaafle%ants Massa%an ui noun.*ssa*d olha nce%of su irvs vsll. • Have a high index of suspicion for possible spinal injuries Hypothermia is often associated with drowning and submersion injuries. • All victims should be transported for evaluation due to potential for worsening over the next several hours. • With pressure injuries (decompression/barotrauma), consider transport to or availability of a hyperbaric chamber. r r i i i 5 17 � ,..,.. RevisedHyperthermlia03/0101/202023 ........................... ..............."I'l""I'll""I'll'll""I'll""I'll",lI............... ......................................................................................................................................... ............... ..............."I'l""I'll""I'll'll""I'll""I.......................... I g I a. t,eJ„<.., D 11e,1 e,.. i,ia • Age,very young and old • Altered mental status/coma • Fever(Infection) • Exposure to increased temperatures • Hot, dry or sweaty skin • Dehydration and/or humidity • Hypotension or shock • Medications • Past medical history/Medications + Seizures 0 Hyperthyroidism(Storm) • Time and duration of exposure Nausea 0 Delirium tremens(DT's) • Poor PO intake, extreme exertion • Heat cramps, exhaustion, stroke • Fatigue and/or muscle cramping • CNS lesions or tumors Signs/Symptoms of Remove from heat source to Hyperthermia cool environment E Passive coolingmeasures Remove tight clothing Blood Glucose Analysis 11111100 Age Appropriate �w Diabetic Protocol Procedure if indicated Assess Symptom Sevent Y % f HEAT CRAMPS HEATSTROKE HEAT EXHAUSTION01, ,,,% Normal to elevated body temperature High body temperature, usually > 104 Elevated body temperature Warm, moist skin Hot, dry skin Cool, moist skin '0016 Weakness, Muscle cramping Hypotension,AMS/Coma Weakness,Anxious, Tachypnea 0/111, 12 PO Fluids as tolerated Active cooling measures Age Appropriate /„ E ® � Airway Protocol(s) // Monitor and Reassess E 12 Lead ECG Procedure as indicated j j P IV Procedure 10 Procedure Age Appropriate j 1 Altered Mental Status Protocol 0/11 h Cardiac Monitor as indicated Normal Saline Bolus Active cooling measures 0 f 500 ml.IV 10 Repeat to effect SBP>90 E 12 Lead ECG Procedure Maximum 2 L PEG:Bolus 20 mL/kg IV/10 IV Procedure 10 Procedure Repeat to effect Age appropriate P Cardiac Monitor ' SBP>_70+(2x Age inyears) Normal Saline Bolus %� r Maximum 60 mL/kg 500 mL IV fQ Repeat to effect SBP>90 Maximum 2 L Hypotension/ P PEG;Bolus 20 mL/kg IV/IU Poor perfusion % Repeat to effect Age appropriate SBP>_70+(2 x Age in years) YES Maximum 60 mL/kgEX it to NO Age Appropriate Seizure Activity uumi 0 :11 Hypotension/Shock/ YES Go to VALE Poor erfusion p Trauma Protocol(s) Seizure Protocol 1 as indicated NO Monitor and Reassess Notify Destination or Contact Medical Control rrr a r r 1 5 8 � ,..,.. Revised Hyperthermia 03/01/2023 J1 /11 % j moo/ l �1 Rcicoumuirne%nded II xsirmu: II'dc:intro Status, dll<un, a ngs, II14m*uuiro • Extremes of age are more prone to heat emergencies(i.e. young and old). Obtain and document patient temperature if able. Predisposed by use of:tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. Cocaine,Amphetamines, and Salicylates may elevate body temperatures. Sweating generally disappears as body temperature rises above 104' F(40'C). • Intense shivering may occur as patient is cooled. COOL SLOWLY! Heat Cramps consists of benign muscle cramping 2'to dehydration and is not associated with an elevated temperature. • Heat Exhaustion consists of dehydration, salt depletion, dizzyness, fever, mental status changes, headache, cramping, nausea and vomiting.Vital signs usually consist of tachycardia, hypotension,and an elevated temperature. Heat Stroke consists of dehydration,tachycardia, hypotension,temperature>104' F(40'C),and an altered mental status. i / 519 Revised H othw � m1a Frostbite' 03/01/2023 y p t:Jry g I :i S y,,<, D i'r ,� • Age,very young and old Altered mental status/coma • Sepsis • Exposure to decreased temperatures • Cold, clammy 0 Environmental exposure but may occur in normal temperatures • Shivering • Hypoglycemia • Past medical history/Medications • Extremity pain or sensory • CNS dysfunction • Drug use:Alcohol, barbituates abnormality Stroke • Infections/Sepsis • Bradycardia Head injury Length of exposure/Wetness/Wind Hypotension or shock Spinal cord injury chill „. .Signs/Symptoms of Remove wet clothing H othermia Yp Dry/Warm Patient and/or Frostbite Passive warming measures Blood Glucose Analysis 111111100 Age Appropriate _�� Diabetic Protocol Procedure if indicated Hypothermia/Frost Bite JSystemic HLocalized Cold Injuryypothermia „ Awake with/without AMS Age Unresponsive �� Monitor and Reassess Appropriate ��IJ Respiratory General Wound Care Respiratory Distress YESP Distress % E % % DO NOT Rub Skin to warm Protocol(s) 1111110 � INI DO NOT allow refreezing pion Age Appropriate ! Airway Protocol(s) YES Pulse j as indicated Age Appropriate NO , �°°�°W Altered Mental Status Protocol j : as indicated Exit to Active warming measures Age Appropriate Cardiac/ IN ,j E 12 Lead ECG Procedure Pulseless Arrest i th h d Arrhythmia P IV Procedure 10 Procedure an Protocols j j Cardiac Monitor See Pearls Normal Saline Bolus '�� g 500 mL IV/IQ Repeat to effect SBP>90 � Maximum 2 L PEG;Bolus 20 mL/kg IV/IQ Repeat to effect Age appropriate SBP>:70+(2 x Age in years) Maximum 60 mL/kg � Age Appropriate I�!!pUINI Hypotension/Shock or Consider Pain Multiple Trauma Protocol Management for p 9 as indicated Frostbite Monitor and Reassess Contact Medical Control i 2 5 0 Revised 03//01/2023 Hypothermia Frostbite 001 AI Use caution when using cold fluids with cold patients. Be sure fluids are above roam temperature. A, % , f% 11cicoirm ine%nded II xsirmu II'dcln[M Status, II Illmlart, II a ngs, Ibdoirnell, IGi�xtua*uuuuti�m* , Ildm�*situ NO PATIENT IS DEAD UNTIL WARM AND DEAD(Body temperature>_93.2 degrees F,32 degrees C.) Hypothermia categories: Mild 90—95 degrees F(32—35 degrees C) Moderate 82—90 degrees F(28—32 degrees C) Severe<82 degrees F (<28 degrees C) • Mechanisms of hypothermia: Radiation: Heat loss to surrounding objects via infrared energy (60%of most heat loss.) Convection: Direct transfer of heat to the surrounding air. Conduction: Direct transfer of heat to direct contact with cooler objects(important in submersion.) Evaporation:Vaporization of water from sweat or other body water losses. Contributing factors of hypothermia: Extremes of age, malnutrition, alcohol or other drug use. • If the temperature is unable to be measured,treat the patient based on the suspected temperature. CPR: Severe hypothermia may cause cardiac instability and rough handling of the patient theoretically can cause ventricular fibrillation. This has not been demonstrated or confirmed by current evidence. Intubation and CPR techniques should not be with-held due to this concern. Intubation can cause ventricular fibrillation so it should be done gently by most experienced person. Below 86 degrees F (30 degrees C)antiarrythmics may not work and if given should be given at reduced intervals.Contact medical control for direction. Epinephrine/Vasopressin can be administered. Below 86 degress F(30 degrees) pacing should not be done. Consider withholding CPR if patient has organized rhythm or has other signs of life.Contact Medical Control. If the patient is below 86 degrees F(30 degree C),defibrillate 1 time if defibrillation is required. Deferring further attempts until more warming occurs is controversial.Contact medical control for direction. Hypothermia may produce severe bradycardia so take at least 45 seconds to palpate a pulse. Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin. / 521 F Revised 03/01/2023 Blast Injuryf/ Inciden ....................................... --I- I fistoiry &gns and Syimptoiins D ffe iire ntlii laI • Type of exposure(heat, gas, • Burns, pain, swelling • Superficial (111 Degree) red - painful (Don't chemical) • Dizziness include in TBSA) • Inhalation injury • Loss of consciousness • Partial Thickness(2"d Degree) blistering • Time of Injury . Hypotension/shock • Full Thickness(3,d Degree) painless/charred • Past medical history/ • Airway compromise/distress could or leathery skin Medications be indicated by hoarseness/ • Thermal injury • Other trauma wheezing • Chemical—Electrical injury • Loss of Consciousness • Radiation injury • Tetanus/Immunization status • Blast injury Nature of Device:Agent/Amount. Industrial Explosion. Terrorist Incident. Improvised Explosive Device. Method of Delivery: Incendiary/Explosive Nature of Environment: Open/Closed. Distance from Device: Intervening protective barrier. Other environmental hazards, Evaluate for: Blunt Trauma/Crush Injury/Compartment Syndrome/Traumatic Brain Injury/Concussion/Tympanic Membrane Rupture/Abdominal hemorrhage or Evisceration, Blast Lung Injury and Penetrating Trauma. Sce na*Safe%td I tdu an l fy and'll i1age% II' afle%urnts I Il...osd and Co Wdi Asse%ssu°ncNint I""II'Mireati nee nt II nrouta* Accidental/ Thermal/Chemical/ Age Appropriate Explosions �`® � Thermal Burn/ Intentional (Pearls) Electrical or YES 99 Chemical and Electrical Burn Protocol a is ion Burn or Radiation Incident START/JumpSTART Exposure YES Protocol uu •� Triage Protocol 1 Y Z� Trauma Protocol Crush In ur YES Crush Syndrome 10 Adult/Pediatric Multiple Trauma Protocol "t if indicated t Adult/Pediatric Airway Protocol(s) '" as indicated �lll� P IV Procedure 10 Procedure if indicated if indicated P Cardiac Monitor if indicated Blast, Lung Injury YES Maintain Oxygen >_ /o p„n„^ Saturation 94 i' Adult/Pediatric Airway ��11111M Adult/Pediatric Pain Control Protocol Protocol(s) H,,,,,;1 as indicated if indicated Rapid Transport to appropriate destination ut, Notify Destination or Contact Medical Control 522 M1161 "u �� i n m I i�ililului� �I I i)eaid iiillluuuui • Types of Blast Iniurv: Primary Blast Injury: From pressure wave. Secondary Blast Injury: Impaled objects. Debris which becomes missiles/shrapnel. Tertiary Blast Injury: Patient falling or being thrown/pinned by debris. Most Common Cause of Death: Secondary Blast Injuries. Care of Blast Iniury Patients: • Blast Injury Patients with Burn Injuries must be cared for using the Thermal/Chemical/Electrical Burn Protocols. Use Lactated Ringers(if available)for all Critical or Serious Burns. • Blast Lung Iniurv: Blast Lung Injury is characterized by respiratory difficulty and hypoxia. Can occur(rarely)in patients without external thoracic trauma. More likely in an enclosed space or in close proximity to explosion. Symptoms: Dyspnea, hemoptysis, chest pain,wheezing and hemodynamic instability. Signs:Apnea,tachypnea, hypopnea, hypoxia, cyanosis and diminished breath sounds. p Air embolism should be considered and patient transported prone and in slight left-lateral decubitus position. Blast Lung Injury patients may require early intubation but positive pressure ventilation may exacerbate the injury, avoid A, hyperventilation. Air transport may worsen lung injury as well and close observation is mandated. Tension pneumothorax may occur requiring chest decompression. Be judicious with fluids as volume overload may worsen lung injury. Accidental Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials.- Evaluate scene safety to include the source of the blast that may continue to spill explosive liquids or gases. Consider structural collapse/Environmental hazards/Fire. Conditions that led to the initial explosion may be returning and lead to a second explosion. Patients who can,will attempt to move as far away from the explosive source. Intentional Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials. Greatest concern is potential threat for a secondary device. Evaluate surroundings for suspicious items: unattended back packs or packages, or unattended vehicles. It Il aflent(s) uslare Uunoolisouous ou tlllere% usl(are%D fstsllotd( ue%s), dui1 ng e%vMu aflon for sugns of Rota*: oolk tou,Will collyfli ng froin die% Il afle%nt(s), or if ut sllslpe%ars tll e% Il afle%nt(s) usl(are%D Ilyu ng on s Il solksge%lpaolk, ou Ili ut(Nin, DO IIdC II a°rlosa* tllie% Il alkNi nt(s) Il:tsoll<away and uu°ninc*duata*Ild and nolffy s Ilaw cli nfouroa*u°rya*i nt office:u. If there are no indications that the patient is connected to a triggering mechanism for a secondary device, expeditiously remove the patients)from the scene and begin transport to the hospital. Protect the airway and cervical spine, however, beyond the primary survey, care and a more detailed assessment should be deferred until the patient is in the ambulance. If there are signs the patient was carrying the source of the blast, notify law enforcement immediately and most likely,a law enforcement officer will accompany your patient to the hospital. Consider the threat of structural collapse, contaminated particles and/or fire hazards. 523 X Revised 03//01/2023 Chemical and Electrical Burn CiiStoir gns and Symptains ' IIC liitt ur rWi4l • Type of exposure(heat, gas, • Burns, pain, swelling • Superficial (15t Degree) red - painful (Don't chemical) • Dizziness include in TBSA) • Inhalation injury • Loss of consciousness • Partial Thickness(2"d Degree) blistering Time of Injury • Hypotension/shock « Full Thickness(3rd Degree) painless/charred • Past medical history/ • Airway compromise/distress could or leathery skin Medications be indicated by hoarseness/ • Thermal injury Other trauma wheezing • Chemical—Electrical injury Loss of Consciousness « Radiation injury • Tetanus/Immunization status • Blast injury Assure t hc1%IlnflcM Sou rc is Ildt l llls�s�dou s t Ilia xlponda rs. II Il Assure II aotlos duroa* IVO ol , oltsot vit� st �t � to to.ouudI Assess Burn/Concomitant Injury Severity �mm., Illllllllllluul "I",""""""",""I'll,""","",,I'll""Il'I'l""I'llI........... Minor Burn Serious Burn Critical Burn 5-15%TBSA 2"d/3rd Degree Burn <5%TBSA 2"d/3�d Degree Burn Suspected inhalation injury or requiring No inhalation injury, Not Intubated, intubation for airway stabilization Normotensive Hypotension or GCS 13 or Less GCS 14 or Greater (When reasonably accessible, transport to a Burn Center) p Cardiac Monitor Age Appropriate Cardiac Arrest/Pulseless Arrest/ Irrigate Involved Eyes)with Age Appropriate Arrhythmiap E Normal Saline for 15 minutes Eye Involvement Protocol(s) May repeat as needed I as indicated i E Flush Contact Area with Normal Saline for 15 minutes � f Identify Contact Points Jill IIIIIIIII Exit to p Age Appropriate ®" Thermal Burn Protocol F)eaidIIS 111ec i nlrn eindod III xaiwn Il e nq.xll Sq.xq:uux Ill "II"`, Il oxll, ILllearil, IL..uulrngs,Albdoi ne n, Ili:xtrm^wnullbes, I1:3xxllk, and Il euuro • Green,Yellow and Red in burn severity do not apply to the Start/JumpStart Triage System. • Refer to Rule of Nines: Remember the extent of the obvious external burn from an electrical source does not always reflect more extensive internal damage. Chemical Burns: Refer to Decontamination Procedure. Normal Saline or Sterile Water is preferred,however if not available,do not delay irrigation using tap water. Other water sources may be used based on availability. Flush the area as soon as possible with the cleanest, readily available water or saline solution using copious amounts of fluids. * Electrical Burns: DO NOT contact patient until you are certain the source of the electrical shock is disconnected. Attempt to locate contact points,generally there will be two or more;a point where the patient contacted the source and a point(s)where the patient was grounded.Sites will generally be full thickness. Do not refer to them as entry and exit sites or wounds. Cardiac Monitor:Anticipate ventricular or atrial irregularity including VT,VF,atrial fibrillation and/or heart blocks. Attempt to identify then nature of the electrical source(AC/DC,)the amount of voltage and the amperage the patient may have been exposed to during the electrical shock. 524 Revised 03/01/2023 Crush Syndrome Trauma I fistoiry �&Igns and Spiriptoiin IDC Iffeiren li4I • Entrapped and crushed under • Hypotension + Entrapment without crush syndrome heavy load >30 minutes • Hypothermia . Entrapment without significant crush • Extremity/body crushed • Abnormal ECG findings Altered mental status • Building collapse,trench • Pain collapse, industrial accident, • Anxiety pinned under heavy equipment Scene _ Age Appropriate Safe YES sa Airway Protocol(s) NO as indicated T IV Procedure 10 Procedure Call for help/additional Normal Saline Bolus 1 L then 500 mL/hr IV/ID Hypotension/ resources Peds:20mlIIV/to then 3x Entrapped > 1 hour Stage until scene safe maintenance fluid rate E 12 Lead ECG Procedure Cardiac Monitor Normal Saline Bonus - P 1L IV/10 Peds:20 mL/kg IV/IU Abnormal ECG/ Hemodynamically unstable IIIIIIIIIIIIIII i, U T Waves Y S 12 seconds YSNOAsystole/PEA—> 6 seconds Immediately Prior to Ex#rication VF/VTf P wave Sodium Bicarbonate YES YES 50 mEa IV/If) qP Peds:1 mEg/kg IV/to Sodium Bicarbonate Sodium Bicarbonate SO mEq IV/to 50 mEq,IV/ID TPeds:1 mEq/kg IV'/IU h Peds:1mEq/kg IV/to P Calcium Chloride 1 gm Calcium Chloride 1 gm IV/I© Peds:20 mg/kg IV/ID Ill/ID Peds:20 mg/kg Over 3 minutes IV/IQ Over 3 minutes Fentanyl 50-75 mcg IV/ID Albuterol 2.5-,5mg Nebulizer Peds:1 mcg/kg IV/IQ ulp **OR** Peds:Maximum bolus 50 mg Repeat Xopenex 1.25'mg 25 mcg(Peds:1 mcg/kg)every 20 Maximum 200 mcg Exit to Repeat X3 PRN minutes as needed. Age Appropriate Cardiac Arrest/Pulseless Arrest/ Arrhythmia Protocol(s) Midazolam 0.5-2 mg IV/10 as indicated C � onsider 1-2 mg IN But do NOT utilize any Age Appropriate Multiple Maximum 5 mg ACLS medications in Trauma Protocol Peds:0.1-0.2 mg/kg IV/10 traumatic arrest. 0.2 mg/kg IN Hypothermia/Hyperthermia � Protocol(s) Maximum 2 mg as indicated Slowly over 2-3 minutes as needed, R Monitor and Reassess Monitor for fluid overload Notify Destination or Contact Medical Control 525 Revised 03/01/2023 Crush Syndrome, Trauma ............ llllllllllu III • Crush syndrome is a localized crush injury with systemic manifestations.These systemic effects are caused by a traumatic rhabdomyolysis(muscle breakdown)and the release of potentially toxic muscle cell components and electrolytes into the circulatory system.Crush syndrome can cause local tissue injury,organ dysfunction,and metabolic abnormalities,including acidosis,'hyperkalemia,and hypocalcemia Albuterol lowers the elevated potassium levels in the bloodstream that characterize hyperkalemia by pushing potassium back into cells, eaids 04 11cicoirm ine%nded m*xsirmu: II'dcl%n[sll Status, II'duuscsllosllrmfle%tM, IdeWro • Scene safety is of paramount importance as typical scenes pose hazards to rescuers. Call for appropriate resources. • Avoid Ringers Lactate IV Solution due to potentially worsening hyperkalemia • Hyperkalemia from crush syndrome can produce ECG changes described in protocol, but may also present with a bizarre,wide complex rhythm. Wide complex rhythms should also be treated using the VF/Pulseless VT Protocol. • Patients may become hypothermic even in warm environments. Pediatric IV Fluid maintenance rate: (4 mL/first 10 kg of weight+2 mL/second 10 kg of weight+ 1 mL for every additional kg). s m s s s 526 Revised Extremity03/01/2023 Trauma I°°fliisfoiry Siiigns and Syrapfourrns DliiffeirerWi4 • Type of injury « Pain, swelling • Abrasion • Mechanism: crush/penetrating/ « Deformity • Contusion amputation • Altered sensation/motor function • Laceration • Time of injury • Diminished pulse/capillary refill 0 Sprain • Open vs. closed wound/fracture • Decreased extremity temperature • Dislocation Wound contamination • Fracture • Medical history « Amputation Medications Serious Signs/Symptoms YES Hypotension, Poor perfusion Age Appropriate o , Multiple Trauma Protocol Wound care Hypotension/Shock Control Hemorrhage with Pressure Protocol(s) u Splinting as required as indicated E Consider 111111HIM i Topical Hemostatic Agent/Dressing ®11°°° if f available' III Bleeding Controlled by NO -< y YES Direct Pressure/Dressings Wound Care- Monitor and Reassess Tourniquet Procedure Age Appropriate Pain Protocol 111111100 Age Appropriate Pain Protocol if indicated mmw �� 1 i0 Procedure f indicated 0 if indicated IV Procedure IV Procedure 10 Procedure if indicated if indicated if indicated Clean amputated part, Wrap t' part in sterile dressing soaked in normal saline and place in Amputation YES E air tight container. YES Amputation CEPlace container on ice if NO available. NO Notify Destination or Contact Medical Control I')saids fccouiruuirucu,,mdcd Il,,xain'r' IIMeiiff4 Sf.m IUS, II;lxfrcluri.ii1y, IINeU111m0 « Peripheral neurovascular status is important. « In amputations, time is critical. Transport and notify medical control immediately, so the appropriate hospital can be determined. Hip dislocations and knee and elbow fracture/dislocations have a high incidence of vascular compromise. • Urgently transport any injury with vascular compromise. Blood loss may be concealed or not apparent with extremity injuries. « Lacerations must be evaluated for repair within 6 hours from the time of injury. « Multiple casualty incident: Tourniquet Procedure may be considered FIRST instead of direct pressure. �� s � s s„ s llllllli, 527 Revised Selective Spiral Immobilization 03/01/2023 tli"'y Circumstances warrant spinal immobilization consideration ovemegnt s sufficient spiinalm motion Entry from appropriate protocol limited to a stretcher move p restriction. E Neuro Exam:Any focal deficit, or loss of Yes Selective Spinal Immobilization control of any body functions? Procedure No E Significant mechanism of injury Yes Selective Spinal Immobilization With clinical indication of Spinal Injury? Procedure No Alertness:Acute alteration in mental st�Uturys]-- No Selective Spinal Immobilization E with a mechanism indicative of Spinal Injury. Yes Procedure uu p Ik E Intoxication:Any evidence Yes Selective Spinal Immobilization With a mechanism indicative of Spinal Injury? Procedure III No Distracting Injury:Any painful injury E that might distract the patient from the pain of Yes Selective Spinal Immobilization a spinal injury without clinical indication of Procedure spinal injury IIIIIII IIIIII No Spinal Exam: Point tenderness a^� E over the spinous process(es)or Yes Selective Spinal Immobilization f' pain to ROM? Procedure No IIIIIIIIIII Mechanism of Injury indicative of Cervical Spine Selective Spinal Immobilization E Yes Procedure t Injury without clinical indication of Spinal Injury oceuu r. No E Isolated Penetrating Head and/or Neck Trauma Yes Spinal Immobilization Not Required No E Spinal Immobilization Exit to Not Required "' appropriate protocol 528 Revised 03/01/2023 Selective Spinal Immobilization I Jill' F)eaids * �1cicoinine%ndc:d �:::xaim� 'Acln[M Status, &<�n, Ne6k, klart, ungs,Xbdoincln, a6k, E:xtircliYflUes, Neuiro 11111h:, * Consider immobilization in any patient with arthritis, cancer, dialysis or other underlying spinal or bone disease. * The decision to NOT implement spinal immobilization in a patient is the responsibility of the paramedic solely. * In very old and very young,a normal exam may not be sufficient to rule out spinal injury. * Significant mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes and may indicate the need for spinal immobilization in the absence of symptoms. * Range of motion should NOT be assessed if patient has midline spinal tenderness. Patient's range of motion should not be assisted. The patient should touch their chin to their chest, extend their neck(look up), and turn their head from side to side without spinal process pain. The acronym "NSAIDS"should be used to remember the steps in this protocol. .IN" = Neurologic exam. Look for focal deficits such as tingling, reduced strength, on numbness in an extremity. 'IS" =Significant mechanism or extremes of age. "A" =Alertness. Is patient oriented to person, place,time, and situation?Any change to alertness with this incident? "I" = Intoxication. Is there any indication that the person is intoxicated, impaired decision-making ability (alcohol, drugs?) I'D" = Distracting injury. Is there any other injury producing significant pain in this patient?Any injury which the patient seems to focus on and rate 6 or greater on the pain scale is likely distracting. 'IS" =Spinal exam. Look for point tenderness in any spinal process or spinal process tenderness with range of motion. Each of the 7 cervical spinal processes must be palpated during the exam. Apply appropriate padding to fill voids especially in the elderly, very young and III or obese patients. F529 Revised Unsafe Provider Environment 03/01/2023 To provide optimum care and safety to all providers and patients in the unsafe setting, use the acronym WARCH eXfiltrate the area ove satiieiiit auiimd i eXtract the patient to a 0. youirsq::. Ito a sq:�cuire safe location .aaii . uim Tourniquet for extremities Massive Hemorrhage Hemostatic agent for torso E See Procedures for direction King airway for unstable Airway airways without a gag reflex NPA for positive gag reflex IF Respirations avM Fluid replacement as Circulation indicated for symptomatic hypovolemia/hypotension Head Assess Neurological Deficit Hypothermia Cover patient for warmth Tertiary Treatment Exit to the appropriate treatment protocol IIIIII LIM IIIIII1�17� `w PEARLS Good Medicine is bad tactics ` Good Tactics is bad medicine You cannot provide good patient care in an unsafe position,the patient must be moved to an area that provides both cover and concealment and the medic can provide the appropriate care This is to be used in the tactical environment as well as when any provider encounters an environment that is unsafe for the patient and ` or the provider 530 noa om fl IIIIIIIIIIII i w ��IIII IIIIIIIIIIIIIII IIIIIIIIIIIIIIII IIIIIIIII IIIIII�IIIII�IIIIII��IIII IIIIIIIIIIIIIIIII �lllllllllnl �IIIIIIIIIIIIII Clinical Indications: Suspected cardiac patient 0 Suspected tricyclic overdose E EMT E Electrical injuries • Syncope Paramedic Procedure: 1. Assess patient and monitor cardiac status. 2. Administer oxygen as patient condition warrants. 3. If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after treatment, perform a 12 Lead ECG. 4. Prepare ECG monitor and connect patient cable with electrodes. 5. Enter the required patient information (patient name, age, etc.) into the 12 lead ECG device. 6. Expose chest and prep as necessary. Modesty of the patient should be respected. 7. Apply chest leads and extremity leads using the following landmarks: RA - Right arm • LA - Left arm ` RL - Right leg /llrr f ;fr LL - Left leg • V1 - 4t" intercostal space at right sternal border « V2 - 4t" intercostal space at left sternal border 1 , • V3 - Directly between V2 and V4 • V4 - 5t" intercostal space at midclavicular Tine W1r° �11r, 0 V5 - Level with V4 at left anterior axillary Tine V6 - Level with V5 at left midaxillary line �li 8. Instruct patient to remain still. 9. Press the appropriate button to acquire the 12 Lead ECG. 10. If the monitor detects signal noise, patient motion or a disconnected electrode, the 12 Lead acquisition will be interrupted until the noise is removed. 11. Once acquired, transmit the ECG data to the appropriate hospital. 12. Contact the receiving hospital to notify them that a 12 Lead ECG has been sent. 13. Monitor the patient while continuing with the treatment protocol. 14. Download data as per guidelines and attach a copy of the 12 lead to the ACR. 15. Document the procedure, time, and results on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II II. III III II. II.II.II.II.II.II. IIIIIIIIIIIIII�II 531 au mow u IIII room, IIII�I IIII� IIIIIIIII IIII��IIIIIIIIII Illlllllllllllla� IIII IIIIIIIIIII� IIIIIIIIIIIIIIIIIIIII� Clinical Indications for Blind Insertion Airway Device (BIAD) Use: • Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport distances that require a more advanced airway. • Incubation is impossible due to patient access or difficult airway anatomy. • Inability to secure an endotracheal tube in a patient who does not have a gag reflex and at least one failed incubation attempt has occurred. • Patient must be unconscious. E EMT E Procedure: 1. Pre-oxygenate and hyperventilate the patient. Paramedic 2. Select the appropriate tube size for the patient. 3. Lubricate the tube. 4. Grasp the patient's tongue and jaw with your gloved hand and pull forward. 5.Gently insert the tube and rotate laterally, 45-90 degrees so that the blue orientation line is touching the corner of the mouth. Once the tip is at the base of the tongue, rotate the tube back to midline. Insert the airway until the base of the connector is in line with the teeth and gums. 6. Inflate the pilot balloon with 45-90 mL of air depending on the size of the device used. 7.Ventilate the patient while gently withdrawing the BIAD until the patient is easily ventilated. 8. Auscultate for breath sounds and sounds over the epigastrium. Look for chest rise and fall. 9. The large pharyngeal balloon secures the device. 10. Confirm tube placement using end-tidal COs detector. 11 III°t lilu stiroingIILy irecoirnirncinded °tlllivat tlll,,iio auiui a of ogauillpirncin°t uiu a auIllaIlh ll4e Ilh e rnoinurtoired uoui 6111 uousll tlll°°iuuiou III,°i a11pino ira11p1[,ii allLoui u' llliu III ulllse Oxuiiilietiry 12. It is strongly recommended that an Airway Evaluation Form should be completed with use of any BIAD. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II. III II. II.II.II II.II.II. a au . w Vl IIIIIIIIIIIIII�I 532 Blind Insertioneirwav nevi .ertea without the IIII � ow Illl�s � Illl�s Clinical Indications for Continuous Positive Airway Pressure (CPAP) use: • Patients with inadequate ventilation, not associated with Asthma, are candidates for the use of CPAP. Inadequate ventilation could be as a result of pulmonary edema, pneumonia, COPD, etc. Clinical Contraindications for Continuous Positive Airway Pressure (CPAP) Use: • Facial features or deformities that prevent an adequate mask seal. • Excessive respiratory secretions. Procedure: 1. Ensure adequate oxygen supply to ventilation device. 2. Explain the procedure to the patient. P Paramedic 3. Consider placement of a nasopharyngeal airway. 4. Place the delivery mask over the mouth and nose. Oxygen should be flowing through the device at this point. 5. Secure the mask with provided straps starting with the lower straps until minimal air leak occurs. 6. If the Positive End Expiratory Pressure (PEEP) is adjustable on the CPAP device adjust the PEEP beginning at 0 cmH20 pressure and slowly titrate to achieve a positive pressure as follows- * 3 — 5 cm H2O for COPD 0 5 — 10 cm H2O for Pulmonary Edema, Near Drowning, possible aspiration or pneumonia 7. Evaluate the response of the patient: Assess breath sounds, oxygen saturation, and general appearance. 8. Titrate oxygen levels to the patient's response. Many patients respond to low FIO2(30-50%). 9. Encourage the patient to allow forced ventilation to occur. Observe closely for signs of complications. The patient must be breathing for optimal use of the CPAP device. 10. Document time and response on patient care report (PCR). 11. Use with caution in patients that are determined to be hypotensive. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System, I I I I i I I m I .I I III�IIIIIII�� 534 �6, u,a� IIII IIIII�IIIIIIIIIIIIIII III IIII�IIIIIIIIIII Illllllnllll I��i IIII IIIIIIII�II� �� III IIIIIIIII III��I IIII IIIIIII aam �II�I��IIII� I@Iln III�II� IIIIIIIIIII aa�i IIIIIIIIIIIIII IuIIIII�IIIII IIII P�imn IIII IIIIIIIIIII� Illlllllnlllll IIII Clinical Indications: Paramedic • Failed Airway Protocol • Management of an airway when standard airway procedures cannot be performed or have failed in a patient > 12 years old. Procedure: 1. Have suction and supplies available and ready. 2. Locate the cricothyroid membrane utilizing anatomical landmarks. 3. Prep the area with an antiseptic swab. 4. Make a vertical incision through the skin, through the tissue to the depth of the tracheal cartridge, approx. 2 inches (1 inch superior and 1 inch inferior to the location of the cricothyroid membrane) 5. Make a horizontal stabbing incision through the membrane approx. 1/2 inches. As an alternative, forceps may be used to incise the membrane. 6. Use skin hook, tracheal hook, or gloved finger to maintain surgical opening. Insert thecuffed tube into the trachea. (Cric tube from the kit or a #6 endotracheal tube is usually sufficient). 7. Inflate the cuff with 5-10cc of air and ventilate the patient while manually stabilizing the tube. IIII of tlll,.io-c utaindaird auucuuurnei t °tculll°iuinuqucu °toir einsuii1ing tullh c III Illaucui oui t uiIIIIII uiunulllurtc uuauullltafloin, ull[°ieut ui se & tallllll, eind t dalll CO2 detcutoir, etc 9. Secure the tube. 10. If Available apply end tidal carbon dioxide monitor (Capnography) and record readings on scene, en route to the hospital, and at the hospital. 11. Document ETT size, time, result, and placement location by the centimeter marks either at the level of the patient's skin on PCR. Document all devices used to confirm initial tube placement and after each movement of the patient. 12. Consider placing an NG or OG tube to clear stomach contents after the airway is secured. 13. An Airway Evaluation Form should be completed with all advanced airway procedures. Certification Requirements: ,► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II. II.II.II.II.II.II. IIIIIIIIIIIIII�I� 535 IlQulll Illy"IIIII Q "'iii�, IIII "" Clinical Indications: • Patients meet clinical indications for oral incubation Contraindications: Paramedic • Two attempts with orotracheal incubation (utilize failed airway protocol) • Age less than eight (8) or ETT size less than 6.5 mm Procedure: 1. Prepare, position and oxygenate the patient with 100% oxygen. 2. Select proper ETT, test cuff and prepare suction. 3.Lubricate the distal end and cuff of the ETT and the distal 1/2 of the Endotracheal Tube Introducer (Bougie). NOTE: Failure to lubricate the Bougie and the ETT may result in being unable to pass the ETT. 4. Using laryngoscopic techniques, visualize the vocal cords. 5. Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized. 6.Once inserted, gently advance the Bougie until you meet resistance. If you do not meet resistance, you have a probable esophageal insertion. Re-attempt tracheal insertion or use the failed airway protocol as indicated. 7.Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie. 8.Gently advance the Bougie and loaded ETT until you have resistance. This helps ensure tracheal placement and minimizes the risk of accidental displacement of the Bougie. 9.While maintaining a firm grasp on the proximal Bougie, introduce the ETT over the Bougie passing the tube to its appropriate depth. 10. If you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn the bevel of the ETT posteriorly. If this technique fails to facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the ETT. This will require an assistant to maintain the position of the Bougie so the ETT can be advanced. 11. Once the ETT is correctly placed, hold the ETT securely and remove the Bougie. 12.Confirm tracheal placement according to the incubation protocol. Inflate the cuff with 3 to 10 cc of air, auscultate for equal breath sounds and reposition accordingly. 13.When final position is determined secure the ETT, reassess breath sounds, apply EtCO2 monitor, and record and monitor readings to assure continued tracheal incubation. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II. I II.II.II.II.II.II.II. Illlllllllllum 536 iruiw w, IIIII�IIIIIIIIIIIIIII IIII IIIIIIIIIIIIII IIIIIIIIn01111 mom IIII IIIII �Ihlln IIII �IIIII�IIIII IIII lu000w IIII IIIIIIIIIIIII� �Illllllnll �IIIIIIIIII ��I�II�I Illlnll�nl IIIII�II� II��I(IIII �I�I�IIIII IIIIIIIII II��I III Illl�lln� IIIIIIIII IIII E EMT E Clinical Indications: Paramedic +► Sudden onset of respiratory distress often with coughing, wheezing, gagging, or stridor due to a foreign-body obstruction of the upper airway. Procedure: 1. Assess the degree of foreign body obstruction: +► Do not interfere with a mild obstruction. Encourage the patient to clear their own airway by coughing. +► In severe foreign-body obstructions, the patient may not be able to make a sound. The victim my clutch his/her neck in the universal choking sign. 2. For an infant, deliver 5 back blows (slaps) followed by 5 chest thrusts repeatedly until the object is expelled or the victim becomes unresponsive. 3. For a child, perform a subdiaphragmatic abdominal thrust (Heimlich Maneuver) until the object is expelled or the victim becomes unresponsive. 4. For adults, a combination of maneuvers may be required. • First, subdiaphragmatic abdominal thrusts (Heimlich Maneuver) should be used in rapid sequence until the obstruction is relieved or victim becomes unresponsive. • If abdominal thrusts are ineffective, chest thrusts should be used. Chest thrusts should be used primarily in morbidly obese patients and patients who are in the late stages of pregnancy. 5. If the victim becomes unresponsive, begin CPR immediately but look in the mouth before administering any ventilations. If a foreign-body is visible, remove it. 6. Do not perform a blind finger sweep in the mouth and posterior pharynx. This may push the object farther into the airway. 7. In unresponsive patients, EMT-Intermediate and EMT-Paramedic level professionals should visualize the posterior pharynx with a laryngoscope to potentially identify and remove the foreign-body using Magil forceps. 8. Document the methods used and result of these procedures on the PCR. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. III III II. II.II.II.II.II.II. IIIIIIIIIIIIII�I� 537 um E EMT E Clinical Indications: • The EtCO2 detector shall be used with any ETT or BIAD use. Paramedic Coin"flinuous Calpinogiralpl['IiyHHI Ilh e used IIIIn III 114auc of oir IIIIn a lufllolin o ° Ill,'llic use of ally 1111 d ii'i'dalll etec olir Procedure: 1. Attach EtCO2 detector to the BIAD or the ETT. 2. Note color change: A color change or CO2 detection will be documented on each respiratory failure or cardiac arrest patient. 3. The CO2 detector shall remain in place with the airway and monitored throughout the prehospital care and transport unless continuous Capnography is used. Any loss of CO2 detection or color change is to be documented and monitored as procedures are done to verify or correct the airway problem. 4. Tube placement should be verified frequently and always with each patient move or loss of color change in the End-Tidal CO2 detector or Capnography. 5. Document the procedure and the results on the PCR and complete the Airway Evaluation Form. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II.II.II. IIIIIIIIIIIIIII�� 538 V Clinical Indications: Paramedic w A spontaneously breathing patient in need of incubation due to inadequate respiratory effort, evidence of hypoxia, carbon dioxide retention, or the need for airway protection. • Rigidity or clenched teeth prohibiting other airway procedures. • Patient must be > 12 years of age. Procedure: 1. Pre-medicate the patient with nasal spray. 2.Select the largest and least obstructed nare and insert a lubricated nasal airway to help dilate the nasal passage. 3. Pre-oxygenate the patient. Lubricate the tube. 4.Remove the nasal airway and gently insert the tube keeping the bevel of the tube toward the septum. 5.Continue to pass the tube listening for air movement and looking for condensation in the tube. As the tube approaches the larynx, the air movement gets louder. 6.On inspiration, gently and evenly advance the tube through the glottic opening. This facilitates passage of the tube and reduces the incidence of trauma to the vocal cords. 7.Upon entering the trachea, the tube may cause the patient to cough, buck, strain, or gag. Do not remove the tube! This is normal, but be prepared to control the cervical spine and the patient, and be alert for vomiting. 8.Auscultate for bilateral, equal breath sounds and absence of epigastrium sounds. Observe for symmetrical chest expansion. The 15mm adapter usually rests close to the nare with proper positioning. 9. Inflate the cuff with 5-10 cc of air. 10. Confirm tube placement using EtCO2 monitoring. 11. Secure the tube. 12.Reassess airway and breath sounds after transfer to the stretcher and during transport. These tubes are easily dislodged and require close monitoring and frequent reassessment. 13. Document the procedure, time, and result on the PCR. 1 [iuo auiirway WHHL Ilh e rnoinurtoired uoui furinaouaIIL l III°io- a114 ui o uia114 Illiu aind I aIlluc Oxuuiilietiry 15. An Airway Evaluation Form will be completed. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIIIIIIIII�� 539 I im VW ' ur iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillilliiiiiiiiiiiiiiiilllll�illillillillillillilliillillillillillillilliillillillillilliillillillillillillillilIIIIII IIII IIII VIIII IIII IIIIIIIIIIIII IIII ��IIII�� IIII IIIIII�� Ililll ilulinil� lfllll�� lulllll ��IIII�� llllnllllnl� � Inllli� �� nllllin Illolilll ��IIII�� filllll Ifiiinlil� Clinical Indications: 11111 T Paramedic • Inability to adequately ventilate a patient with a BVM or longer EMS transport distances require a more advanced airway. • An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort. • A component of Drug Assisted Incubation Procedure: 1. Prepare, position and oxygenate the patient with 100% Oxygen. 2. Select proper ETT and stylette (if used) and have suction ready. 3. Using laryngoscope, visualize vocal cords. 4. Limit each incubation attempt to 30 seconds using BVM in between attempts. 5. Visualize tube passing through vocal cords. 6.Confirm and document tube placement using an EtCO2 monitoring. Record readings on scene, en route to the hospital and at the hospital. 7. Inflate the cuff with 3-to10 cc of air; secure the tube. 8.Auscultate for bilateral, equal breath sounds and absence of epigastrium sounds. If you are unsure of placement, remove tube and ventilate patient with BVM. 9. Consider using a Blind Insertion Airway Device if incubation efforts are unsuccessful. 10. Document ETT size, time, result and placement location by the centimeter marks either at the patient's teeth or lips on the PCR. Document all devices used to confirm initial tube placement. Also document positive or negative breath sounds before and after each movement of the patient. 11.Consider placing an NG or OG tube to clear stomach contents after the airway is secured with an ETT. 12 Il [,iuo auiirway u °t Ilh e urnoinuitoired uoui fluilaouaIIL tlll°iuiroa IIIo- a11pino hall Il[,iu aind III','° aIlluc 13. An Airway Evaluation Form must be completed. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II.II.II.II.II.II. IIIIIIIIIIIIII�� 540 um IIIO II IIIU n III .................................................................... Clinical Indications: +► Patients experiencing bronchospasm. Paramedic Procedure: 1. Gather the necessary equipment. 2. Assemble the nebulizer kit. 3. Instill the premixed drug (such as Albuterol or other approved drug) into the reservoir well of the nebulizer. 4. Connect the nebulizer device to oxygen at 4 - 6 liters per minute or adequate flow to produce a steady, visible mist. 5. Instruct the patient to inhale normally through the mouthpiece of the nebulizer. The patient needs to have a good lip seal around the mouthpiece. 6. The treatment should last until the solution is depleted. Tapping the reservoir well near the end of the treatment will assist in utilizing all of the solution. 7. Monitor the patient for medication effects. This should include the patient's response to the treatment along with reassessment of vital signs, ECG, and breath sounds. 8. Assess and document peak flows before and after nebulizer treatments. 9. Document the treatment, dose, and route on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIIIIIIIII�� 541 IIIII� IIIII IIII IIIIVIIIIIIII IIIIIIIIIIIII � IIII Illllllllll ll�l��n IIII�I�O� JNI�II IIII IIII IIII��IIII IIII IIIII IIII IIIII��II� IIhI IIIII�IIIh IIII II��IIII IIII III IIIIIII IIIIIIIII Clinical Indications: w Transport of an incubated patient Paramedic Procedure: 1. Confirm the placement of tube as per airway procedure. 2. Ensure adequate oxygen delivery to the respirator device. 3. Preoxygenate the patient as much as possible with bag-valve mask. 4. Remove BVM and attach tube to respiration device. 5. Per instructions of device, set initial respiration values. For example, set an inspiratory-expiratory ratio of 1.4 (for every 1 second of inspiration, allow 4 seconds for expiration) with a rate of 12 to 20. 6. Assess breath sounds. Allow for adequate expiratory time. Adjust respirator setting as clinically indicated. IIII uiu uircgWired °IIII°iva° Ill aflein.ts oin a tuirains� l oir ein'fl 4' ouir Ill e urnoinu ouirc oin'flinuou 111 u fl,io- a 11pin o uira 114 I[,iu a in d III'' a Ill uc Oxuiiirnetiry [,iu c o ui fl Ill a° o uir rate a III iu ou Ill d Ilh e adjusted "to uirnauiintaurin a 114 a Ill uc oxuiinietiry of >90 W iuHle iiirnauiiiii"tauiiiiiuiiiiig a pCO2 0°�°3 35ui m ui Illh°°IH 8. If there is a dramatic change (lowering) of 02 saturation, consider malfunction in respirator. Remove the respirator and utilize BVM for ventilation. 9. Document time, complications, and patient response on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II II.II. IIIIIIIIIIIIII�� 542 IIII�IIIIIIIIIIIIIII IIII IIII�IIIIIIIIIIII IIIIII�IIIII I�� IIII I�IIIII�IIIII Illl��il� Illlll�lln IIIIIII IIII Il�lln IIII IIII Ili IIIIIIII�� IIII�IIIIIIIIIIIIIIII IIIIIIIII0111 IIIIIII IIIIII�IIIIII IIIIIII Illllllllln Illlllllll� IIIIIIIIIIIIIII Clinical Indications: Paramedic • Obstruction of the airway secondary to secretions, blood, or any other foreign body/ substance. Utilized in a patient currently being assisted by an airway adjunct such as a naso- tracheal tube, ETT, tracheostomy tube, or a cricothyrotomy tube. Procedure: 1. Ensure suction device is in proper working order. 2. Pre-oxygenate the patient as well as possible. 3. Attach suction catheter to suction device, keeping sterile plastic covering over catheter. 4.Measure the depth desired for the catheter (judgment must be used regarding the depth of suctioning with cricothyrotomy and tracheostomy tubes). 5. If applicable, remove ventilation device from the airway. 6. With the thumb port of the catheter uncovered, insert the catheter through the airway device. 7.Once the desired depth (measured in #4 above) has been reached, occlude the thumb port and remove the suction catheter slowly. 8. A small amount of Normal Saline (10 mI) may be used to loosen secretions for suctioning. 9. Reattach ventilation device (e.g., bag-valve mask) and ventilate the patient 10. Document time and result on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. IIIII III IIIIIIII II. I I II.II.II.II.II. Illlllllllllll�l� 543 �6, Q lug IIII h � IIIIIIIUIi IoWm IIII�IIIIIIIIIIIIIIII IIII IIII II IIIIII�IIIII IIIIII�IIIII ��n IIII hII�IIIIIII II�IIIICIIII��I�I�IIn II�IIII III �Illllllllnl IIII IIII IIII �� m �� Illlllllllllln IIIIIIIII�IIIII Illllllln IIII Illlllllllln E EMT E Clinical Indications: T Paramedic + Obstruction of the airway secondary to secretions, blood, or any other foreign body/substance in a patient who cannot maintain or keep the airway clear. Procedure: 1. Ensure suction device is in proper working order with suction tip in place. 2. Preoxygenate the patient as is possible. 3. Explain the procedure to the patient if they are coherent. 4. Examine the oropharynx and remove any potential foreign bodies or material which may occlude the airway if dislodged by the suction device. 5. If applicable, remove ventilation devices from the airway. 6. Use the suction device to remove any foreign substance(s). 7. The alert patient may assist with this procedure. 8. Reattach ventilation device (e.g., BVM) and ventilate or assist the patient. 9. Record the time and result of the suctioning on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. �II II II. IIIII III IIIIIIII II.II. I I II.II.II.II.II.II. IIIIIIIIIIIIII�II 544 III IIIII IIIIII�IIII III�IIIIII IIIIIII �IIIIIIIII IIIIIIII�Illlnlll IIIIII mmoo III IIII�IIIIIIIIIIIIII IIII IIIIIIIIIIIIII IIIIIIII�III i��l IIII IIII IIII I n�IIIIIIIIIIII Illln III III IIII ��IIIIII IIIIIIIIIII� IIIII II IIIIIII III L... � IIIIII Clinical Indications: • Presence of Tracheostomy site. Paramedic • Urgent or emergent indication to change the tube, such as obstruction that will not clear with suction. Dislodgement or inability to oxygenate/ventilate the patient without other obvious explanation also includes need for change. Procedure: 1.Have all airway equipment prepared for standard airway management, including equipment of orotracheal incubation and failed airway. 2.Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (e.g., if the patient has a #6.0 Shilley, then have a 6.0 and a 5.5 tube). 3. Lubricate the replacement tube(s) and check the cuff. 4.Remove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to pre-oxygenate the patient as much as possible. 5.Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages. 6. If applicable, deflate the cuff on the tube. If unable to aspirate air with a syringe, cut the balloon off to allow the cuff to lose pressure. 7. Remove the tracheostomy tube. 8. Insert the replacement tube. Confirm placement via standard measures except for esophageal detection which is ineffective for surgical airways. 9. If there is any difficultly placing the tube, re-attempt procedure with the smaller tube. 10. If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal incubation (as per protocol). More difficulty with tube changing can be anticipated for tracheostomy sites that are immature — i.e., less than two weeks old. Great caution should be exercised in attempts to change immature tracheotomy sites. 11. Document procedure, confirmation, patient response, and any complications on the PCR. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment for this skill should include direct observation at least once per certification cycle. II II IIIII III III IIIII II.ii I I II.II.II.II.II.II. IIIIIIIIIIIIII�II 545 um VW ' ur �11 QQ Ilb IIII All, uw IIII�IIIIIIIIIIIIIIII IIII IIII�II(IIIII IIIII Illlll�lllll I11M mill IIII IIII (IIII 1111111111111111h�lln�lll IIII Illl�ln IIIII Ilhllfl�lll� �I� IIII Illlll�llll III�III��Illl�l�ll IIII�� Clinical Indications: Paramedic w Management of a patient during a prolonged or interfacility transport that is on a ventilator. Procedure: 1.Transporting personnel should review the operation of the ventilator with the treating personnel (physician, nurse, or respiratory therapy) in the referring facility prior to transport if possible. 2.All ventilator settings, including respiratory rate, FiO2, mode of ventilation, and tidal volumes should be recorded prior to initiating transport. Additionally, the recent trends in oxygen saturation should be noted. 3.Prior to transport, specific orders regarding any anticipated changes to ventilator settings as well as causes for significant alarm should be reviewed with the referring medical personnel and medical control. 4. Once in the transporting unit, confirm adequate oxygen delivery to the ventilator. 5. Frequently assess breath sounds to assess for possible tube dislodgment during transfer. 6.Frequently assess the patient's respiratory status, noting any decreases in oxygen saturation or changes in tidal volumes, peak pressures, etc. 7. Note any changes in ventilator settings or patient condition in the PCR. 8. Consider placing an NG or OG tube to clear stomach contents. 3 luo auiirway i must Ilh e uoin'flinuousll ui oinutoire u' 111°,iu a114 ui o uia114 IIIiu aind I ullluo Oxurirnetiry 10. If any significant change in patient condition, including vital signs or oxygen saturation or there is a concern regarding ventilator performance/alarms, remove the ventilator from the endotracheal tube and use a BVM with 100% 02. Contact medical control immediately. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. IIIII III III IIIII II. I I II.II.II.II.II.II. IIIIIIIIIIIIII�I� 546 �I m%W idµ i6 a%YM1. mll4i ApN �I rvn � v � lu " uA� tlP "u N1N@ '"Vflllu IIVN" w �� IIII II�III� � � IIIIIIIIII� � �� II�IIII��IIIIIIIIIIII�IIIIIII�I IIIIIIIIII� II�IIII�II IIII �� IIIII � � �� IIIII�II� �� IIII II�IIIII� �� III�I�� IIIIIII�I IIIIIIIIIII Clinical Indications: Paramedic +► Transport of a patient with an existing arterial line. Procedure: 1. With invasive monitoring unavailable, ensure the Arterial Line is secured. 2. The pressure bag must be inflated, and secured to the arterial line. 3. Disconnect the ECG monitoring line from the hospital monitor. 4. Place the IV pressure bag with solution on the stretcher IV pole. 5. Ensure the transferring RN has witnessed and has approved the transport of the Arterial Line. 6. Document this procedure with the sending RN name in your EPCR. *Do n i use Hie ailer�4i Il�ne for rnini lr llion of any Hdds or rne6catlons. Dislodgement of Arterial Line: 1. If there is dislodgement of the arterial line and bleeding results, remove the line and apply direct pressure over the site for at least 5 minutes before checking to ensure hemostasis. 2. If bleeding persists, continue direct pressure and reassess after 5 minutes. Inadequate hemostasis can facilitate hematoma formation with subsequent vessel occlusion, limb ischemia or fistula formation. 3. Direct pressure is required until bleeding has stopped. 4. Apply a "simple" pressure dressing using gauze sponge(s) and coban. Monitor continuously for bleeding. 5. Minimize limb movement for at least one hour post removal. Ensure limb site is visible in order to promptly detect bleeding. 6. Monitor for hematoma or bleeding. Assess distal extremity and monitor for decreased circulation, change in limb color or delay in capillary refill q 5 minutes X 30 minutes, then q 30 minutes X 2 then q 1 h X 4. Reapply pressure if bleeding present. 7. Document removal, treatment and follow-up assessment in EPCR. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Ilpl';"" IIIIIIII II IIII • II I II.II.II.II.II. IIIIIIIIIIIIII�� 547 mn ulm, dnn a �Im mm ,fl6, �IIIV WIW"e 4AW I� " �� III��IIIIII�I III�IIIIIIIIIIIIII Illl�lllllnl nlllllll �� I�� IIIIII�I� � �� IIIIIII IIII IIII�IIIIIIIIIIIIIIII IIIIIIII�IIIII IIIIIIIIIIIIII IIII IIIIIIII E EMT E Clinical Indications: Paramedic +► Any patient requesting a medical evaluation that cannot be measured with the Broselow- Luten Resuscitation Tape. Procedure: 1.Ensure scene safety and no environmental hazards are present as well as ensuring by- stander safety. Don universal precautions and assess for the need of additional resources. 2. Initial assessment includes: General Impression and a quick assessment of the patient's Airway, Breathing and Circulation. 3. Obtain patient's initial AVPU and GCS. 4. Control any major hemorrhage and assess overall priority of patient. 5. Perform a focused history and physical based on patient's chief complaint. 6. Assess the need for critical interventions and complete critical interventions identified. 7.Perform a complete secondary exam to include a baseline set of vital signs as directed by protocol. 8.Maintain an on-going assessment throughout transport; to include patient response to interventions, need for additional interventions, and assessment of evolving patient complaints/conditions. 9.Document all findings and information associated with the assessment, performed procedures, and any administration of medications on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. IIIIIII II I II.II.II.II.II.II. IIIIIIIIIIIIII�� 548 ur V W ➢➢ I um � �' � l IIII Clinical Indications: • Any patient with pain. E EMT E Definitions: • Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Paramedic • Pain is subjective (whatever the patient says it is). Procedure: 1. Initial and ongoing assessment of pain intensity and character is accomplished through the patient's self report, physical assessment and physiological responses to described pain. 2. Pain should be assessed and documented on the PCR during initial assessment, before starting pain control treatment, and with each set of vitals. 3. Pain should be assessed using the appropriate approved scale. 4. Three pain scales are available- the 0 — 10, the Wong - Baker "faces", and the FLACC._ • 0 — 10 Scale: The most familiar scale used by EMS for rating pain with patients. It is primarily for adults and is based on the patient being able to express their perception of the pain as related to numbers. Avoid coaching the patient; simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever. • Wong — Baker "FACES" scale- This scale is primarily for use with pediatrics but may also be used with geriatrics or any patient with a language barrier. The faces correspond to numeric values from 0-10. This scale can be documented with the numeric value. 0 2 4 6 8 10 No hurt Hurts little Hurts little Hurts evert Hurts whole Hurts worst bit more more lot From Hockenberry MJ,Wilson D,Winkelstein ML:Wong's Essentials of Pediatric Nursing,ed.7,St. Louis,2005,p. 1259. Used with permission. Copyright, Mosby. • FLACC scale- This scale has been validated for measuring pain in children with mild to severe cognitive impairment and in pre-verbal children (including infants). C�#f EGG1R'TES SCORING -0--------------------�-&�--------------I-----------------------------------------------2------------------------- FACE Mo particular expression siionai grimace or Frequent to constant or smile crown, withdrawn, quivering chin, clenched jaw. d i si r terested. LEGS Normal posiition or uneasy,restless,tense'. Kiclking, or legs drawn up. retoxed. ................................................................................................................................................................................................. ACTIVITY Lying quietly, normal Sgluirm,ing,shifting back and ,arched, rigid orjerlking. Ipositiion moves easily. forth,tense. CRY No cry„(awake or Moans or whiimpers„ Crying steadily,screams or asleep) occasional comp W0 nt soos,frequent complaints. CONSOLABILITY Content,relaxed. Reassured by occasional Difficulty to console or t:o.,hlriq hugging or being comfort talked to, distractablie. CertificationRequirements:................................................................................................................................................................................................................................................................................................................................ • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II II II IIIII III IIIIIIII II. II.II.II.II.II.II. IIIIIIIIIIIIII�II 549 q, liuwinui 'u n p IIII Ui anu u iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillilliillillillillillillillillilliillillillillillillilliillillillillillillilliillillillillillillillilli�MlI�iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiI(IIIIIIII IIII�IIIII IIIIIIII IIII�IIIIIIIII Illnllllllll �� IIIIIIII � � IIIIIIII (III IIII IIIIIIII IIIIIIII�IIII IIII IIIIIIIIIIIII IIIIIIII IIII IIII�IIIIIIIIIIiiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillillillillillillilillillillillillillilliillillillillillillilliillillilillir Clinical Indications: +► Any child that can be measured with the I El EMT E Broselow-Luten Resuscitation Tape. Paramedic Procedure: 1. Ensure scene safety and no environmental hazards are present as well as ensuring by- stander safety. Don universal precautions and assess for the need of additional resources. 2. Assess patient using the pediatric triangle: • Airway and appearance: speech/cry, muscle tone, inter-activeness, look/gaze, movement of extremities • Work of breathing: absent or abnormal airway sounds, use of accessory muscles, nasal flaring, body positioning • Circulation to skin: pallor, mottling, cyanosis 3. Establish spinal immobilization if suspicion of spinal injury. 4. Establish responsiveness appropriate for age (AVPU, GCS, etc.). 5. Utilize an approved pediatric color measuring tape to color code the patient. 6. Perform a more focused disability assessment: Pulse, motor function, sensory function, papillary reaction. 7. Perform a focused history and physical exam. Recall that pediatric patients easily experience hypothermia and thus should not be left uncovered any longer than necessary to perform an exam. 8. Record vital signs (BP > 3 years of age, cap refill < 3 years of age) 9. Include Immunizations, Allergies, Medications, Past Medical History, last meal, and events leading up to injury or illness when appropriate. 10. Treat chief complaint as per protocol Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. I II II II. (IIII III IIIIIIII II. II.II.II II.II.II. IIIIIIIIIIIIII�II 550 iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillillilillillillillillillilliillillillillillillilliillillillillillillilliillillililllillillillillI IIIIIIIIIIIIII� IIII��I�IInI IIIII�II Illlllnlll �hIIIII�� IIII I�Illnllllll �IIIIIIIII� IIIIII�II� Illlllllln IIIIIIII� IIII ��IIIIII IIIIII lll�nl�llll IIII II�� IIII�Ill�llln Clinical Indications: +► Patients with suspected hypoglycemia (diabetic emergencies, change in mental status, bizarre behavior, etc.) E EMT E Procedure: Paramedic 1. Gather and prepare equipment. 2. Blood samples for performing glucose analysis can be obtained through a finger-stick or when possible, simultaneously with intravenous access. 3. Place correct amount of blood on reagent strip or site on glucometer per the manufacturer's instructions. 4. Time the analysis as instructed by the manufacturer. 5. Document the glucometer reading and treat the patient as indicated by the analysis and protocol. 6. Repeat glucose analysis as indicated for reassessment after treatment and as per protocol. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. II II II II.II IIIII III IIIIIIII II. II.II.II.II II.II.II. IIIIIIIIIIIIII�II 551 n„ I�IIII�IIIIII� h�III�IIII��✓NI��I IIIIIII��IIII�II m�� I�III�IIII�� I�IIII�� E EMT E Clinical Indications: Paramedic • Capnography will be used (when available) in conjunction with the use of all invasive airway procedures. This includes ETT, nasotracheal, cricothyrotomy, or BIAD. • Capnography should also be used when possible with CPAP. Procedure: 1. Attach capnography sensor to the BIAD, ETT, or oxygen delivery device. 2. Note CO2 level and waveform changes. These will be documented on each respiratory failure, cardiac arrest, or respiratory distress patient. 3. The capnometer shall remain in place with the airway and be monitored throughout pre- hospital care and transport. 4. Any loss of CO2 detection or waveform indicates an airway problem and should be immediately corrected and documented. 5. The capnogram should be monitored as procedures are performed to verify or correct the airway problem. 6. Document the procedure and results on the PCR and complete the Airway Evaluation Form. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II II.II.II. IIIIIIIIIIIIII�� 552 ur V" m VW ' ur IIIIIIIII�� P11111111111181111ii, IIII IIIIIIIn01111 IIIIIIIII� III IIIIIIIIIIIIIIIIII IIIII��IIIIIII III �II�IIIII IIII III��IIII hIIIIIIIIIIII IIIII IIIIII�� l�lllnlllllll Ill�n IIII IIIIIIII�� Clinical Indications: Paramedic +► Patients with symptomatic bradycardia (heart rate < 60/minute) with signs and symptoms of inadequate cerebral or cardiac perfusion such as: Chest Pain + Hypotension • Pulmonary Edema, Respiratory distress Altered Mental Status, Syncope, etc. Ventricular escape beats Procedure: 1. Attach standard four-lead monitor. 2. Apply pacing pads to chest. • One pad to right upper chest below clavicle • One pad to lower, left border of rib cage. 3. Rotate selector switch to pacing option. 4. Adjust heart rate to 70 BPM for an adult and 100 BPM for a child. 5. Note pacer spikes on EKG screen. 6. Slowly increase output until capture of electrical rhythm on the monitor. 7. If unable to capture while at maximum current output, stop pacing immediately. 8. If capture observed on monitor, check for corresponding pulse and assess vital signs. 9. Consider the use of sedation or analgesia if patient is uncomfortable. 10. Document the dysrhythmia and the response to external pacing with ECG strips on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II.II.II II.II.II. IIIIIIIIIIIIII�� 553 �W � miw V�' V mUu miw Clinical Indications: • Basic life support for the patient in cardiac arrest E EMT E Procedure: 1. Assess the patient's level of responsiveness (shake and shout) Paramedic 2. If no response, open the patient's airway with the head-tilt, chin-lift and look, listen, and feel for respiratory effort. If the patient may have sustained C-spine trauma, use the modified jaw thrust while maintaining immobilization of the C-spine. For infants, positioning the head in the sniffing position is the most effective method for opening the airway. 3. Check for pulse (carotid for adults and older children, brachial for infants) for at least 10 seconds. If no pulse, begin chest compressions based on chart below: Vull III UU III miil�� IIIII„�1Il,,,,1,,ll III IIIIII IIIII IIIIII IIIII IIIIII IIIIIIII II I Over sternum, Infant between nipples 1.5 inches At least 100/minute (inter-mammary line), 2-3 fingers .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... Over sternum, just At least 100/minute Child cephalad from 2 inches (3 compressions xyphoid process heel of one hand Every 2 seconds) ........................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................... ........................................................................................................................................................................ Over sternum, just cephalad from At least 100/minute Adult xyphoid process, At least 2 inches (3 compressions hands with Every 2 seconds) interlocked fingers 4. If the patient is an adult, go to step 5. If no respiratory effort in a pediatric patient, give two ventilations. If air moves successfully, go to step 5. If air movement fails, proceed to the Airway Obstruction Protocol. 5. Go to Cardiac Arrest Protocol. Begin ventilations in the adult as directed in the Cardiac Arrest Protocol. 6. Provide 8 - 10 breaths per minute with the BVM. Use EtCO2 to guide your ventilations as directed in the Cardiac Arrest Protocol. 7. Chest compressions should be provided in an uninterrupted manner. Only brief interruptions ( < 5 seconds with a maximum of 10 seconds) are allowed for rhythm analysis, defibrillation, and to perform procedure(s). 8. Document the time and procedure on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II. II.II.II. IIIIIIIIIIIIII�� 554 ��Illllllln Illln ��IIIIIII�� IIIIIIII III lllllllnl � IIIIIIIII� � IIIIIIII Clinical Indications: Paramedic • Unstable patient with a tachydysrhythmia (rapid atrial fibrillation, SVT, VT) • Patient is not pulseless. (The pulseless patient requires defibrillation.) Procedure: 1.Ensure the patient is attached properly to a monitor/defibrillator that is capable to perform synchronized cardioversion. 2.Have all equipment prepared for unsynchronized cardioversion/defibrillation if the patient fails synchronized cardioversion and the condition worsens. 3. Consider the use of pain or sedating medications. 4. Set energy selection to the appropriate setting. 5. Set monitor to synchronized cardioversion mode. 6. Make certain all personnel are clear of patient. 7.Press and hold the shock button to cardiovert. Stay clear of the patient until you are certain the energy has been delivered. NOTE: It may take the monitor several cardiac cycles to "synchronize", so there may a delay between activating the cardioversion and the actual delivery of energy. 8.Note patient response and perform immediate defibrillation if the patient's rhythm has deteriorated into pulseless ventricular tachycardia/ventricular fibrillation. Follow the procedure for defibrillation. 9. If the patient's condition is unchanged, repeat steps 2 to 8 above, using escalating energy settings. 10. Repeat until maximum setting is reached or until efforts succeed. Consider discussion with medical control if cardioversion is unsucessful after 2 attempts. 11. Note procedure, response, and time on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle or other mechanisms as deemed appropriate by the local EMS System. II.II.II II.II.II. . IIIIIIIIIIIIIII�� 555 iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillillilillillillillillillilliillillillillillillilliillillillillillillilliillillililllillillillillI �Illlll��nl �III�I�I IIIIII�I�II �� III�III� IIII�hll� Clinical Indications: Paramedic w Patients with hypotension (SBP <90), clinical signs of shock, and at least one of the following signs: Jugular vein distention. + Tracheal deviation away from the side of the injury (often a late sign). • Absent or decreased breath sounds on the affected side. • Hyper-resonance to percussion on the affected side. • Increased resistance when ventilating a patient. • Patients in traumatic arrest with chest or abdominal trauma for whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above. Procedure: 1. Don personal protective equipment (gloves, eye protection, etc.). 2. Administer high flow oxygen. 3. Identify and prep the site: Locate the second ICS in the mid-clavicular line on the effected side. • If unable to place anteriorly, lateral placement may be used at the fourth ICS mid-axillary line. w Prepare the site with providone-iodine ointment or solution. 4. Insert the catheter (14 gauge for adults) into the skin over the third rib. Direct the catheter just over the top of the rib (superior border) into the interspace. 5. Advance the catheter through the parietal pleura until a "pop" is felt and air or blood exits under pressure through the catheter. Advance catheter to chest wall. 6. Remove the needle, leaving the plastic catheter in place. 7. Secure the catheter hub to the chest wall with dressings and tape. 8. Attach a three-way stop cock to the catheter hub to allow for purging. 9. Alternative to step #8, consider placing a finger cut from an exam glove over the catheter hub. Cut a small hole in the end of the finger to make a flutter valve. Secure the glove finger with tape or a rubber band. (Note — DO NOT waste time preparing the flutter valve; if necessary control the air flow through the catheter hub with your gloved thumb.) Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation once per certification cycle. II.II.II II.II.II. IIIIIIIIIIIIII�� 556 u IIIII� IIIIIIIIIIII IIII��IIII IIII IIII IIIIIIIIIIIIII III�IIII� IIII IIIIIIIIII IIII��IIII Clinical Indications: E EMT ME+► Imminent delivery with crowning Paramedic Procedure: 1.Delivery should be controlled. This allows a controlled delivery of the infant and this will prevent injury to the mother and infant. 2. Support the infant's head as needed. 3.Check the umbilical cord to ensure it is not surrounding the neck. If it is present, slip it over the head. If unable to free the cord from the neck, double clamp the cord and cut between the clamps. 4. Suction the airway with a bulb syringe. 5.Grasping the head with hands over the ears, gently pull down to allow delivery of the anterior shoulder. 6. then gently pull up on the head to allow delivery of the posterior shoulder. 7. Slowly deliver the remainder of the infant. 8. If no previous cord issues, clamp the cord 2 inches from the abdomen with 2 clamps and cut the cord between the clamps. 9. Record APGAR scores at 1 and 5 minutes post delivery. 10. Follow the Newly Born Protocol for further treatment. 11.The placenta will deliver spontaneously, usually within 5 minutes of the infant. Do not force the placenta to deliver. 12. Massaging the uterus may facilitate delivery of the placenta and decrease bleeding by facilitating uterine contractions. 13. Continue rapid transport to the hospital. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II II.II.II. IIIIIIIIIIIIIII�� 557 um Clinical Indications: Paramedic +► Presence of an epidural catheter in a patient requiring transport Procedure: 1. Prior to transport, ensure catheter is secure. Make certain transport personnel are familiar with medication(s) being delivered and devices used to control medication administration. 2. No adjustments in catheter position are to be attempted. 3. No adjustments in medication dosage or administration are to be attempted without direct approval from on-line medical control. 4. Report any complications immediately to on-line medical control. 5. Document the time and dose of any medication administration or rate adjustment on PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II I II. II II. II.II.II. IIIIIIIIIIIIIIIIIII�� 558 V W m VW W' II III iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillilliillillillillillillilliillillillillillillilliillillillillillillillillillillilliillillilillillillilff... ....... iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillilliillilI iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillillillilillillillillillillillillillilliillillillillillillilliillillilillillillillillilillillillillillililp E EMT E Clinical Indications: Paramedic Any patient who may have been exposed to significant hazardous materials, including: chemical, biological, or radiological weapons. Procedure: 1. In coordination with HAZMAT and other Emergency Management personnel, establish hot, warm and cold zones of operation. 2. Ensure that personnel assigned to operate within each zone have proper personal protective equipment. 3. In coordination with other public safety personnel, assure each patient from the hot zone undergoes appropriate initial decontamination. This is specific to each incident; such decontamination may include: • Removal of patients from Hot Zone • Simple removal of clothing • Irrigation of eyes • Passage through high-volume water bath (e.g., between two fire apparatus) for patients contaminated with liquids or certain solids. Patients exposed to gases, vapors, and powders often will not require this step as it may unnecessarily delay treatment and/or increase dermal absorption of the agent(s). 4. Initial triage of patients should occur after step #3. Immediate life threats should be addressed prior to technical decontamination. 5. Assist patients with technical decontamination (unless contraindicated based on #3 above). This may include removal of all clothing and gentle cleansing with soap and water. All body areas should be thoroughly cleansed. Overly harsh scrubbing can break the skin should be avoided. 6. Place triage identification on each patient. Match triage information with each patient's personal belongings which were removed during technical decontamination. Preserve these personnel affects for law enforcement. 7. Monitor all patients for environmental illness(-es). 8. Transport patients per local protocol to appropriate facility if possisible. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II II.II.II. IIIIIIIIIIIIII�� 559 iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillillilillillillillillillilliillillillillillillilliillillillillillillilliillillililllillillillillI�� II ��Inllllll� �� IIII �� IIIIIIII� IIIII�� Illllfllill IIII �� IIIIIIII� IIIIII IIIIIIIII �� IIIIIIIIII��IIIII IIIIIII IIIIII�I�� Clinical Indications: • Patients in cardiac arrest (pulseless, non-breathing). E EMT E • Age < 8 years, use Pediatric Pads if available. Contraindication: Paramedic +► Pediatric patients who are so small that the pads cannot be placed without touching one another. Procedure: 1.If multiple rescuers are available, one rescuer should provide uninterrupted chest compressions while the AED is being prepared for use. 2.Apply defibrillator pads per manufacturer recommendations. Based on 2010 guidelines, place pads preferably in AP or AL position when implanted devices (pacemakers, AICDs) occupy preferred pad positions. Avoid placing directly over device if possible. 3. Remove any medication patches on the chest and wipe off any residue. 4.If necessary, connect defibrillator leads: white to the anterior chest pad and the red to the posterior chest pad. 5. Activate AED for analysis of rhythm. 6.Stop CPR and clear the patient for rhythm analysis. Keep interruption in CPR as brief as possible. 7.Defibrillate if appropriate by depressing the "shock" button. Assertively state "CLEAR" and visualize that no one, including yourself, is in contact with the patient prior to defibrillation. The sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic defibrillators will determine the correct joules accordingly. 8.Begin CPR (chest compressions and ventilations) immediately after the delivery of the defibrillation. 9.After 2 minutes of CPR, analyze rhythm and defibrillate if indicated. Repeat this step every 2 minutes. 10. If "no shock advised" appears, perform CPR for two minutes and then reanalyze. 11. Transport and continue treatment as indicated. 12.Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation. 13. If pulse returns, use the Post Resuscitation Protocol. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II.II.II.II.II.II. IIIIIIIIIIIIII�� 560 �� IIIIIIII�I � ��IIIII I� � � �� Illlln �Illln ��IIIII � �� IIII IIIIIII�IIIIIIIII IIIIIIIIIIIII IIII��IIII IIIIIIIIIIIII IIIIIIIn01111 IIII Paramedic Clinical Indications: • Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia Procedure: 1.Ensure that Chest Compressions are adequate and interrupted only when absolutely necessary. 2. Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation. 3.After application of an appropriate conductive agent if needed, apply defibrillation hands free pads (recommended to allow more continuous CPR) or paddles to the patient's chest in the proper position • Pads: right of sternum at 2nd ICS (just below clavical) and anterior axillary line at 5th ICS For patients with implanted pacers/defibrillators, paddles or pads can be in AP or AL positions. The presence of implanted pacers/defibrillators should not delay defibrillation. Attempt to avoid placing paddles or pads directly above device. 4. Set the appropriate energy level 5.Charge the defibrillator to the selected energy level. Continue chest compressions while the defibrillator is charging. 6.Hold Compressions, assertively state, "CLEAR" and visualize that no one, including yourself, is in contact with the patient. 7.Deliver the countershock by depressing the discharge button(s) when using paddles, or depress the sl[,iIo6k h u°tfoin for hands free operation. 8.Immediately resume chest compressions and ventilations for 2 minutes. After 2 minutes of CPR, analyze rhythm and check for pulse only if appropriate for rhythm. 9. Repeat the procedure every two minutes as indicated by patient response and ECG rhythm. 10.Keep interruption of compressions as brief as possible. Adequate CPR is a key to successful resuscitation. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II. IIIII III IIIIIIII II. I I II.II.II.II.II.II. IIIIIIIIIIIIII�I� 561 IIIIIIIIII ' 'WNII wµµ.ai pWNW I PoAM'• �� III �WI YYWP W PoN Q� IIIIIIIIIIIIII� ��II�I�� III�Inlflll Ill�ll�n III�III�IIIII IIII�I�III I@I�II� IIII��IIIII �lllll�ln IIIIIIII I�III��I��IIIIIII�� IIIIIIIIIIIIIIIIII IIIII�IIIIII III�III III�I��IIII IIIIIIII III�II�IIII IIII IIIIIIIIIII� III�I�� III IIII IIl�lll��l IIII IIII �� II�II�III III�I IIII�I�IIII�I IIII�IIIIIIIII Paramedic Clinical Indications: • Any patient who has persisted in ventricular fibrillation/tachycardia, without even transient interruption of fibrillation, as per the persistent VF/VT protocol. • At least one shock was delivered using different pads applied so as to produce a different current vector than the first set and all other indicated treatment modalities have been implemented. • A paramedic has verified the persistence of the arrhythmia immediately post-shock Procedure: 1. Ensure quality of CPR is not compromised during prolong efforts. 2. Prepare the sites for attachment of an additional set of external defibrillation pads by drying the sites and minimizing interference of hair or other obstacles to good pad adhesion. 3. Apply a new set of external defibrillation pads anterior and posterior as long as it does not appreciably interrupt compressions. If this is not possible then place a new set of pads adjacent to, but not touching the pad set currently in use. 4. Assure that controls for the second cardiac monitor are accessible to the code commander 5. The provider will verify that the resuscitation checklist has been fully executed 6. On rhythm check, the provider will confirm the rhythm a. If a shockable rhythm is detected, CPR will resume immediately. The enhanced care provider will verify that both cardiac monitors/defibrillators are attached to the patient, that all pads are well adhered, and direct the simultaneous charging of both attached cardiac monitors. When both monitors are charged to maximum energy and all persons are clear, the code commander or other paramedic will push both shock buttons as synchronously as possible. A brief rhythm/pulse check will occur and CPR will resume as appropriate. b. If a non-shockable rhythm is present, care will resume according to the appropriate protocol. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by NHT. Assessment should include direct observation at least once per certification cycle. IIIIIII II I II. I II. II II.II.II.II.II. IIIIIIIIIIIIII��I 562 ��llnllllllll�� lllllll�il Illnllllnll lillll�� Inlllll� �� IIIII il�lll IIIIIIIIII �� IIIIII� ��IIIIII � �Illln ��IIIII� � � Clinical Indications: Paramedic Gastric decompression in incubated patients or for administration of activated charcoal in patients with altered mental status. Procedure: 1. Estimate insertion length by superimposing the tube over the body from the nose to the stomach. 2. Flex the neck, if not contraindicated, to facilitate esophageal passage. 3. Liberally lubricate the distal end of the tube and pass through the patient's nostril along the floor of the nasal passage. Do not orient the tip upward into the turbinates. This increases the difficulty of the insertion and may cause bleeding. 4. In the setting of an incubated patient or patient with facial trauma, oral insertion of the tube may be considered or preferred after securing airway. 5. Continue to advance the tube gently until the appropriate distance is reached. 6. Confirm placement by injecting 20cc of air and auscultate for the swish or bubbling of the air over the stomach. Additionally, aspirate gastric contents to confirm proper placement. 7. Secure the tube. 8. Decompress the stomach of air and food by connecting the tube to suction or manually aspirating with the large catheter tip syringe. 9. Document the procedure, time, and result on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIIIIIIIII�� 563 Clinical Indications: Paramedic • When medication administration is necessary and must be administered as a primary or alternative route via the SQ or IM route(s). Il l,ilis does un l indude Hie use of an aulo... injector. Procedure: 1. Receive and confirm medication order or perform according to standing orders. 2. Prepare equipment and medication expelling air from the syringe. 3. Explain the procedure to the patient and reconfirm patient allergies. 4. The most common site for SQ injection is the arm. • Injection volume should not exceed 1 cc. 5. The possible injection sites for IM injections include the arm, buttock and thigh. • Injection volume should not exceed 1 cc for the arm • Injection volume should not exceed 2 cc in the thigh or buttock. 6.The thigh should be used for injections in pediatric patients and injection volume should not exceed 1 cc. 7. Expose the selected area and clean the injection site with alcohol. 8. Insert the needle into the skin with a smooth, steady motion SQ: 45 degree angle IM: 90 degree angle skin pinched skin flattened 9. Aspirate for blood 10. Inject the medication. 11. Withdraw the needle quickly and dispose of properly without recapping. 12. Apply pressure to the site. 13. Monitor the patient for the desired therapeutic effects as well as any possible side effects. 14. Document the medication, dose, route, and time on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II.II. IIIIIIIIIIIIII�� 564 III ' III V gum V V WIC E EMT E Clinical Indications: Paramedic +► Patients with suspected blood/fluid loss or dehydration with no indication for spinal immobilization. Orthostatic vital signs are not routinely recommended. • Patients > 8 years of age or patients larger than the Broselow-Luten tape • Orthostatic vital signs are not sensitive nor specific for volume loss/dehydration and may induce syncope in some cases. Assessment of orthostatic vital signs are not routinely recommended. Local Medical Director should indicate and educate on situations where they may be helpful. Procedure: 1. Gather and prepare standard sphygmomanometer and stethoscope. 2. With the patient supine, obtain pulse and blood pressure. 3. Have the patient sit upright. 4. After 30 seconds, obtain blood pressure and pulse. 5. If the systolic blood pressure decreases by 20 mmHg or the pulse increases by 20 bpm, the patient is considered to be orthostatic. 6. If a patient experiences dizziness upon sitting or is obviously dehydrated based on history or physical exam, formal orthostatic examination should be omitted and fluid resuscitation initiated. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II.II. IIIIIIIIIIIIII�� 565 �IIIIW � a unm IIII�� l�lllnllllll III Iliilil�� Il��lln IIIII�II�IIII IIIIIIIIIII III IIIIIII�III I��II III IIII �� Clinical Indications: w Patients with suspected hypoxemia. E EMT E Procedure: Paramedic 1.Apply probe to patient's finger or any other digit as recommended by the device manufacturer. 2. Allow machine to register saturation level. 3. Record time and initial saturation percent on room air if possible on PCR. 4. Verify pulse rate on machine with actual pulse of the patient. 5.Monitor critical patients continuously until arrival at the hospital. If recording aone-time reading, monitor patients for a few minutes as oxygen saturation can vary. 6.Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia. 7. In general, normal saturation is 97-99%. Below 94%, suspect a respiratory compromise. 8.Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the device. 9.The pulse oximeter reading should never be used to withhold oxygen. Patients in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain, should still receive oxygen. Supplemental oxygen is not required if the oxyhemoglobin saturation is > 94%, unless there are obvious signs of heart failure, dyspneic, or hypoxic to maintain to 94%. 10. Factors which may reduce the reliability of the pulse oximetry reading include but are not limited to: • Poor peripheral circulation (blood volume, hypotension, hypothermia) Excessive pulse oximeter sensor motion Fingernail polish (may be removed with acetone pad) Carbon monoxide bound to hemoglobin Irregular heart rhythms (atrial fibrillation, SVT, etc.) Jaundice Placement of BP cuff on same extremity as the sensor. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II II II IIIII III IIIIIIII II. II.II.II.II.II.II. IIIIIIIIIIIIII�II 566 F111111111111111111111111I IIIIIIIIIIII IIIIIII IIII IIIIIIIII011111 IIII IIII IIII IIIII IIIIIIIIIII IIII (IIII IIIIIII IIIIIIIIIIII IIII IIIIIIIIIIII (IIIIIIIIIIII IIII E EMT E Clinical Indications: Paramedic Any patient who may harm himself, herself, or others may be gently restrained to prevent injury to the patient or crew. This restraint must be in a humane manner and used only as a last resort. Other means to prevent injury to the patient or crew must be attempted first. These efforts could include reality orientation, distraction techniques, or other less restrictive therapeutic means. Physical and chemical restraint should be a last resort technique. Procedure: 1. Attempt less restrictive means of managing the patient. 2. Request law enforcement assistance and Cointact III' c ui all4 ointiii 6. 3. Ensure that there are sufficient personnel available to physically restrain the patient safely. 4. Restrain the patient in a lateral or supine position. No devices such as backboards, splints, or other devices will be on top of the patient. The patient will never be restrained in the prone position. 5. The extremities that are restrained will have a circulation check at least every 15 minutes. The first of these checks should occur soon after placement of the restraints. This MUST be documented on the PCR. 6. Documentation on the PCR should include the reason for the use of restraints, the type of restraints used, and the time restraints were placed. 7. If the above actions are unsuccessful or if the patient is resisting the restraints, consider administering medications per protocol. (Chemical restraint may be considered earlier.) 8. If a patient is restrained by law enforcement personnel with handcuffs or other devices EMS personnel can not remove, a law enforcement officer must accompany the patient to the hospital in the transporting EMS vehicle. 9. Physical restraints require the use of chemical restraints in conjunction. If the patient is managed with chemical restraints, physical restraints are not required. 10.The patient must be under constant observation by the EMS crew at all times. This includes direct visualization of the patient as well as cardiac and pulse oximetry monitoring. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II II II.�� IIIII III III IIIII II.II.II.II.II.II. IIIIIIIIIIIIIIIIIII�II 567 �III�II� IIIIIIIIII�I IIII ��I�IIIII �� III IIII�IIIIIIII ��IIII�IIII IIIII�� Ill�ill��l �� IIIIIIIIIIIIIII III��IIII IIIIII�� IIII�III IIIIIIIII Clinical Indications: w Need for spinal immobilization as determined by protocol E EMT I E Procedure: ffl-Paramedic 13 1. Gather a backboard, straps, C-collar appropriate for patient's size, tape, and head rolls or similar device to secure the head. 2. Explain the procedure to the patient 3. Place the patient in an appropriately sized C-collar while maintaining in-line stabilization of the C-spine. his stabilization, to be provided by a second rescuer, should not involve traction or tension but rather simply maintaining the head in a neutral, midline position while the first rescuer applies the collar. 4. Once the collar is secure, the second rescuer should still maintain their position to ensure stabilization (the collar is helpful but will not do the job by itself.) 5. Place the patient on a long spine board with the log-roll technique if the patient is supine or prone. For the patient in a vehicle or otherwise unable to be placed prone or supine, place them on a backboard by the safest method available that allows maintenance of in-line spinal stability. 6. Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is secured to the backboard, the second rescuer may release manual in-line stabilization. 7. NOTE: Some patients, due to size or age, will not be able to be immobilized through in-line stabilization with standard backboards and C-collars. Never force a patient into a non-neutral position to immobilize them. Such situations may require a second rescuer to maintain manual stabilization throughout the transport to the hospital. Special equipment such as football players in full pads and helmet may remain immobilized with helmet and pads in place. 8. Document the time of the procedure on the PCR. Certification Requirements: ,► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Ilpl';"" IIIIIIII II • II I II.II.II.II.II. IIIIIIIIIIIIII�� 568 �14n ;x reiw m mx ,ems �III�II�III lll�l�n IIII IIII�I�I �III�II� II�III�� IIII llll�lnl �IIII�II�III Ilnl�ll �� IIIIIIII III�II�IIII IIII �� IIIIIIIIII IIII�� Ill�il IIII �� IIIIIIIIIIIIIII Illl�n�llll III �� IIII� IIII��No Clinical Indications: w Need for selective spinal immobilization as determined by protocol Procedure: Paramedic 1. Gather a C-collar appropriate for patient's size, to maintain inline stabilization of the cervical spine. 2. Explain the procedure to the patient 3. Place the patient in an appropriately sized C-collar while maintaining in-line stabilization of the C-spine. This stabilization, to be provided by a second rescuer, should not involve traction or tension but rather simply maintaining the head in a neutral, midline position while the first rescuer applies the collar. 4. Once the collar is secure, the patient should be instructed to maintain their head in a still and midline position, not turning their head side to side. 5. Use of a short spine board or similar immobilization device may be warranted to facilitate the limitation of movement of the head and neck. 6. Document the time of the procedure on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIIIIIIIII�� 569 U� �IIIIIIIIIII ��✓NIIIIII IIII IIII IIIIIIII IIIIIII IIII IIII��IIII Pm� n E EMT E Clinical Indications: ff—P—aramedic • Immobilization of an extremity for transport, either due to suspected fracture, sprain, or injury. • Immobilization of an extremity for transport to secure medically necessary devices such as intravenous catheters Procedure: 1. Assess and document pulses, sensation, and motor function prior to placement of the splint. If no pulses are present and a fracture is suspected, consider reduction of the fracture prior to placement of the splint. 2. Remove all clothing from the extremity. 3. Select a site to secure the splint both proximal and distal to the area of suspected injury, or the area where the medical device will be placed. 4. Do not secure the splint directly over the injury or device. 5. Place the splint and secure with Velcro, straps, or bandage material (e.g., kling, kerlex, cloth bandage, etc.) depending on the splint manufacturer and design. 6. Document pulses, sensation, and motor function after placement of the splint. If there has been a deterioration in any of these 3 parameters, remove the splint and reassess. 7. If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, the following procedure may be followed for placement of a femoral traction splint: Assess neurovascular function as in #1 above. • Place the ankle device over the ankle. • Place the proximal end of the traction splint on the posterior side of the affected extremity, being careful to avoid placing too much pressure on genitalia or open wounds. Make certain the splint extends proximal to the suspected fracture. If the splint will not extend in such a manner, reassess possible involvement of the pelvis. + Extend the distal end of the splint at least 6 inches beyond the foot. « Attach the ankle device to the traction crank. Twist until moderate resistance is met. • Reassess alignment, pulses, sensation, and motor function. If there has been deterioration in any of these 3 parameters, release traction and reassess. 8. Document the time, type of splint, and the pre and post assessment of pulse, sensation, and motor function on the PCR. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II. I I II. II.II.II.II.II.II. IIIIIIIIIIIIII�I� 570 Iu �I U �i �� i IIIIIIIIIIII I�� I �UB �lllnlllll�� IIIII�I�� IIIIIIII �I �� IIIIIIII lnllllln� ��Ilflllli � Ilfnllll IIIIIIII �� IIII IIII�IIIIIIII IIIII IIIIIIIIIIIIIIIII IIII IIIIIIIIIIII IIIII IIIIIIIIIII�� IIII Clinical Indications: w Suspected Stroke Patient I E EMT I E Procedure: Paramedic 1. Assess and treat suspected stroke patients as per protocol. 2. The Miami Emergency Neurological Deficit (M.E.N.D.) exam will be used on any patient that presents with signs and symptoms of stroke. 3. Screen the patient for the following criteria: No history of a seizure disorder • New onset of symptoms in last 24 hours • Hypertension history • Blood glucose between 50-400 • No history of migraine headaches 4. The initial criterion consists of performing a patient exam looking for facial droop, inappropriate speech (slurring or inappropriate words) or unilateral arm weakness (arm drift). One of these exam components must be positive to answer "yes" on the screening unless disqualifier is noted. 5. Early notification to the Stroke Center is important. "Code Stroke" will be used to make proper activation of the Code Stroke team. Refer to appropriate protocol of guidelines. 6. Additional components of the MEND exam will be completed while enroute to the Stroke Center to include additional assessment of mental status, cranial nerves and limbs. 7. Proper documentation of findings to include MEND exam will be placed on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II II II IIIII III III IIIII II.II.II.II.II. IIIIIIIIIIIIII��I 571 IIIII IIIN IIIIIII �III��I�IIIIIIII�IIII Illllflll�lll III�I�II III III��IIIII III III��IIIIII III IIII��I III��IIIIIIIII��I��IIII IIII��IIII nl�I �II��IIIIII III �II��I� III�IIII�IIIIII Ill�lln IIIIIII null E EMT E Clinical Indications: Paramedic +► Monitoring body temperature in a patient with suspected infection, hypothermia, hyperthermia, or to assist in evaluating resuscitation efforts. Procedure: 1. For adult patients that are conscious, cooperative, and in no respiratory distress, an oral temperature is preferred (steps 3 to 5 below). For infants or adults that do not meet the criteria above, a rectal temperature is preferred (steps 6 to 8 below). 2. To obtain an oral temperature, ensure the patient has no significant oral trauma and place the thermometer under the patient's tongue with appropriate sterile covering. 3. Have the patient seal their mouth closed around thermometer. 4. If using an electric thermometer, leave the device in place until there is indication an accurate temperature has been recorded (per the "beep" or other indicator specific to the device). If using a traditional thermometer, leave it in place until there is no change in the reading for at least 30 seconds (usually 2 to 3 minutes). Proceed to step 9. 5. Prior to obtaining a rectal temperature, assess whether the patient has suffered any rectal trauma by history and/or brief examination as appropriate for patient's complaint. 6. To obtain a rectal temperature, cover the thermometer with an appropriate sterile cover, apply lubricant, and insert into rectum no more than 1 to 2 cm beyond the external anal sphincter. 7. Follow guidelines in step 5 above to obtain temperature. 8. Record time, temperature, method (oral, rectal), and scale (C° or F°) on PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. IIIIIII II I II. I II.II.II.II.II.II. IIIIIIIIIIIIII�� 572 Clinical Indications: III Paramedic w Transport of a patient with a central venous pressure line already in place Procedure: 1. Prior to transportation, ensure the line is secure. 2. Medications and IV fluids may be administered through a central venous pressure line. Such infusions must be held while the central venous pressure is transduced to obtain a central venous pressure, but may be restarted afterwards. 3. Do not manipulate the central venous catheter. 4. If the central venous catheter becomes dysfunctional, does not allow drug administration, or becomes dislodged, contact medical control. 5. Document the time of any pressure measurements, the pressure obtained, and any medication administration on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II.II. IIIIIIIIIIIIII��L 573 moon Clinical Indications: Paramedic o Inability to obtain adequate peripheral access. • Access of an existing venous catheter for medication or fluid administration. • Central venous access in a patient in cardiac arrest. Procedure: 1. Clean the port of the catheter with alcohol wipe. 2. Using sterile technique, withdraw 5-10 ml of blood and discard syringe in sharps container. 3. Using 5cc of normal saline, access the port with sterile technique and gently attempt to flush the saline. 4. If there is no resistance, no evidence of infiltration (e.g., no subcutaneous collection of fluid), and no pain experienced by the patient, then proceed to step 4. If there is resistance, evidence of infiltration, pain experienced by the patient, or any concern that the catheter may be clotted or dislodged, do not use the catheter. 5. Begin administration of medications or IV fluids slowly and observe for any signs of infiltration. If difficulties are encountered, stop the infusion and reassess. 6. Record procedure, any complications, and fluids/medications administered on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIII Illlllllli�� 574 moon Clinical Indications: Paramedic • External jugular vein cannulation is indicated in a critically ill patient > 8 years of age who requires intravenous access for fluid or medication administration and in whom an extremity vein is not obtainable. • External jugular cannulation can be attempted initially in life threatening events where no obvious peripheral site is noted. Procedure: 1. Place the patient in a supine head down position. This helps distend the vein and prevents air embolism. 2. Turn the patient's head toward the opposite side if no risk of cervical injury exists. 3. Prep the site as per peripheral IV site. 4. Align the catheter with the vein and aim toward the same side shoulder. 5. Lightly with one finger, apply slight pressure above the clavicle, causing a "tourniquet" effect, puncture the vein midway between the angle of the jaw and the clavicle and cannulate the vein in the usual method. 6. Attach the IV and secure the catheter avoiding circumferential dressing or taping. 7. Document the procedure, time, and result (success) on the PCR. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIIIIIIIIII�� 575 a ,u r��,, �" IIIIIIIIIIII II�� IIII�IIII �� IIIIIIIIIIII IIIIIIII�� nlllllll ��II�� IIIIIII�I III�IIII I�IIIIIIIIII III�IIIIII �nlllllll IIII IIIIIIIIIIIIIIIII IIIII�IIIIIIII IIIII�IIII �IIIIIIIII� IIII IIIIIIII III IIIIIIII 11 Clinical Indications: • Any patient where intravenous access is indicated (significant Paramedic In trauma, emergent or potentially emergent medical condition). Procedure: 1.Saline locks may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the ALS professional. 2.Paramedics can use intraosseous access where threat to life exists as provided for in the Venous Access-Intraosseous procedure. 3.Use the largest catheter bore necessary based upon the patient's condition and size of veins. 4. Fluid and setup choice is preferably: • Lactated Ringers with a macro drip (10 gtt/cc) for burns • Normal Saline with a macro drip (10 gtt/cc) for medical conditions, trauma or hypotension • Normal Saline with a micro drip (60 gtt/cc) for medication infusions 5. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles. 6.Connect IV tubing to the solution in a sterile manner. Fill the drip chamber half full and then flush the tubing bleeding all air bubbles from the line. 7. Place a tourniquet around the patient's extremity to restrict venous flow only. 8. Select a vein and an appropriate gauge catheter for the vein and the patient's condition. 9. Prep the skin with an antiseptic solution. 10. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the bloody flashback is visualized in the catheter. 11.Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle into the proper container without recapping. 12. Draw blood samples when appropriate. 13. Remove the tourniquet and connect the IV tubing or saline lock. 14.Open the IV to assure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated. Rates are preferably: • Adult: KVO: 60 cc/hr (1 gtt/6 sec for a macro drip set) • Pediatric: KVO: 30 cc/hr (1 gtt/12 sec for a macro drip set) If shock is present: • Adult: 500 cc fluid boluses repeated as long as lungs are clear and SBP < 90. Consider a second IV line. • Pediatric: 20 cc/kg blouses repeated PRN for poor perfusion. 15. Cover the site with a sterile dressing and secure the IV and tubing. 16. Label the IV with date and time, catheter gauge, and name/ID of the person starting the IV. 17. Document the procedure, time and result (success) on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II II. II.II.II.II.II.II.II. W��Iil Nill� IIIIIIIIIIIIII��I 576 Clinical Indications: • When regular IV access is unavailable with any of the following: OT—Paramedic • Cardiac arrest. • Multisystem trauma with severe hypovolemia. « Severe dehydration with vascular collapse and/or loss of consciousness. • Respiratory failure/ Respiratory arrest. • Burns. Contraindications: • Fracture proximal to proposed intraosseous site. + History of Osteogenesis Imperfecta « Current or prior infection at proposed intraosseous site. • Previous intraosseous insertion or joint replacement at the selected site. Procedure: 1. Don personal protective equipment (gloves, eye protection, etc.). 2.Identify anteromedial aspect of the proximal tibia (bony prominence below the knee cap). The insertion location will be 1-2 cm (2 finger widths) below this. If this site is not suitable, and patient >12 years of age, identify the anteriormedial aspect of the distal tibia (2 cm proximal to the medial malleolus). Proximal humerus is also an acceptable insertion site: for patients > 40 kg, lateral aspect of the humerus, 2 cm distal to the greater tuberosity. 3.Prep the site recommended by the device manufacturer with providone-iodine ointment or solution. 4. For the intraosseous device, hold the intraosseous needle at a 60 to 90 degree angle, aimed away from the nearby joint and epiphyseal plate, rotate the driver until a "pop" or"give" is felt indicating loss of resistance. Do not advance the needle any further. Utilize the yellow needle for the proximal humerus. The pink needle is only intended for use in neonatal patients. 5. Remove the stylette and place in an approved sharps container. 6.Attach a syringe filled with at least 5 cc NS and then inject at least 5 cc of NS to clear the lumen of the needle. 7. Attach the IV line and adjust flow rate. A pressure bag may assist with achieving desired flows. 8. Stabilize and secure the needle with dressings and tape. 9.You may administer 10 to 20 mg (1 to 2 cc) of 2% Lidocaine in adult patients who experience infusion- related pain. This may be repeated prn to a maximum of 60 mg (6 cc). 10. Following the administration of any IO medications, flush the IO line with 10 cc of IV fluid. 11. Document the procedure, time, and result on the PCR. Certification Requirements: w Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. II.II.II.II.II.II. I. IIIIIIIIIIIIIII�� 577 '�pp �@ IIUUI aUw nllU. d iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillillilillillillillillillilliillillillillillillilliillillillillillillilliillillililllillillililI�I� � IIIIIIIIII �IIIIIII�� IIIIIII � �IIIIIIIIII IIIIII�� IIIIIIIII IIIIIIIIIIIIIII IIIIIIIIIIII IIII (III IIIIIIIIIIIII IIII (IIIIIIIIIIIII IIII Clinical Indications: w Protection and care for open wounds prior to and during transport. I E EMT E Procedure: Paramedic 1. Use of personal protective equipment, including gloves, gown, and mask as indicated. 2. If active bleeding, elevate the affected area if possible and hold direct pressure. Do not relyon "compression" bandages to control bleeding. Direct pressure is much more effective. 3. Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate (this may have to be avoided if bleeding was difficult to control). Consider analgesia per protocol prior to irrigation. 4. Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to ensure the bandage is not too tight. 5. Monitor wounds and/or dressings throughout transport for bleeding. 6. Document the wound and assessment and care on the PCR. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II IIIIIII II. II II. II II.II.II.II.II.II. IIIIIIIIIIIIII�� 578 iiiiiiiiiiiiiiiiiiiiiillillillillillillilliillillillillillillilliillillillillilililIIf�� hIIIII IIIIIIIIII�� I�III�� IIIIIIIIIIII� IIII � IIIIIIII Illlillli (IIIIIII(IIII (III IIIIIIIIII IIIIIIII llllllllln lllulllllll IIIIIII IIIIIIIn01111 IIIII�IIII lllllllln IIIII� IIIII uuoimm (IIIIIIII IIIIIIIIIIIIII IIIIIII IIIIIII IIII Clinical Indications: w Serious hemorrhage that can not be controlled by other means. E EMT E Contraindications: Paramedic • Wounds involving open thoracic or abdominal cavities. Procedure: 1. Apply approved non-heat-generating hemostatic agent per manufacturer's instructions. 2. Supplement with direct pressure and standard hemorrhage control techniques. 3. Apply dressing. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II. IIIIIIIIIIIIII�� 579 II �I�� nllllll Illlllnll� �� IIIIII�� IIIIIIIIII Inlllll�� IIIIIIIII IIIII �IIIIIIIII IIIIIIII011111 IIII� IIIIIIII III IIIIIIII�� IIIIIIII0111�IIIIIIIIII IIIIIII E EMT E Paramedic Clinical Indications: • Life threatening extremity hemorrhage that can not be controlled by other means. • Serious or life threatening extremity hemorrhage and tactical considerations prevent the use of standard hemorrhage control techniques. Contraindications: • Non-extremity hemorrhage • Proximal extremity location where tourniquet application is not practical Procedure: 1. Place tourniquet proximal to wound. 2. Tighten per manufacturer instructions until hemorrhage stops and/or distal pulses in affected extremity disappear. 3. Secure tourniquet per manufacturer instructions. 4. Note time of tourniquet application and communicate this to receiving care providers. 5. Dress wounds per standard wound care protocol. 6. If delayed or prolonged transport and tourniquet application time > 45 minutes, consider reattempting standard hemorrhage control techniques and removing tourniquet. Certification Requirements: +► Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. II.II.II.II.II.II.II. IIIIIIIIIIIIII�� 580 1� Clinical Indications: • Need for advanced airway control in a patient who has a gag reflex or trismus (jaw clinching). Clinical Contraindications: P'I Paramedic P' • Significant burns between 24 hours old and 2 weeks old. • Known neuromuscular disease such as myasthenia gravis, amyotrophic lateral sclerosis, muscular dystrophy, Guillain-Barre syndrome + Chronic renal failure and on hemodialysis • Age < 12 years old • Patient or family history of malignant hyperthermia • A minimum of 2, EMT-Paramedics on scene able to participate in patient care Procedure: 1. Pre-oxygenate patient with 100% oxygen via NRB mask or BVM. 2. Monitor oxygen saturation with pulse oximetry and heart rhythm with ECG. 3. Ensure functioning IV access. 4. Evaluate for difficult airway. L.E.M.O.N.) (See Appendix) 5. Perform focused neurological exam. 6.Prepare equipment (incubation kit, BVM, suction, RSI medications, BIAD, Cricothyrotomy kit, waveform capnography). 7. Administer Etomidate. 8. Stroke/head trauma suspected? If yes, use Lidocaine 1 mg/kg. 9. In-line c-spine stabilization performed by second caregiver in trauma setting. 10. Have third caregiver apply cricoid pressure. 11. Administer Succinylcholine and wait for fasciculation and jaw relaxation. 12. I ntubate trachea. 13. Verify ET placement through auscultation, Capnography, and Pulse Oximetry. 14. May repeat Succinylcholine if there is inadequate relaxation after 2 minutes. 15. Release cricoid pressure and secure tube. 16.Coin"flinuous a in d III a Ill uo Oxurinietiry i o in ui toil ui i ui u uiro q u ui uirc d °to air III 1rug uuuistcd IIIi toIlyatauoin [°ic Ill ui o urui toIlh atuiouim Illc oIllu, iiW�inurirnaIII Illc oIlla duii1ing ii toIlyatauoin, aind flout alai tulll atuioui Illc olllu ui must Ilh e uircuoirded oin tlll,,iie III" 17. Re-verify tube placement after every move and upon arrival in the ED. 18. Document ETT size, time, result and placement location by the centimeter marks either at the patient's teeth or lips on the PCR. Document all devices/methods used to confirm initial tube placement and those used after/with patient movement. 19. Consider placing a gastric tube to clear stomach contents after the airway is secured. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per certification cycle. IIIPpI�I IIIIIII IIIppIII all IIIIII Illlllllllllll�u III�III IIIIII IIIIII�IIIIIIII IIII�III III�II III�IIIIII IIIIII� III 581 u.e "°1° � � � � IIII IIIIIIIIIIII IIII Clinical Indications for Epinephrine 1:1,000 Administration (Vial or Ampule) • In a effort to control costs associated with health care, the use of manually delivered Epinephrine 1:1000 will be utilized by our EMT-B personnel. • Epinephrine 1:1000 IM is used in moderate to severe allergic reations/anaphylaxis (Protocol ). EMT-B may use Epinephrine 1:1000 Auto Injector is available. If auto injector is not available, then use Epinephrine 1:1000 vial or ampule Paramedic Relative Contraindications for Epinephrine 1:1000 Administration (Vial or Ampule) • Mild reactions (Flushing, hives, itching, erythema with normal blood pressure and perfusion • Advanced cardiac disease such as a CHF exacerbation Procedure: 1. Receive and confirmation medication order or perform according to protocol standing orders. 2. Prepare the equipment and observe standard personal protection measures. 3. Explain the procedure to the patient and confirm the patient is not allergic to epinephrine. 4. Examine the medication, including the name and expiration date, inspect for discoloration or particles in the medication. Do not administer if discolored or if particles are present. 5. "Shake Down" the ampule. This will force the liquid to the lower portion of the ampule so that it can be broken without medication lose. 6. Break the ampule with a 2 X 2 pad to prevent injury 7. Draw out using a filtered needle with a 1 cc syringe and invert the syringe to expel the air. 8. Choose a suitable site. The easiest and most accessible site is the deltoid muscle in the arm. 9. The mid, lateral thigh should be used in pediatric patients. 10. Prepare the site by cleaning it with providone-iodine or alcohol preparation using a firm circular motion. 11. Change the needle to a 21 — 25 gauge 1 '/2 inch to administer the medication 12. Insert the needle into the muscle at a 90 degree angle with a smooth, steady motion. 13. Aspirate the syringe to assess for blood. If you have blood return, withdraw the needle and reattempt in another site (change needles) 14. Inject medication slowly (5-10 seconds) 15. Withdraw the needle and syringe quickly. Do not recap the needle. 16. Apply pressure over the site 17 Dispose of the syringe and needle only in an approved sharps container. 18. Cover with an adhesive strip (band aid) 19. Closely monitor the patient for the desired therapeutic effects and possible undesired side effects. 20 Document medication, dose, route, and time on/with patient care report. Certification Requirements: • Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. I I I I i I I I m I III�IIIIIII�I� 582 u.e Clinical Indications for Naloxone Administration (Auto-InjectorEVZIO) • Any patient that may have used, in excess, a narcotic medication, prescription orillicit • Depressed respiratory function with associated narcotic use • An altered mental status with associated or suspected narcotic use Ef—P—aramedic Relative Contra-indications for Naloxone Administration (Auto-Injector EVZIO) Mild reactions (Flushing, hives, itching, erythema with normal blood pressure and perfusion Procedure: 1. Receive and confirmation medication order or perform according to protocol standing orders. 2. Prepare the equipment and observe standard personal protection measures. 3. Explain the procedure to the patient and confirm the patient is not allergic to Naloxone; if possible. 4. Examine the medication, including the name and expiration date. 5. Pull the EVZIO from the outer case. 6. Pull off the red safety guard. 7. Place the black end against the outer thigh, through clothing (pants, jeans, etc.), if necessary, then press firmly and hold in place for 5 seconds. 8. Re-Assess the patient for a second dose if necessary. Certification Requirements: Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. I I I i I I m I .I . III�IIIIIII�I� 583 Policy: CPR and ALS treatment are to be withheld only if the patient is obviously dead or a valid State of Florida Do Not Resuscitate form (see separate policy) is present. Purpose: The purpose of this policy is to: • Honor those who have obviously expired prior to EMS arrival. Procedure: 1. If a patient is in complete cardiopulmonary arrest (clinically dead) and meets one or more of the criteria below, CPR and ALS therapy need not be initiated: • Body decomposition 0 Rigor mortis Dependent Iividity • Blunt force trauma • Injury not compatible with life (i.e., decapitation, burned beyond recognition, massive open or penetrating trauma to the head or chest with obvious organ destruction) +► Extended downtime with Asystole on the ECG 2. If a bystander or first responder has initiated CPR or automated defibrillation prior to an EMS paramedic's arrival and any of the above criteria (signs of obvious death) are present, the paramedic may discontinue CPR and ALS therapy. Lead EMS personnel must communicate with medical control prior to discontinuation of the resuscitative efforts. 3. If doubt exists, start resuscitation immediately. Once resuscitation is initiated, continue resuscitation efforts until either: a) Resuscitation efforts meet the criteria for implementing the Discontinuation of Prehospital Resuscitation Policy (see separate policy) b) Patient care responsibilities are transferred to the destination hospital staff. 110584 Policy: Unsuccessful cardiopulmonary resuscitation (CPR) and other advanced life support (ALS) interventions may be discontinued prior to transport or arrival at the hospital when this procedure is followed. Purpose: The purpose of this policy is to: +► Allow for discontinuation of prehospital resuscitation after the delivery of adequate and appropriate AILS therapy. Procedure: 1. Discontinuation of CPR and AILS intervention may be implemented prior to contact with Medical Control if A" of the following criteria have been met: Patient must be 18 years of age or older + Adequate CPR has been administered • Airway has been successfully managed with verification of device placement. Acceptable management techniques include orotracheal incubation, nasotracheal incubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy IV or IO access has been achieved • No evidence or suspicion of any of the following- -Drug/toxin overdose -Active internal bleeding -Hypothermia -Preceding trauma • Rhythm appropriate medications and defibrillation have been administered according to local EMS Protocols for a total of 3 cycles of drug therapy without return of spontaneous circulation (palpable pulse) • All EMS paramedic personnel involved in the patient's care agree that discontinuation of the resuscitation is appropriate 2. If all of the above criteria are not met and discontinuation of prehospital resuscitation is desired, cointact III' c ui alll Cointii,6L Document all patient care and interactions with the patient's family, personal physician, medical examiner, law enforcement, and medical control in the EMS patient care report (PCR). 585 e e Policy: Any patient presenting to any component of the EMS system with a completed Florida Do Not Resuscitate (DNRO) form (yellow form) shall have the form honored. Treatment will be limited as documented on the DNR. Purpose: + To honor the terminal wishes of the patient To prevent the initiation of unwanted resuscitation Procedure: 1. When confronted with a patient or situation involving the DNR form(s), the following form content must be verified before honoring the form(s) request. w The form(s) must bean original State of Florida DNR form (yellow form - not a copy) and the effective date and expiration date must be completed and current. w The DNR form must be signed by a physician, physician's assistant, or nurse practitioner. 2. A valid DNR or MOST form may be overridden by the request of- * The patient The guardian of the patient The patients power of attorney. If the patient or anyone associated with the patient requests that a DNR form not be honored, EMS personnel should contact IIIMedui alll Cointii,6 to obtain assistance and direction 3. A living will or other legal document that identifies the patient's desire to withhold CPR or other medical care may be honored with the approval of III' c ui all4 ointiiioL This should be done when possible in consultation with the patient's family and personal physician. 586 Policy: The complete EMS documentation associated with an EMS events service delivery and patient care shall be electronically recorded into a Patient Care Report (PCR) prior to end of shift. Definition: The EMS documentation of a Patient Care Report (PCR) is based on the appropriate and complete documentation of the EMS data elements as required by the state of Florida. Since each EMS event and/or patient scenario is unique, only the data elements relevant to that EMS event and/or patient scenario should be completed. A complete Patient Care Report (PCR) must contain the following information (as it relates to each EMS event and/or patient): • Service delivery and Crew information regarding the EMS Agency's response « Dispatch information regarding the dispatch complaint Patient care provided prior to EMS arrival Patient Assessment as required by each specific complaint based protocol Past medical history, medications, allergies, and DNR status + Trauma and Cardiac Arrest information if relevant to the EMS event or patient + All times related to the event All procedures and their associated time All medications administered with their associated time # Disposition and/or transport information • Communication with medical control Appropriate Signatures (written and/or electronic) Purpose: The purpose of this policy is to: • Promote timely and complete EMS documentation. Promote quality documentation that can be used to evaluate and improve EMS service delivery, personnel performance, and patient care. w Promote quality documentation that will decrease EMS legal and risk management liability. Provide a means for continuous evaluation to assure policy compliance. WIN ON587 Policy: Every patient encounter by EMS will be documented. Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented for any patient who receives some assessment component. Purpose: To insure: • Evaluation of every patient's volume and cardiovascular status • Documentation of a complete set of vital signs Procedure: 1. Two complete set of vital signs must be completed on all patients: Pulse rate * Systolic AND diastolic blood pressure • Respiratory rate • Pain / severity (when appropriate to patient complaint) GCS 2. Based on patient condition and complaint, vital signs may also include: Pulse Oximetry + Temperature • End Tidal CO2 (If Invasive Airway Procedure) Breath Sounds Level of Response 4. If the patient refuses this evaluation, the patient's mental status and the reason for refusal of evaluation must be documented. 5. Document situations that preclude the evaluation of a complete set of vital signs. 6. Record the time vital signs were obtained. 7. Any abnormal vital sign should be repeated and monitored closely. lizil EJ588 e Policy: Domestic violence is physical, sexual, or psychological abuse and/or intimidation, which attempts to control another person in a current or former family, dating, or household relationship. The recognition, appropriate reporting, and referral of abuse is a critical step to improving patient safety, providing quality health care, and preventing further abuse. Elder abuse is the physical and/or mental injury, sexual abuse, negligent treatment, or maltreatment of a senior citizen by another person. Abuse may be at the hand of a caregiver, spouse, neighbor, or adult child of the patient. The recognition of abuse and the proper reporting is a critical step to improve the health and wellbeing of senior citizens. Purpose: Assessment of an abuse case based upon the following principles: Protect the patient from harm, as well as protecting the EMS team from harm and liability. • Suspect that the patient may be a victim of abuse, especially if the injury/illness is not consistent with the reported history. o Respect the privacy of the patient and family. Collect as much information and evidence as possible and preserve physical evidence. Procedure: 1. Assess the/all patient(s) for any psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, behavioral disorders, substance abuse, medical non-compliance, or repeated EMS requests. This is typically best done in private with the patient. 2. Assess the patient for any physical signs of abuse, especially any injuries that are inconsistent with the reported mechanism of injury. Defensive injuries (e.g. to forearms), and injuries during pregnancy are also suggestive of abuse. Injuries in different stages of healing may indicate repeated episodes of violence. 3. Assess all patients for signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition. 4. Immediately report any suspicious findings to both the receiving hospital (if transported). If an elder or disabled adult is involved, also contact the Department of Social Services (DSS) or equivalent in the county. After office hours, the adult social services worker on call can be contacted by the 911 communications center. 5. EMS personnel should attempt in private to provide the patient with the phone number of the local domestic violence program, or the National Hotline, 1-800-799-SAFE. 589 Policy: Anyone requesting EMS services will receive a professional evaluation, treatment, and transportation (if needed) in a systematic, orderly fashion regardless of the patient's problem or condition. Purpose: +► To ensure the provision of appropriate medical care for every patient regardless of the patient's problem or condition. Procedure: 1. Treatment and medical direction for all patient encounters, which can be triaged into an EMS patient care protocol, is to be initiated by protocol. 2. When confronted with an emergency or situation that does not fit into an existing EMS patient care protocol, the patient should be treated by the Universal Patient Care Protocol and a Meduicall4 ointiii 6l III° Il[,ii sui6ain should be contacted for further instructions. OW590 Policy: The State of Florida Poison Center should be utilized by the 911 centers and the responding EMS services to obtain assistance with the pre-hospital triage and treatment of patients who have a potential or actual poisoning. Purpose: The purpose of this policy is to: • Improve the care of patients with poisonings, envenomations, and environmental/biochemical terrorism exposures in the prehospital setting. • Provide for the most timely and appropriate level of care to the patient, including the decision to transport or treat on the scene. • Integrate the State Poison Center into the prehospital response for hazardous materials and biochemical terrorism responses Procedure: 1. The call center will identify and if EMD capable, complete key questions for the Overdose/ Poisoning, Animal Bites/Attacks, or Carbon Monoxide/Inhalation/HazMat emergency medical dispatch complaints and dispatch the appropriate EMS services and/or directly contact the State Poison Center for consultation. 2. If no immediate life threat or need for transport is identified, EMS personnel may conference the patient/caller with the Poison Center Specialist at the State Poison Center at 800-222-1222. If possible, dispatch personnel should remain on the line during conference evaluation. 3. The Poison Center Specialist at the State Poison Center will evaluate the exposure and make recommendations regarding the need for on-site treatment and/or hospital transport in a timely manner. If dispatch personnel are not on-line, the Specialist will recontact the 911 center and communicate these recommendations. 4. If the patient is determined to need EMS transport, the poison center Specialist will contact the receiving hospital and provide information regarding the poisoning, including treatment recommendations. EMS may contact medical control for further instructions or to discuss transport options. 5. If the patient is determined not to require EMS transport, personnel will give the phone number of the patient/caller to the Poison Center Specialist. The Specialist will initiate a minimum of one follow-up call to the patient/caller to determine the status of patient. 6. Minimal information that should be obtained from the patient for the state poison center includes: • Name and age of patient • Substance(s) involved • Time of exposure • Any treatment given • Signs and symptoms 7. Minimal information which should be provided to the state poison center for mass poisonings, including biochemical terrorism and HazMat, includes: • Substance(s) involved • Time of exposure • Signs and symptoms • Any treatment given IN MEN 591 Policy: All individuals served by the EMS system will be evaluated, treated, and furnished transportation (if indicated) in the most timely and appropriate manner for each individual situation. Purpose: To provide- * Rapid emergency EMS transport when needed. • Appropriate medical stabilization and treatment at the scene when necessary Protection of patients, EMS personnel, and citizens from undue risk when possible. Procedure: 1. All trauma patients with significant mechanism for trauma will be transported as soon as possible. The scene time should be 10 minutes or less. 2. All acute Stroke and acute ST-Elevation Myocardial Infarction patients will be transported as soon as possible. The scene time should be 10 minutes or less for acute Stroke patients and 10 minutes or less (with 12 Lead ECG) for STEMI patients 2. Other Medical patients will be transported in the most efficient manner possible considering the medical condition. Advanced life support therapy should be provided at the scene if it would positively impact patient care. Justification for scene times greater than 15 minutes should be documented. 3. No patients will be transported in initial response non-transport vehicles. 4. In unusual circumstances, transport in other vehicles may be appropriate when directed by EMS administration. ° ® m 592 POLICY: To properly determine the appropriate age group for selection of treatment protocol. The purpose of this policy is to- -Define what is a Patient and what defines Adult, Minor, and Pediatric A Patient is defined as any person who requires medical assistance, assessment, or treatment of any kind. Definition of an Adult: 1. One who has reached the age of 18 2. One who is under the age of 18 and has been legally emancipated a. Any minor over the age of 16 that has successfully petitioned the courts for emancipation b. Any minor over 16 serving in the military c. Any minor over 16 who is legally married Definition of a Minor: 1. Under the age of 18 2. Has not been legally emancipated Definition of a Pediatric: 1. Defined by those which fit on the Broselow-Luten Resuscitation Tape 2. Age 15 or less. � « r 005193 POLICY#11-MED National Health Transport Policies and Procedures Procedure for medical guidance Purpose: To provide medical guidance when treating and transporting a patient. Procedure: From time to time, NHT EMTs and Paramedics need consultation on the appropriate care of a patient being transported. The following steps shall be followed when the need arises. 1. Consult the NHT Medical Protocols 2. Consult QA (if questioning the medical necessity of a transport) 3. Consult the discharging caregiver. 4. Consult the Shift Commander if applicable in your operation. 5. Consult on call NHT Medical Control person if the above options have been exhausted. On Call NHT Medical control can be contacted by requesting such through NHT's dispatch. 594 POLICY#700-MED National Health Transport Policies and Procedures Procedure for identification of unknown/unfamiliar medication Purpose: To ensure proper administration of medications not on the NHT Medical Protocol list. Procedure: 1. Assess the patient and medication(s) being administered. 2. Speak with RN and/or the prescribing physician or mid-level to gain understanding of why the patient is receiving such medication. 3. Ensure the Six (6) rights of medication administration are met: • Identify the right patient • Verify the right medication • Verify right indication • Calculate right dose • Make sure it's the right time • Check the right route 4. In conjunction with the six rights, also investigate the contraindications of the medication(s). S. If the Paramedic reaches step "5" with no clear understanding and knowledge of the medication, exhaust all options of research and repeat steps 1 through 4 or contact the on call medical control officer. 595 urug List CIiuiinirenit Ilde6cslliion Ill st approved for Ii.uisc by III dS II')urrrrov:� ideurrrrs for II'TI III I II dS Medication Dosing Provider Acetaminophen Adult Dosing • Paramedic (Tylenol) 0 15mg/kg PO • Max dose of 650mg NHT EMS Protocol: 6-Pain Control-Adult Pediatric Dosing 40-Pain Control-Pediatric 60-Fever See Collbir Coded Ill....liist • 15 mg/kg po Indications/Contraindications: • Indicated for pain and fevercontrol • Avoid in patients with severe liver disease Adenosine Adult Dosina • 6 mg IV push over 1-3 seconds.If • Paramedic (Adenocard) no effect after 1-2 minutes, • Repeat with 12 mg IV pushover NHT EMS Protocol: 1-3 seconds. 13-Adult Tachycardia Narrow • Repeat once if necessary Complex 14-Adult Tachycardia Wide Pediatric Dosing Complex • 0.1 mg/kg IV(Max 6 mg) pushover 45-Pediatric Tachycardia 1-3 seconds. If no effect after 1-2 minutes, Indications/ • Repeat with 0.2 mg/kg IV(Max12 Contraindications: mg) push over 1-3 seconds. • Specifically for treatment or • (use stopcock and NormalSaline diagnosis ofSupraventricular flush with each dose) Tachycardia Ph Is CDII"Iru l a ll";y Is pil"Ov I d:0:'�{as a 1rp I''G"II"Pince on I It GRo cs not contain a I I oI'the co kntirdmfications d i,W Ilk CD'i'ential dd GNo:iI,4G"II"eactioi",I'oreach Il,tkec1 dIIruy.It is the II"Ps I"bC nsil.b 1.Ik'y oI'each :�,:IMS Systeir,AGko:nc`k ai,W kkq'."k'��Ical I34lreckcoll to assuII"G'that each ::IMS"bIPCDV'G':,x,xIonal is hItlowled:goal.bleal'.'bout the use each GRIrug iknthis CDII"IfiIQQEv';&II"y. 596 urug List li ui�� i II dS If)rovliidsu s iforII'�14III I II;I II"dS u u su�li s .uissiui�::ur�l uis sllIlu..r��:�rs ��:u..r li alas d Medication Dosing Provider Albuterol Adult Dosina • 2.5-5.0 mg in nebulizer • Paramedic Beta-Agonist continuously x 3doses. NHTEMS Protocol: Pediatric Dosina * 19-Allergic Reaction • See Colllour Coded Ill....liisi Anaphylaxis 21-COPD Asthma • 2.5-5.0 mg in nebulizer * 48-Pediatic Allergic Reaction continuously x 3 doses. See local * 53-Pediatric Respiratory Distress protocol for relative contraindications and/or indications Indications/Contraindications: to contact medical control for use of this drug. • Beta-Agonist nebulized treatment for use in respiratory distresswith bronchospasm Amiodarone Adult Dosina V-fib/pulseless V-tach • Paramedic (Cordarone) 0 300 mg IV push • Repeat dose of 150 mg IV push CFVEMS Protocol: for recurrent episodes 14-Adult Tachycardia Wide Complex V-tach with a pulse 15-VF Pulseless VT 0150 mg in 100cc D5W over 10 min 45-Pediatric Tachycardia 46-Pediatric VF Pulseless VT Pediatric Dosina V-fib/pulseless V-tach 47-Pediatric Post Resuscitation 5 mg/kg IV push over 5 minutes Indications/Contraindications: May repeat up to 15mg/kg IV • Antiarrhythmic used mainly inwide complex tachycardia and V-tach with a pulse ventricular fibrillation. 5 mg/kg IV push over 20 minutes • Avoid in patients with heart blockor . Max Dose is 150mg profound bradycardia. . Avoid in Length Tape Color,,,I= • Contraindicated in patientswith iodine hypersensitivity Post Resuscitation • 5mg/kg over 10 minutes Dirug (Page, of 14 Ph Is aII"Imu G4i&II"y Is pIrov I G1q'kk'��as a II"p Well"Pine'on I It GRo cs not Contain a I I oI'the co k'tlklyddmfications d i,W koB'G Mill ddG#`dp31n,v: II"eactioi", aIreach Ilsted k'�{IIrug.It is the II"4°,xppC nsil.),Ik'y oI'each p:,�,:IMS S°ysteIm Ago:ncv and: IIkBar¢��11cuul 13irector to assuu"e that each I IIMS pvlroV'essionaI is Iknow Ied:go:alll.I alb out the use each d:rug in this I'orlr uI airy. 597 urug List l ui�� i II dS If)r��vrr der s forII'�14III i II;I II"dS u u eu�,i e .uiesiui�:uur�, uis ^ IIIIu..r��:rre ��:u..r l alas . Medication Dosing Provider Asl2irin Adult Dosina • 81 mg chewable (baby)Aspirin • EMT NHT EMS Protocol: Give 4 tablets to equal usualadult • Paramedic 11-Chest Pain and STEMI dose. • Or one 325mg ASA Indications/ Contraindications: Pediatric Dosina • None Currently • A platelet deaggregate drug for use in cardiac chest pain Atropine Adult Dosina Bradvcardia • Paramedic NHT EMS Protocol: • 0.5 mg IV every 3—5 minutes up 8-Bradycardia Pulse Present to 3 mg. * 42-Pediatric Bradycardia (If endotracheal-- max 6 mg) Organophosphate Indications/Contraindications: • 2 mg IM/ IV/ IO otherwise as per medical control for minor exposure • Anticholinergicdrag used in • Repeat every 5 minutes as needed bradycardias. 0 6mg IV/IM/IO for major exposure • (For Endotracheal Tube use ofthis . Repeat every 5 minutes as needed drug, double the dose) • In Organophosphate toxicity,large Pediatric Dosina doses may be required (>10 mg) 111,1111, See C6oir Coded Ill....liist Bradvcardia • 0.02 mg/kg IV, IO (Max total dose 1 mg IV) • (Min 0.1 mg) per dose • May repeat in 5 minutes Organophosphate • 0.02- 0.05 mg/kg IV or IO otherwise as per medicalcontrol • Repeat every 5 minutes as needed Dirug (Page, of 14 PA Is I!all"Imu G4i&II"y Is'bIrov I G10"k'��as a IIr4 V'cII"Pine'on Ry.„k GRo cs not contain all oI'the co kntirddmfications d i,W pCD$'G'Iptial dd GNo:iI,4G"II"eactioi",I'CDIPeach I sted k'�{IIrug.„k is the IIrpsl"bCDnsil,.b,I i&y oI'each p:,:„Mu Syst lfi AGAG':ncy,and: „�q'."k'��I cal 13irector to assuII"G'that each, ,,MS pIPCDVG",x,xICDnaI is„know I ed:gq'."alb,G'4i&„'.'bout t,AG"44,xG"each G�IIrug rug this I'CDIrru I4i&II";y. 598 urug List li ui�� i II dS If)rovliideu s for II'�14 III I II;I II"dS u u su�li e .uiesiui�::ur�l uis sllIlu..r��:�rs ��:u..r li alas . Medication Dosing Provider Calcium Chloride Adult Dosina • 1 gm IV/ 10 • Paramedic NHT EMS Protocol: • Avoid use if pt is taking digoxin :41C 23-Dialysis Renal Failure 26-Overdose Toxic Ingestion Pediatric Dosina 52-Ped OD Toxic Ingestion • See C6oir Coded Ill....liist Indications/ Contraindications: Overdose • 60mg/kg over 10 minutes • Indicated for severe hyperkalemia Dextrose 10%. 250//0• Adult Dosina • Paramedic 50% Glucose solutions • See local protocol for concentration Oral Glucose and dosing NHTEMS Protocol: Pediatric Dosing * Multiple IIII� See C6oir Coded Ill....liist Indications/Contraindications Use in hypoglycemic states. NO • See local protocol for concentration oral in AMS. and dosing Diltiazem Adult Dosina First Dose Paramedic (Cardizem) • 20mg IV/10 Calcium Channel • >60 years of age reduce to 10mg IV/10, and follow with 10mg IV/10 Blocker in 5 minutes • Follow with 5mg/hr infusion NHT EMS Protocol: 13-Adult Tachycardia Narrow Second Dose Complex • 25mg IV/10 • >60 years of age reduce to 15mg Indications/ IV/10, and follow with 10mg IV/10 Contraindications: in 5 minutes • Calcium channel blocker used to Follow with 10mg/hr infusion treat narrow complex SVT • Contraindicated in patientswith Pediatric Dosina heart block, ventricular tachycardia, and/or acute MI • None Currently D Ph Is oII"Imu G4i&II"y Is pIro`d I G10"k'��as a II"p V'olI"Piece on I It doo,4 not contain a I I of the cokntlyddmfications d i,W potential dd No21I,4G"II"eactioi",I'oII"each Iiste 1 k'�{IIrug.It is the II"4 sIponsil.).ity of each p:,�,:IMS Systolm Ago:ncv and: IIkBar¢��11cuul 13irector to assuu"e that each I IIMS pproV'essio aI is Iknow Ied:go:alll.Ie sittlfboauk the use each d:rug in this I'olrlr uI airy. 599 urug List li ui�� i II dS If)rgw:vidsu s for II'�14III I II;I II"dS u u su�li s .uissiui�::urtl uis ^ IIIIu..r��:rrs ��:u..r li alas . Medication Dosing Provider Diphenhydramine Adult Dosing (Benadryl) • 25-50 mg IV/10/IM/PO • Paramedic Pediatric Dosing NHT EMS Protocol: 11111111 See S6bir Coded Ill....liist )�u 19-Allergic ReactionAnaphylaxis • 1 mg/kg IV/10/IM/PO 48-Pediatic Allergic Reaction • Do not give in infants < 3 mo Indications/Contraindications • Antihistamine for control of allergic reactions Dopamine Adult Dosina • 10 -20 micrograms/kg/min IV or • Paramedic NHT EMS Protocol: 10, titrate to BP systolic of 90 Multiple mmHg Pediatric Dosing Indications:Contraindications: See Solllour Coded Ill....liisi • 10 -20 micrograms/kg/min IV or • Avasopressor used in shock or 10, titrate to BP systolic appropriate hypotensive states for age Epinephrine 1 :1 .000 Adult Dosina • 0.3-0.5mgIM NHT EMS Protocol: • See local protocol for relative • Paramedic Multiple contraindications and/orindications to contact medical control for use Indications/Contraindications: of this drug. • Vasopressor used in allergic Pediatric Dosing reactions or anaphylaxis 11111111 See Soour Coded ....Nisi • 0.01 mg/kg IM • (Max dose 0.5 mg) Ph I s OII"Imu GGi&II"y Is"blro`d I G10"k'��as a II"4 I!eirpime oitlIy It G�oGcs ktl of coi taim a I I of the coi tlraiixficatloitls d i,W kotei tial dd No21I,4G"II"eactioi",I'oreach Iistec1 dIiruy.It is the II rpsjj"boitlsil.b 1.it`k of each p:,�,:IMS Sy stolen Ago: my,ai,W llk8ar¢��11cuul 13irector to a ssuu"e that each l IIMS pvlroV'essioimI is llkimwIed:go:uull.aIe alfboaut the use each d:rug m this I'OIrIr uRwry 600 urug List li ui�� i II d If)rgwuvideu s forII'�14III I u u su�li e .uissiui�:uur�l uis ^ IIIIu..r��:rrs ��:u..r li alas . Medication Dosing Provider Epinephrine 1 :10.000 Adult Dosina • 1.0mg IV/10 NHT EMS Protocol:Multiple • One Dose Only in Medical Arrest • Paramedic • None used in Traumatic Arrest Indications/ • (Maybe given by Endotracheal Contraindications: tube in double the IVdose) • Vasopressor used in cardiac Pediatric Dosina arrest. 11111111 See C6 oir Coded Ill....liist • 0.01 mg/kg IV or 10 • (Max dose 1 mg) • Repeat every 3 -5 minutes per protocol • (Maybe given by Endotracheal tube in double the IV dose) Fentanyl Adult Dosina • 1mcg/kg IM/IV/10/IN bolus then25 (Sublimaze) mcg IM/IV/10/IN every minutes • Paramedic Narcotic Analgesic until a maximum of200 mcg or clinical improvement NHT EMS Protocol: Pediatric Dosina Multiple IIII� See 6oir Coded Ill....liist Indications/ • 1 mcg/kg IM/IN/IV/10 Contraindications: May repeat 0.5 mcg/kg every 5 • Narcotic pain relief minutes Maximum dose 2 mcg/kg • Possible beneficial effect in pulmonary edema • Avoid use if BP < 110 1 Ph Is aII"Imu GGi&II"y Is"bIrov I G10"k'��as a IIrp I!eiI"Pine'on I It GRo cs not contain a I I oI'the co kntirdmfications d i,W koB'G Mill dd GNo:iI,4G"II"eactioi",I'oreach Ilsted k'�{IIrug.It is the II"4°,xl"bC nsil.b 1.Ik'y oI'each p:,�,:IMS Systeir,AGko:nc`k and: kkq'."k'��IcaIIb4lreckcolltoassuII"G'that each IMS"bIPCDVG':,x,xIonaIis know Ied:go:alb leal'.'boot the use each GRI rug ikn this I'orruR wry. 601 urug List li ui�� i II dC If)r��vrr der s forII'�14III I u u eu�li e .uiesiui�:uur�l uis ^ IIIIu..r��:rre ��:u..r li alas . Medication Dosing Provider Glucagon Adult Dosina • 1 -2 mg IM/IN • Paramedic NHT EMS Protocol: • Repeat blood glucose NONE measurement in 15 minutes, if<_69 mg /dl repeat dose. Indications/ Contraindications: Pediatric Dosina • See C6 oir Coded Ill....liist • Drug acting to release glucose into • 0.1 mg/kg IM, Maximum 1 mg blood stream by glycogen • Repeat blood glucose breakdown measurement in 15 minutes, if<_69 • Use in patients with no IV access mg /dl repeat dose. • Max Dose for OD is 2mg Haloperidol Adult Dosina • 5 mg IV/IM, may repeat once • Paramedic (Haidol) • >65 years of age reduce dose to Phenothiazine 2.5mg IV/IM, may repeatonce Preperation Pediatric Dosina • None Currently NHT EMS Protocol: 5-Behavioral Indications/Contraindications: • Medication to assist with sedation of agitated patients IDratroaium Adult Dosina • 0.5 mg per nebulizer treatment • Paramedic (Atrovent) • Max 3 treatments NHT EMS Protocol: Pediatric Dosina 19-Allergic ReactionAnaphylaxis Use in Pediatrics as a combined 21-COPD Asthma Therapy with a Beta Agonistsuch 48-Pediatic Allergic Reaction as Albuterol 53-Pediatric Respiratory Distress • 0.5 mg per nebulizer treatment • Max 3 treatments Indications/Contraindications: • Medication used in addition to albuterol to assist in patientswith asthma and COPD Dirug (Page, of 14 Ph s all"Iru G4i&II"y Is fill"Ov I G10"k'��as a II"p Well"Piece on I It GR oc s not contain a I I oI'the co kntlPddmficatlons d i,W potential dd GNo:iI,4G"II"eactioi",I'or ach Ilsted k'�{IIrug.It is the II"Ps IsC nsi is 1.it`k oI'each p:,:IMS Sy st°Ifi Ago:nc`k and: ktq'."k'��I cal It41PG':cto to a&1sI:ulire that eachIMS Its IPCDV'G'ssionadl is hItlowled:goal.ble al'.'bout the use each GR rug inthis CDII"Ifil&Plarf. 602 ri urug List li ui�� i II dS If)rovliidsu s forII'�14III I II;I II"dS u u su�li s .uissiui�::ur�l uis sllIlu..r��:�rs ��:u..r li alas . Medication Dosing Provider Ketorolac Adult Dosing (Toradol) • 30 mg IV/10 • Paramedic Non-steroidal Anti- Pediatric Dosina • 0.5 mg/kg IV/ 10/IM inflammatory Drug Maximum 30 mg NHT EMS Protocol: 6-Pain Control Adult 40-Pediatric Pain Control Indications/Contraindications: • Avoid NSAIDS in women who are pregnant or could be pregnant • A nonsteroidal anti-inflammatory drug used for pain control. • Not to be used in patients with history of GI bleeding (ulcers), renal insufficiency, or in patients who may need immediate surgical intervention (i.e.obvious fractures). • Not to be used in patientswith allergies to aspirin or other NSAID drugs such as motrin • Avoid in patients currentlytaking anticoagulants such as coumadin Dirl (Page, of 14 Ph Is IOII"Iru G4i&II"y Is"blro`d I G10"k'��as a IIr4 V'olI"Piece on I Ilk G�oGcs not contain a I I o i the cokntlyddmficatlons d i,W potential dd No21I,4G"II"eactioi",IOII"each Ilstec1 k'�{IIrug.Ilk is kF v: II"4 sIponsil.b 1.it`k o i each p:,�,:IMS Sy tolm Ago:ncv and: IIkBar¢��11cuul 13irector to assuu"e that each I IIkBS pprolles,Io aI is i led:go:alb le sittlfboaut the use each d:rug in this IOIrIr uI airy. 603 urug List Ii ui�� i II dS If)rovliidsu s forII'�14III I II;I II"dS u u su�1i s uissiui�::ur�1 uis sllIlu..r��:�rs ��:u..r Ii alas . Medication Dosing Provider Ketamine Adult Dosina • Lead Paramedic or above (Ketalar) • 1 mg/kg to 2mg/kg IV Push Anesthetic over one minute • Higher dose range will often decrease the chance of early CFVEMS Protocol: re-emergence 4-Drug Assisted Airway " 21- Post Resuscitation Pediatric Dosina • None Currently Indications/Contraindications: • Avoid in patients with Hypertensive Crisis • An anesthetic medication thathas properties that can facilitate intubation or other airway techniques • May be beneficial to patients with COPD or other respiratory Emergencies Labetalol Adult Dosina (Trandate) • See protocol for dosing • Paramedic NHTEMS Protocol: 24-Hypertension Pediatric Dosina Indications/Contraindications: °III°' ConsL ll'Q Ae6cW CoVi'tV"()I • Symptomatic HTN with SBP> 220 OR DBP> 120. Do notgive in heart blocks or failure. Levophed Adult Dosina • Paramedic • 4mg in 250ml of DSW.Titrate (Norepinephrine) 0.2-1 mcg/kg/min. Treat to a CFVEMS Protocol: MAP of 65 or greater. * NONE Pediatric Dosina Indications/Contraindications: 11111111 ConsLflQ II`ded'licW Contr011 Severe Hypotension 1' Ph 1II s 011"Ifi4 Ia ll""y I p11"Ov I GRG,"GR as a IIrp V'c11"Piece clplIy It GRo c,s not contain a I.cI the colntir5dmficatiolps ai,W pCd"ael tial 5d GNC'IIhG"II"ea Gtfioi"+ICdIreach II;"ted G�Irug.It Is the II"Ps pCdl sill)I i ty oI'each IMS Syst 1fi ACMG':ncy,and: �q'."k'��I cal Id41PG':ctor to assu lire that each ::IIMS")IPCDV�G':,x,xIonal is hIpCD`u1`led:goalblc alb out the use each GRIrug in this CDIinv PEG,&11"y. 604 urug List Ii ui�� i II dS If)rgw:videu s for II'�14III I II;I II"dS u u eu�Ii e .uiesiui�::ur�I uis ^ IIIIu..rr��:rre ��:u..r Ii alas . Medication Dosing Provider Magnesium Sulfate Adult Dosina Respiratory Distress: • Paramedic • 2 g IV/ 10 over 10 minutes NHT EMS Protocol:Multiple Repeat dosing per local protocol Obstetrical Seizure: Indications/Contraindications: • 2-4 g IV/ 10 over 2-3 minutes • Elemental electrolyte used totreat . Dose may be repeated once,or as eclampsia during the third per local protocol trimester of pregnancy. • A smooth muscle relaxor used in Cardiac Patients refractory respiratory distress • 2 G IWO over 2 minutes resistent to beta-agonists • An electrolyte that may beeffective Pediatric Dosina in Torsades de Pointes/ • 40 mg/kg IV/ 10 over 20 minutes Polymorphic V-Tac (Max 2 gms) • Repeat dosing per local protocol Methylarednisolone Adult Dosina (Bola-medrol) • 125 mg IV/10 • Paramedic Steroid Preparation Pediatric Dosina III See C6 .it Coded Ill....liisi NHT EMS Protocol: • 2 mg/kg IV/ 10 (Max 125 mg) 19-Allergic ReactionAnaphylaxis 21-COPD Asthma 48-Pediatic Allergic Reaction 53-Pediatric Respiratory Distress Indications/Contraindications: • Steroid used in respiratorydistress to reverse inflammatory and allergic reactions bkL- Ph s CII"Ifiu IA:hIIry I "rovIG ed: as a IIrp V'cII"Piece clplIy It GR ocs not contain a I.cI the colntir5dmficatiolps ai,W pCd"ael tial 5d GNC'Inhv: II"ea Gtfioi"+ICdIreach II;"ted G�Irug.It is the II"Ps pCdl sill)I i ty oI'each', IMS Syst lfi ACto:ncy and: �q'."k'��I cal It41PG':c'tor to as,+uire that each IMu")IPCDVG':,x,xIonaI is know Ied:g':aI.)Ic G,&I'.out the use each GRIrug in this form&IG,&II"y. 605 urug List li ui�� i II dS If)r��vrr der s forII'�14III I II;I II"dS u u su�,i e .uiesiui�:uur�, uis ^ IIIIu..r��:rrs ��:u..r li alas . Medication Dosing Provider Midazolam Adult Dosina • 0.5-5mg IV/IO/IN/IM • Paramedic (Versed) Max 5mg Benzodiazepine Pediatric Dosina See C6 oir Coded Ill....liisi NHT EMS Protocol: See individual protocols fordosing Multiple Usual total dose 0.1-0.2 mg/kg IV/ IO/ IM/IN Indications/Contraindications: • Max 2mg • Benzodiazepine used tocontrol seizures and sedation • Quick acting Benzodiazepine • Preferred over Valium for IM use Use with caution if BP < 110 Morphine Sulfate Adult Dosina • 4 mg IM/IV/IO bolus then 2 mg • Paramedic Narcotic Analgesic IM/IV/IO every 5-10 minutes untila maximum of 10 mg or clinical NHT EMS Protocol: improvement NONE Pediatric Dosina Indications/Contraindications: 1l,lll,l� See C6 olir Coded ....lust • Narcotic pain relief • 0.1 mg/kg IV/ IO/IM • Possible beneficial effect in May repeat every 5 minutes pulmonary edema Maximum single dose 5 mg • Avoid use if BP < 110 Maximum dose 10 mg Naloxone • Adult Dosina • 0.4-2 mg IV/ IO/ IM / IN /ETT • Paramedic (Narcan) bolus titrated to patient's Narcotic Antagonist respiratory response Pediatric Dosina HT EMS Protocol: See C6 oir Coded Ill....liist 26-Overdose Toxic Ingestion • 0 1 mg/kg IV/ IO/ IN�� / IM/ETT r 52-Ped OD Toxic Ingestion (Max 2 mg) • Repeat as per protocol Indications/Contraindications: • Narcotic antagonist Dirug (Page, of 14 Ph s aII"Imu G4i&II"y Is sIrov I G10"k'��as a IIrp I!eiI"Pine'on I It GR ocs not contain a I I oI'the co kntlPddmfications d i,W potential dd GNo:iI,4G"II"eactioi",I'oreach Ilsted k'�{IIrug.It is the II"Ps IsC nsil.b 1.ity oI'each p:,:,IMS Systeir,AGto:nc`t and: �q'."k'��IcaIId41PG"c't'CDIItoasI:uII"G'that each IMSItsIPCDVG':,x,xIonaIis know Ied:go:alb IeSi&lbout the use each GRI rug ikn this I'orruR airy. 606 ri urug List li ui�� i II dS If)rovliideu s forII'�14III I II;I II"dS u u su�li e .uiesiui�::ur�l uis sllIlu..r��:�rs ��:u..r li alas . Medication Dosing Provider Normal Saline Adult Dosina • See individual protocol forbolus • Paramedic Crystalloid Solutions dosing and/or infusion rate NHT EMS Protocol: Pediatric Dosina Multiple 11111111 See C6oir Coded Ill....liisi. • See individual protocol forbolus Indications/Contraindications: dosing and/or infusion rate IV fluid for IV access • Usual initial bolus 20 mL/kg IV/ or volume infusion IO Nitroglycerin Adult Dosina • 0.3/0.4 mg SL every 5 minutes • EMT NHT EMS Protocol: until painfree • Paramedic 11-Chest Pain and STEMI • See Chest Pain Protocol forpaste 12-CHF Pulmonary Edema dosing Indications/Contraindications: Pediatric Dosina • Vasodilator used in anginal • None Currently syndromes and CHF. Ondansetron Adult Dosing • 4mgIV/ I0/ IM/PO/ODT (Zofran) • May repeat in 15 minutes • Paramedic Anti-emetic Pediatric Dosing NHT EMS Protocol: • 0.15 mg/kg IV/ IO/IM 18-Abdominal Pain Protocol (Max 4 mg) 31-Vomiting and Diarrhea 55-Pediatric Vomiting and Diarrhea Indications/Contraindications: • Anti-Emetic used to control Nausea and/or Vomiting • Ondansetron (Zofran) is the recommended Anti-emetic for EMS use since it is associated with significantly less side effects and sedation. Dirug (Page, of 14 Ph I s IoIirir QG4i&II"y Is pIro`d I G10"k'��as a IIr4 V'olI"Piece on I Ilk G�oGc,s not contain a I I o i the cokntlyddmficatlons d i,W potential dd No21I,4G"II"eactioi",IoII"each Ilstec1 k'�{IIrug.Ilk is ov: II"4 sIponsil.).it`k o i each p:,�,:IMS Sy stolen Ago:ncv and: IIkBar¢��11cuul 13irector to a ssuu"e that each I IIMS pprolles,Io aI is i led:go:alll.Ie sittlfboaut the use each d:rug in this Iolrlr uI airy. 607 urug List li ui�� i II dS If)rovliidsu s forII'�14III I II;I II"dS u u su�li s .uissiui�::ur�l uis sllIlu..r��:�rs ��:u..r li alas . Medication Dosing Provider Oxygen • Adult Dosina • 1-4 liters/min via nasal can nula • EMT NHT EMS Protocol: • 6-15 liters/min via NRB mask • Paramedic Multiple • 15 liters via BVM/ETT/BIAD Indications/Contraindications: • Pediatric Dosina • Indicated in any condition with • 1-4 liters/min via nasal cannula increased cardiac work load, . 6-15 liters/min via NRB mask respiratory distress, or illness or injury resulting in altered 15 liters via BVM/ETT/BIAD ventilation and/or perfusion. Goal oxygen saturation94-99%. • Indicated for pre-oxygenation whenever possible prior to endotracheal intubation. Goal oxygen saturation 100%. Oxvmetazoline Adult Dosina • 2 sprays in affected nostril • EMT (Afrin or Otrivin) • Usual concentration is 0.05%by • Paramedic Nasal Decongestant volume Pediatric Dosina NHT EMS Protocol: IIppI See Coour Coded ....Nisi * NONE • 1-2 sprays in affected nostril Indications/Contraindications: • Usual concentration is 0.05%by volume • Vasoconstrictor used with nasal intubation and epistaxis Relative Contraindication is significant hypertension Pralidoxime Adult Dosina • 600 mg IV/ IO/ IM over 30 • Paramedic (2-PAM) minutes for minor symptoms • 1800 mg IV/ IO/ IM over 30 NHT EMS Protocol: minutes for major symptoms NONE • See local protocol for minorversus major indications IndicationslContraindications: • Antidote for Nerve Agents or Pediatric Dosina Organophosphate Overdose • 15—25 mg/kg IV/ IM/ IO over 30 • Administered with Atropine minutes • See local protocol for specific pediatric dosing recommendations Dirug (Page, of 14 Ph Is aII"Imu G4i&II"y Is"bIrov I G10"k'��as a IIrp I!eiI"Piece on I It GRo cs not contain a I I oI'the co kntlyddmficatlons d i,W potential dd GNo:iI,4G"II"eactioi",I'oreach Ilsted k'�{IIrug.It is the IIrpsl"bC nsil.b 1.it`k oI'each p:,�,:IMS Systeir,Ago:ncv and: IIkBar¢��11cuul 13irector to assuu"e that each I IIMS pvlroV'essionaI is Iknow Ied:go:alll.I alb out the use each d:rug in this I'orlr uI airy. 608 urug List Ii ui�� i II dS If)u�gw:vidsu s iforII'�14III I II;I II"dS u u su�Ii s .uissiui�::ur�I uis sllIlu..r��:�rs ��:u..r Ii alas d Medication Dosing Provider Sodium Bicarbonate Adult Dosina • Initial bolus 50 mEq IV/10 • Paramedic NHT EMS Protocol: Beta Blocker/Calcium Channel 23-Dialysis Renal Failure Blocker Overdose 26-Overdose Toxic Ingestion . 50mEq IWO 52-Ped OD Toxic Ingestion f 72-Crush Syndrome Tricyclic Antidepressant Overdose Indications/Contraindications: • 50mEq IWO • A buffer used in acidosis to Pediatric Dosina increase the pH in Cardiac Arrest, Hyperkalemia orTricyclic "'III"' SeeColllour Coded Ill....liisi Overdose. • Initial bolus 1 mEq /kg IV/10 • Maximum 50 mEq Overdose • Repeat 0.5mg/kg in 10 minutes if QRS remains >0.09secs. 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