Southern Tier Regional Emergency Medical Services
2012 Regional Patient Care Protocols EMT INTERMEDIATE CRITICAL CARE TECHNICIAN PARAMEDIC PHYSICIAN
TABLE OF CONTENTS Introduction from Regional Medical Director ................................................................... 3 Acknowledgements............................................................................................................. 5 Adult Cardiac Arrest: General Adult CPR.......................................................................... 6 Adult Cardiac Arrest: Asystole .......................................................................................... 7 Adult Cardiac Arrest: Pulseless Electrical Activity (PEA)................................................. 8 Adult Cardiac Arrest: Termination of Resuscitation ......................................................... 9 Adult Cardiac Arrest: Ventricular Fibrillation / Pulseless V-Tach................................... 10 Adult Cardiac Arrest: ROSC – Therapeutic Hypothermia………………………………11 Adult Cardiac: Acute Coronary Syndrome - Suspected .................................................. 13 Adult Cardiac: ST Elevation MI - CONFIRMED ........................................................... 14 Adult Cardiac: Cardiogenic Shock .................................................................................. 15 Adult Cardiac: Wide Complex Tachycardia with a Pulse ............................................... 16 Adult Cardiac: Narrow Complex Tachycardia ................................................................ 17 Adult Cardiac: Symptomatic Bradycardia / Heart Blocks ............................................... 18 Adult General: Nausea and/or Vomiting ......................................................................... 19 Adult General: Pain Management Adult........................................................................... 20 Adult General: Patient Restraint ...................................................................................... 21 Adult General: Procedural Sedation ................................................................................ 22 Adult Medical: Anaphylaxis ............................................................................................ 23 Adult Medical: Diabetic Emergencies ............................................................................. 25 Adult Medical: Overdose or Toxic Exposure .................................................................. 26 Adult Medical: Seizures.................................................................................................... 27 Adult Medical: Shock / Hypoperfusion ........................................................................... 28 Adult Medical: Suspected Stroke...................................................................................... 29 Adult OB/Gyn: Childbirth ............................................................................................... 30 Adult OB/Gyn: Eclampsia ............................................................................................... 32 Pediatric Emergencies....................................................................................................... 33 Pediatric Cardiac Arrest: Asystole or PEA....................................................................... 34 Pediatric Cardiac Arrest: Ventricular Fibrillation / Pulseless V-Tach.............................. 35 Pediatric Cardiac: Bradycardia .........................................................................................36 Pediatric Cardiac: Tachycardia .........................................................................................37 Pediatric: Acute Asthma ...................................................................................................38 Pediatric: Anaphylaxis ......................................................................................................39 Pediatric: Diabetic Emergencies....................................................................................... 40 Pediatric: Hypoperfusion ..................................................................................................41 Pediatric: Overdose or Toxic Exposure ........................................................................... 42 Pediatric: Pain Management/Procedural Sedation............................................................ 43 Pediatric: Seizures............................................................................................................. 44 Pediatric: Stridor .............................................................................................................. 45 Adult Respiratory: Acute Asthma..................................................................................... 46 Adult Respiratory: Acute Pulmonary Edema................................................................... 47 Adult Respiratory: COPD Exacerbation........................................................................... 48 STREMS PROTOCOLS 2012 1
Adult Respiratory: Upper Airway Obstruction / Stridor…..……………………………. 49 Trauma: Adult Trauma Triage and Transport……………………………………………50 Trauma: Pediatric Trauma Triage and Transport………………………………………...51 Trauma: General…………………………………………………………………………52 Adult Trauma: Burns…..………………………………………………………………...53 Adult Trauma: Burn Care Considerations…..…………………………………………...54 Adult Trauma: Chest Trauma…..………………………………………………………..55 Adult Trauma: Crush Injuries…..………………………………………………………..56 Adult Trauma: Hypoperfusion / Hypovolemia……..……………………………………57 Aeromedical Utilization………………………………………………………………….58 Airway Management and Oxygen Delivery……………………………………………..59 Emergency Incident Rehab………………………………………………………………61 Smoke Inhalation – Symptomatic………………………………………………………..62 Inter-Hospital Transport………………………………………………………………….63 Medication and Medical Control………………………………………………………...65 Medication Formulary…………………………………………………………………...66 Medication Infusions…………………………………………………………………….67 Procedure: Sedation Assisted Intubation……...…………………………………………68 Transfer of Care………………………………………………………………………….69 Vascular Access………………………………………………………………………….70 Vascular Devices, Pre-Existing………………………………………………………….71
STREMS PROTOCOLS 2012 2
Introduction from Regional Medical Director The Regional Medical Advisory Committee is proud to put forth these protocols for the STREMS region. These have been developed after an extensive review of protocols from other regions, research, as well as recent relevant medical literature. These evidence based guidelines for care are designed to improve patient outcomes, while decreasing any potential risk to the patient and maximizing the interventions appropriate for each level of care. The color coded format of the protocols has been added. This will serve to allow each EMS professional to easily follow the potential interventions which could be performed by advanced level care. EMT
●
EMT, EMT-1, EMT-CC, and Paramedic standing orders
EMT STOP INTERMEDIATE
●
EMT-1, EMT-CC, and Paramedic standing orders
INTERMEDIATE STOP CCT
●
EMT-CC, and Paramedic standing orders
CCT STOP PARAMEDIC
● ●
Paramedic standing orders Many CCT physician options
PARAMEDIC STOP PHYSICIAN
●
Any order within the level of care for the provider
Key Points/Considerations
● Additional points specific to patients that fall within the protocol The protocols are designed to serve the region as a whole, and include all levels of field providers. As taught in every EMT class, BLS should be done before ALS, and advanced providers are responsible for all appropriate basic interventions. At all provider levels, the standing orders are highlighted, while the corresponding standing order STOP line is clearly delineated. STREMS PROTOCOLS 2012 3
STREMS PROTOCOLS 2012 4
Acknowledgements The 2012 STREMS Medical Advisory Protocol Subcommittee and the EMSTAR staff all contributed to this update.
William E. Huffner, MD, MBA, FACEP, FACHE Kevin P. O’Connor, MD, FACEP Robert C. Rajsky, MSED, NREMT-P Richard Kimball, NREMT-P Ann Repsher, RN Daryl Tombs, CCEMT-P Don DuVall, NRCCEMT-P
STREMS PROTOCOLS 2012 5
Adult Cardiac Arrest: General Adult CPR ALL PROVIDERS
Do not delay beginning compressions to begin ventilations- compressions must begin as soon as it is determined the patient does not have a pulse The AED should be applied to the patient as soon as it is available and without interrupting compressions Push hard and fast (greater than or equal to100/min) Ensure full chest recoil Minimize interruptions in chest compressions Cycle of CPR = 30 compressions then 2 breaths, 5 cycles = 2 minutes Avoid hyperventilation Defibrillation as appropriate Secure airway and confirm placement with wave form capnography as appropriate After an advanced airway is placed, rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pauses for breaths. Give 8-10 breaths/minute Check rhythm every two minutes Rotate compressors every two minutes with rhythm checks Use mechanical CPR adjuncts as available (e.g. AutoPulse or Thumper) Search for and treat possible contributing factors: Hypovolemia Hypoxia Hydrogen Ion (acidosis) Hypo-hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension pneumothorax Thrombosis (coronary or pulmonary) Trauma
SEE RHYTHM SPECIFIC PROTOCOLS
STREMS PROTOCOLS 2012 6
Adult Cardiac Arrest: Asystole EMT
CPR consistent with current AHA guidelines. EMT STOP
INTERMEDIATE
Secure airway. Initial use of oropharyngeal airway and bag-mask device is acceptable, with advanced airway deferred initial care Vascular access, Normal Saline 500 ml IV bolus INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 Transcutaneous pacing if witnessed cardiac arrest Epinephrine 1:10,000 dose 1 mg IV\IO repeat every 4 minutes, or Vasopressin 40 units IV\IO once in place of first or second dose epinephrine CCT AND PARAMEDIC STOP
PHYSICIAN OPTIONS
Sodium Bicarbonate 50 mEq IV Termination of resuscitation
Key Points/Considerations
Do not interrupt compressions for placement of an advanced airway during the first 4 minutes of CPR Check asystole in more than 1 lead Continue CPR during pacing unless pacing produces palpable pulse Refer to the Termination of Resuscitation Protocol as needed Consider and treat causes, including: Hypoxemia, Hypovolemia, Hypoglycemia, Hypothermia, Hyperkalemia, Hydrogen Ion (acidosis), Tension Pneumothorax, Tablets/Toxins (Overdose), Trauma, Tamponade, Thrombosis
STREMS PROTOCOLS 2012 7
Adult Cardiac Arrest: Pulseless Electrical Activity (PEA) EMT
CPR consistent with current AHA guidelines. EMT STOP
INTERMEDIATE
Secure airway. Initial use of oropharyngeal airway and bag-mask device is acceptable, with advanced airway deferred Vascular access, Normal Saline 500 ml IV bolus INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 Consider and treat causes of PEA Epinephrine 1:10,000 dose 1 mg IV\IO repeat every 4 minutes, or Vasopressin 40 units IV\IO once in place of first or second dose epinephrine CCT AND PARAMEDIC STOP
PHYSICIAN OPTIONS
Sodium Bicarbonate 50 mEq IV Termination of resuscitation
Key Points/Considerations
Do not interrupt compressions for placement of an advanced airway during the first 4 minutes of CPR Refer to the Termination of Resuscitation Protocol as needed Consider and treat causes, including: Hypoxemia, Hypovolemia, Hypoglycemia, Hypothermia, Hyperkalemia, Hydrogen Ion (acidosis), Tension Pneumothorax, Tablets/Toxins (Overdose), Trauma, Tamponade, Thrombosis
STREMS PROTOCOLS 2012 8
Adult Cardiac Arrest: Termination of Resuscitation EMT
Resuscitative efforts for patients in cardiac arrest should not be initiated if: o The patient presents with significant dependent lividity, rigor mortis, decomposition and/or injuries incompatible with life (such as decapitation) o There is a signed NYS Out of Hospital DNR (Do Not Resuscitate) Order Form #3474 and/or MOLST form #B-1620 o The patient is in a health care facility (as defined in NYS Public Health Law Article 28) and has a DNR order appropriate to that facility For all other patients in respiratory or cardiac arrest, the EMS provider MUST start BLS care, including defibrillation, and consult medical control EMT STOP
INTERMEDIATE CCT PARAMEDIC
Complete standing orders appropriate to presenting rhythm INTERMEDIATE CCT AND PARAMEDIC STOP
PHYSICIAN OPTIONS
Field termination of resuscitation, if cardiac arrest patient meets all of the following: o Non-hypothermic o Failed response to appropriate treatment o Scene is appropriate for termination order
Key Points/Considerations Resuscitative efforts must be initiated while attempting to contact a Physician. If there is an extended time required to contact a Physician, transport must be initiated Health Care Facilities (as defined in NYS Public Health Law Article 28) may have DNR forms appropriate to the level of facility. If identified by the facility staff as correct, these forms should be honored. If a patient presents in respiratory or cardiopulmonary arrest and there is any other form of advanced directive on the scene, other than NYS DOH #3474 and/or MOLST form # B1620 the EMS Provider must start BLS care (including Defibrillation), and contact Medical Control. Other forms of advanced directives include: Living Wills, Health Care Proxies, and In-Hospital Do Not Resuscitate orders. Any certified EMS provider may consult an on-line medical control physician to request termination of resuscitation. If a patient with a DNR is a resident of a Nursing Home and expires during transport, contact the receiving facility to determine if they are willing to accept the patient. If not, return the patient to the sending facility. A copy of the DNR must be attached to the PCR and retained by the agency. STREMS PROTOCOLS 2012 9
Adult Cardiac Arrest: Ventricular Fibrillation / Pulseless V-Tach EMT
CPR consistent with current AHA guidelines. Defibrillation as appropriate EMT STOP
INTERMEDIATE
Secure airway. Initial use of oropharyngeal airway and bag-mask device is acceptable, with advanced airway deferred initial care Vascular access, Normal Saline 500 ml IV bolus INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 Epinephrine 1:10,000 dose 1 mg IV\IO. Repeat every 4 minutes, or Vasopressin 40 units IV\IO once, in place of first or second dose epinephrine Defibrillation after each medication administration/end of CPR cycle if indicated Amiodarone 300 mg IV\IO. Repeat 150 mg in 4 minutes or Lidocaine IV\IO 1.5 mg\kg. Repeat in 4 minutes at 0.75 mg\kg If pulses return: use antiarrhythmic of conversion o Amiodarone 150 mg in 100 ml NS over 10 minutes (10 ml/min) or Lidocaine drip 2-4 mg/minute o 12 lead EKG CCT STOP
PARAMEDIC
Consider: Sodium Bicarbonate 50 mEq for renal failure or suspected hyperkalemia Consider: Magnesium 2 grams IV if suspected hypomagnesemic or torsades de pointes PARAMEDIC STOP
PHYSICIAN OPTIONS
Antiarrhythmic rebolus or infusion rate adjustments
Key Points/Considerations
Do not interrupt compressions for placement of an advanced airway during the first 4 minutes of CPR Refer to the Termination of Resuscitation Protocol as needed STREMS PROTOCOLS 2012 10
Adult Cardiac Arrest – ROSC – Therapeutic Hypothermia EMT
Airway management and appropriate oxygen therapy Ice packs in axilla, groin and neck; change every 10-15 minutes EMT STOP
INTERMEDIATE
Vascular access at 2 sites (no more than one IO) Infuse chilled (Approx. 39◦F) normal saline to a total of 30 mL/kg or 2 L max, rapid infusion INTERMEDIATE STOP
CCT PARAMEDIC
Treatment for appropriate presenting rhythm *see key points below Cardiac Monitor with 12 lead EKG acquired and transmitted as soon as possible Complete neurologic exam including specific GCS items and pupillary response Maintain MAP > 65 (SBP>80) o Consider Dopamine 5 mcg/kg/min if needed after fluid bolus complete Prevent shivering o Midazolam 2 mg IV every 5 minutes as needed (SBP>/=100) o Etomidate 10 mg IV every 10 minutes (SBP80) Antiarrhythmic (additional Amiodarone or Lidocaine) Dopamine titration Management of hypertension SBP>200 with either o Nitroglycerin 0.4 mg SL o Metoprolol 5 mg IV over 5 min to a max of 15 mg (DO NOT BOLUS)
STREMS PROTOCOLS 2012 11
Adult Cardiac Arrest – ROSC – Therapeutic Hypothermia (Continued) Key Points/Considerations
INCLUSION CRITERIA: Patients with ROSC following cardiac arrest who have a GCS of 120 mmHg EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor with 12 Lead EKG/SpO2 Notify medical control AS SOON AS POSSIBLE For ST Elevation MI, with 1 mm or more of elevation in 2 contiguous leads, or new LBBB. Machine interpretation notes “Acute MI”, do not delay transport. Follow STEMICONFIRMED protocol. Nitroglycerin 0.4 mg per dose, up to 3 doses, 5 minutes apart, provided the patient’s systolic BP is above 100 mmHg If systolic BP drops below 90 mmHg: Normal Saline 250 ml IV bolus CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Repeat Nitroglycerin 0.4 mg every 5 minutes Morphine slow IV push
Key Points/Considerations
Focus on maintaining ABC, pain relief, rapid identification, rapid notification and appropriate transport to an appropriate facility Vitals, including 12 Lead EKG, should be monitored frequently during transport The first dose of Nitroglycerin may be administered while preparing to establish vascular access A total of 3 doses of Nitroglycerin may be administered by pre-hospital providers, prior to consulting medical control Do not administer Nitroglycerin to patients taking sexual enhancing or pulmonary hypertensive medications STREMS PROTOCOLS 2012 13
Adult Cardiac: ST Elevation MI - Confirmed EMT
ABC and vital signs Aspirin 324 mg (4 x 81 mg tabs) chewed Airway management and appropriate oxygen therapy Assist patient with their own prescribed Nitroglycerin (1 dose), if SBP is >120 mmHg EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac Monitor with 12 Lead EKG/SpO2 Notify medical control ASAP for ST elevation myocardial infarction (STEMI) or new onset LBBB Strongly recommend transport to facility capable of primary angioplasty if transport time is less than one hour Notify receiving hospital as soon as possible to discuss transport options if patient requests facility not capable of primary angioplasty. Nitroglycerin 0.4 mg per dose, up to 3 doses, 5 minutes apart, SBP>100 mmHg If systolic BP drops below 90 mmHg: Normal Saline 250 ml IV bolus CCT STOP
PARAMEDIC
Morphine 0.05 mg/kg slow IV if Sys BP>100 and ONLY IF severe chest pain PARAMEDIC STOP
PHYSICIAN OPTIONS
Repeat 0.4 mg doses of Nitroglycerin every 5 minutes
Key Points/Considerations
Focus on rapid identification, rapid notification and rapid transport to appropriate facility 12 Lead EKG should be transmitted to receiving facility if possible Vitals, including 12 Lead EKG, should be monitored frequently during transport Use caution administering NTG with an Inferior wall MI Do not administer Nitroglycerin to patients taking sexual enhancing or pulmonary hypertensive medications STREMS PROTOCOLS 2012 14
Adult Cardiac: Cardiogenic Shock EMT
ABC and vital signs Airway management and appropriate oxygen therapy Aspirin 324 mg (4 x 81 mg tabs) chewed Place patient supine unless dyspnea is present EMT STOP
INTERMEDIATE
Vascular access Normal saline 250 ml IV bolus; recheck lung sounds and repeat if unchanged INTERMEDIATE STOP
CCT
Cardiac Monitor with 12 Lead EKG/SpO2 Notify medical control ASAP for ST elevation myocardial infarction (STEMI) or new onset LBBB CCT STOP
PARAMEDIC
If UNSTABLE, Dopamine infusion 5 micrograms/kg/min PARAMEDIC STOP
PHYSICIAN OPTIONS
Dopamine infusion at 5-20 micrograms/kg/min Additional Normal Saline
Key Points/Considerations
For patients with Suspected Acute Coronary Syndrome and signs of hypoperfusion Unstable is defined as systolic BP less than 90 mmHg and/or decreased level of consciousness Refer to Dysrhythmia protocols as needed 12 Lead EKG should be transmitted to receiving facility if possible Vitals, including 12 Lead EKG, should be monitored frequently during transport
STREMS PROTOCOLS 2012 15
Adult Cardiac: Wide Complex Tachycardia with a Pulse EMT
ABC and vital signs Airway management and appropriate oxygen therapy EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 12 Lead EKG If UNSTABLE, consider sedation (see Procedural Sedation Protocol) o Synchronized cardioversion. Repeated as needed, maximum 3 times o If rhythm is converted: Amiodarone 150 mg in 100 ml NS IV\IO over 10 minutes, or Lidocaine, IV\IO 1.0-1.5 mg/kg followed by 2-4 mg/min drip CCT STOP
PARAMEDIC
If STABLE, Amiodarone 150 mg in 100 ml NS over 10 minutes, or Lidocaine IV\IO 1.0-1.5 mg/kg followed by 2-4 mg/min drip If STABLE and regular, monomorphic, wave form present; consider Adenosine 6 mg IV push. May consider repeat dose of Adenosine 12 mg IV push. PARAMEDIC STOP
PHYSICIAN OPTIONS
Synchronized cardioversion Repeat Amiodarone 150 mg in 100 ml Normal Saline, over 10 minutes or, Lidocaine 0.5 mg-0.75 mg/kg bolus, followed by a 2-4 mg/min drip Magnesium 2 g IV, over 20 minutes for STABLE patient, over 2 minutes for UNSTABLE patient
Key Points/Considerations If no pulse treat as V-Fib UNSTABLE is defined as ventricular rate>150 bpm with symptoms of chest
pain, dyspnea, altered mental status, pulmonary edema, ischemia, infarction or hypotension (systolic BP 150 bpm with symptoms of
chest pain, dyspnea, altered mental status, pulmonary edema, ischemia, infarction or hypotension (systolic BP < 90 mmHg) STREMS PROTOCOLS 2012 17
Adult Cardiac: Symptomatic Bradycardia / Heart Blocks EMT
ABC and vital signs Airway management and appropriate oxygen therapy Have AED available EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 12 Lead EKG Transcutaneous pacing, consider sedation (see Procedural Sedation Protocol) Atropine 0.5 mg IV CCT STOP
PARAMEDIC
Repeat Atropine 0.5 mg IV, every 3 min, up to a max of 3 mg Dopamine infusion 5 micrograms/kg/min PARAMEDIC STOP
PHYSICIAN OPTIONS
Dopamine infusion 5-20 micrograms/kg/min
Key Points/Considerations Only treat bradycardia if patient is symptomatic Symptomatic presentation includes chest pain, dyspnea, altered mental
status, pulmonary edema, ischemia, infarction or hypotension (systolic BP < 90 mmHg) Consider “H’s & T’s”
STREMS PROTOCOLS 2012 18
Adult General: Nausea and/or Vomiting EMT
ABC and vital signs Airway management and appropriate oxygen therapy EMT STOP
INTERMEDIATE
Vascular access Normal Saline 250 ml bolus IV INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 Consider 12 Lead EKG Ondansetron 4 mg IV or IM, may repeat x 1 in 10 minutes CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Midazolam 0.05 mg/kg IV, IM or atomized intranasal Diphenhydramine 12.5-25 mg IV or IM for motion sickness
STREMS PROTOCOLS 2012 19
Adult General: Pain Management Adult EMT
ABC and vital signs Airway management and appropriate oxygen therapy EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 Morphine up to 5 mg slow IV or IM (SEE KEY POINTS BELOW) Morphine may be repeated with total dose not to exceed 10 mg Ondansetron 4 mg IV or IM, if patient becomes nauseous CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Fentanyl 0.5-1 mcg/kg slow IV, IM or atomized intranasal Additional Morphine IV or IM Additional Ondansetron IV or IM Midazolam 0.05 mg/kg IV, IM or atomized intranasal
Key Points/Considerations
For patients with: o Severe burns without hemodynamic compromise o Isolated extremity injuries such as fractures or dislocation with severe pain o Suspected hip fractures should be treated as extremity injuries o Shoulder injuries should be treated as extremity injuries For all other painful conditions, providers must consult Medical Control for orders Contraindications to standing order pain management: altered mental status, hypoventilation, SBP100 Midazolam 0.05 mg/kg IV/IM or atomized intranasal for transcutaneous pacing or post-intubation o May be repeated every 5 minutes as needed if SBP>100 PARAMEDIC STOP
PHYSICIAN OPTIONS
Morphine IV or IM Fentanyl IV or IM or atomized intranasal Ondansetron 4 mg IV o IM if patient becomes nauseous
Key Points/Considerations
For patients with the following anxiety producing or painful procedures including: o Cardioversion o Transcutaneous pacing o Post-intubation sedation, following confirmed endotracheal intubation Not for disentanglement or management of suspected fractures without Medical Control consultation This protocol may NOT be used in conjunction with the Pain Management Protocol, unless Medical Control consulted
STREMS PROTOCOLS 2012 22
Adult Medical: Anaphylaxis EMT
ABC and vital signs Airway management and appropriate oxygen therapy Determine if patient has utilized their own Epinephrine auto injector Patient previously prescribed Epinephrine auto injector with severe resp. distress, edema, hypotension o Administer appropriate Epinephrine auto injector Patient NOT previously prescribed Epinephrine auto injector with severe resp. distress, edema, hypotension o Contact Medical Control for orders to administer IF UNABLE to contact Medical Control: o Administer appropriate Epinephrine auto injector EMT STOP
INTERMEDIATE
Vascular access Normal Saline 500 ml IV bolus INTERMEDIATE STOP
CCT
Cardiac Monitor/ Albuterol 2.5 mg in 3 ml (unit dose) + Ipratropium 0.5mg in 2.5ml (unit dose) mixed together, via nebulizer. May repeat to a total of three doses for wheezing if HR remains < 160 Diphenhydramine 50 mg IV or IM Epinephrine 1:1,000 dose 0.5 mg IM, if patient has hypotension and/or respiratory distress w/ airway swelling, hoarseness, stridor or wheezing CCT STOP
PARAMEDIC
Methylprednisolone 125mg IV PARAMEDIC STOP
STREMS PROTOCOLS 2012 23
Adult Medical: Anaphylaxis (continued) PHYSICIAN OPTIONS
Additional Albuterol unit dose, via nebulizer Dopamine infusion 5-20 micrograms/kg/min Epinephrine infusion (1mg in 250ml Normal Saline), at 5 micrograms/min
Key Points/Considerations
If an Epinephrine auto injector has already been used, consult Medical Control prior to administering additional epinephrine If an Epinephrine auto injector has already been used, consult Medical Control prior allowing a patient to RMA
STREMS PROTOCOLS 2012 24
Adult Medical: Diabetic Emergencies EMT
ABC and vital signs Airway management and appropriate oxygen therapy Check blood glucose level, if equipped If blood glucose is known or suspected to be low and patient is able to self administer and swallow on command, give oral glucose one unit dose (19-24g) If blood glucose is CONFIRMED to be high, do not administer oral glucose Call for ALS Intercept if unable to swallow on command, or mental status remains altered following administration of oral glucose EMT STOP
INTERMEDIATE
Vascular access If glucose level is below 80 and patient cannot swallow on command, administer D5W 500 ml IV bolus If glucose level is above 400, administer Normal Saline 250ml IV bolus INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 If glucose level is below 80 and patient cannot swallow on command, administer Dextrose 50% 25g IV; may redose if hypoglycemia recurs during transport If unable to obtain vascular access, Glucagon 1mg IM or SC CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Additional Normal Saline IV bolus, if patient is hyperglycemic Additional Dextrose 50%, if patient is hypoglycemic
Key Points/Considerations
If the patient wishes to refuse transportation to a hospital and you have administered any medications you must document risks/benefits/patients mental status and have the patient sign a refusal If the patient’s blood glucose level is below 80 and the patient is able to self administer and swallow on command, administer oral glucose or equivalent rather than establishing vascular access, if possible
STREMS PROTOCOLS 2012 25
Adult Medical: Overdose or Toxic Exposure EMT
Decontamination as needed ABC and vital signs Airway management and appropriate oxygen therapy Determine what was taken, when and how much, if possible Check blood glucose level, if equipped. If level is abnormal refer to Diabetic Protocol EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 Opiate overdose with respiratory compromise: 0.4 mg Naloxone: IV, IM or atomized intranasal. May redose until respiratory status improves 12 Lead EKG if bradycardic or tachycardic (for QRS widening or QT prolongation) CCT STOP
PARAMEDIC
For symptomatic patients with: o Organophosphate poisoning: Atropine 2-5mg IV per dose until secretions dry o Dystonic reaction: Diphenhydramine 50mg IV or IM o Calcium channel blocker OD: Calcium Chloride 1g IV, Glucagon 2mg IV o Beta blocker OD: Glucagon 2mg IV, Calcium Chloride 1g IV o Tricyclic antidepressant OD: Sodium Bicarbonate 1 mEq/kg IV until QRS complex narrows below 100 mSec PARAMEDIC STOP
PHYSICIAN OPTIONS
Sympathomimetic OD (cocaine/amphetamines): Midazolam 0.05 mg/kg IV, IM or atomized intranasal
Key Points/Considerations
Includes patients who are unconscious/unresponsive without suspected trauma If suspected narcotic overdose administer Naloxone prior to checking blood glucose level Do NOT give naloxone to any patient who is intubated without physician order Dystonic reaction is uncontrolled muscle contractions of face, neck or tongue If suspected WMD refer to NYS Advisory on Mark 1 Kits, SEMAC Advisory 03-05 STREMS PROTOCOLS 2012 26
Adult Medical: Seizures EMT
ABC and vital signs Airway management and appropriate oxygen therapy Check blood glucose level, if equipped. If level is abnormal refer to Diabetic Protocol EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 Midazolam 5mg IM, IV/IO or atomized intranasal CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Magnesium 4 g IV over 2 minutes, if patient is pregnant Additional Midazolam 2-5mg IV, IM or atomized intranasal
Key Points/Considerations
Protect the patient and EMS crew from injury during the seizure Standing orders are for tonic/clonic seizures (grand mal seizures) only Refer to the Eclampsia protocol if patient is pregnant
STREMS PROTOCOLS 2012 27
Adult Medical: Shock / Hypoperfusion EMT
ABC and vital signs Airway management and appropriate oxygen therapy Place patient in supine position unless dyspnea is present Place patient in modified Trendelenburg position, if tolerated Consider MAST, if available EMT STOP
INTERMEDIATE
Vascular access If no pulmonary edema: o Additional vascular access o Normal Saline 500ml IV; check lung sounds, repeat NS Bolus if lung sounds unchanged INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 12 Lead EKG CCT STOP
PARAMEDIC
Repeat Normal Saline 500ml bolus IV, up to 3 times Consider Dopamine infusion 5 micrograms/kg/minute PARAMEDIC STOP
PHYSICIAN OPTIONS
Additional Normal Saline IV bolus Dopamine infusion 5-20 micrograms/kg/minute Epinephrine infusion 2-10 micrograms/minute
Key Points/Considerations
Hypoperfusion is defined as Systolic BP220 or diastolic BP>120 contact Medical Control CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Metoprolol 5mg slow IV push
Key Points/Considerations
Refer to NYS BLS Stroke Protocol Cincinnati Pre-Hospital Stroke Scale: o Have the patient repeat “You can’t teach an old dog new tricks”. Assess for correct use or words, without slurring o Have the patient smile Assess for facial droop o Have the patient close eyes and hold arms straight out for 10 seconds Assess for arm drift or unequal movement of one side
STREMS PROTOCOLS 2012 29
Adult OB/GYN: Childbirth Management of a Normal Delivery
Support the baby’s head over the perineum If the membranes cover the head after it emerges, tear the sac with your fingers or forceps to permit escape of the amniotic fluid. Suction mouth then nose with bulb syringe Suctioning is reserved for depressed newborns with suspected thick meconium aspiration, obvious obstruction or those that require positive pressure ventilation. Gently guide the head downward until the shoulder appears. The other shoulder is delivered by gentle upward traction. The infant’s face should be upward at this point. If the cord is around the neck, AND it cannot be slipped over the head, clamp it with two clamps, cut the cord between the clamps, and unwrap the cord from around the neck. This is an emergency, as the baby is no longer getting any oxygen either through the cord or by breathing. Clamp the umbilical cord with two clamps and cut the cord between them. Assess APGAR score
Management of a Breech Delivery
Support the buttocks or extremities until the back appears. Grasp the baby’s ILIAC WINGS and apply gentle downward traction. DO NOT pull on the legs or back, as this may cause spine dislocation or adrenal hemorrhage. Gently swing the infant’s body in the direction of least resistance. By swinging anteriorly and posteriorly, both shoulders should deliver posteriorly. Splint the humerus bones with your two fingers, apply gentle traction with your fingers. Gentle downward compression of the uterus will assist in head delivery. Swing the legs upward until the body is in a vertical position. This will permit delivery of the head.
Management of a Prolapsed Cord or Limb Presentation
Place the mother in a face-up position with hips elevated Place a gloved hand in the vagina; attempt to hold the baby’s head away from the cord. Keep the cord moist using a sterile dressing and sterile water. Transport as soon as possible.
APAGAR Score
Score should be recorded at 1 minute and 5 minutes after birth Do not withhold resuscitation efforts to determine APGAR score
SIGN A - Appearance P - Pulse G - Grimace (flick soles of feet) A – Activity (muscle tone) R – Respirations
0 Blue, pale Absent No Response Limp No effort
1 Body pink, extremities blue Below 100 bpm Grimace Some flexion Weak, irregular
STREMS PROTOCOLS 2012 30
2 Completely pink Above 100 bpm Vigorous cry Active motion Strong cry
Adult OB/GYN: Childbirth (continued) Key Points
Determine the estimated date of expected birth, the number of previous pregnancies and # of live births Determine if the amniotic sac (bag of water) has broken, if there is vaginal bleeding or mucous discharge, or the urge to bear down Determine the duration and frequency of uterine contractions Examine the patient for crowning. If delivery is not imminent, transport as soon as possible. If delivery is imminent, prepare for an on-scene delivery If multiple births are anticipated but the subsequent births do not occur within 10 minutes of the previous delivery transport immediately After delivery of the placenta gently massage the uterus Bring the placenta and any other tissue to the hospital for inspection Suctioning is reserved for newborns with obvious obstruction or those that require positive pressure ventilation.
STREMS PROTOCOLS 2012 31
Adult OB/GYN: Eclampsia EMT
ABC and vital signs Airway management and appropriate oxygen therapy EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac monitor/SpO2 CCT STOP
PARAMEDIC
If patient is seizing or has had a witnessed seizure, administer: o Magnesium 4g over 2 minutes, IV PARAMEDIC STOP
PHYSICIAN OPTIONS
Additional Magnesium infusion or bolus Metoprolol 5mg Slow IV every 5 minutes (max 3 doses) Midazolam 2-5mg IV, IM or atomized intranasal
Key Points/Considerations
Pre-eclampsia is defined as BP greater than 140/90 in a pregnant patient, or one who has recently given birth, with severe headache, confusion and/or hyperreflexia Eclampsia is the above with seizure activity If the patient has a known seizure history, refer to “Seizure Protocol”
STREMS PROTOCOLS 2012 32
Pediatric Emergencies For these protocols, pediatric patients are defined as children from birth to puberty (breast development in females, underarm hair in males) Procedures for Paramedics and Critical Care Technicians are only for the following clinical situations: o Cardiac or Respiratory Arrest o Cardiac Dysrhythmias (Bradycardia, Supraventricular Tachycardia) o Asthma/Acute Bronchospasm o Anaphylaxis/Allergic Reaction o Stridor o Seizures o Pain Management o Sedation o Altered Mental Status/Overdose o Diabetic Emergencies o Major Trauma o Hypoperfusion In all other clinical situation you must contact Medical Control Have a Broselow Pediatric Tape or similar device available to accurately determine the correct medication dosage Normal Vital Signs for Infants and Children: AGE RESPIRATIONS PULSE SYSTOLIC BP Newborn 30-60 100-180 >60 Infant (60 Toddler (1-3 years) 24-40 90-150 >70 Preschooler (3-5 years) 22-34 80-140 >75 School-aged (6-8 years) 18-30 70-120 >80 From: American Academy of Pediatrics, Pediatric Education for Prehospital Professionals
STREMS PROTOCOLS 2012 33
Pediatric Cardiac Arrest: Asystole or PEA EMT INTERMEDIATE
CPR consistent with current AHA guidelines. Airway management and appropriate oxygen therapy via BVM. EMT and INTERMEDIATE STOP
CCT
Vascular access Cardiac Monitor/SpO2 Normal Saline 20 ml/kg rapid IV or IO bolus Epinephrine 1:10,000 dose 0.01 mg/kg IV or IO CCT STOP
PARAMEDIC
Secure airway Repeat Epinephrine every 4 minutes PARAMEDIC STOP
PHYSICIAN OPTIONS
Sodium Bicarbonate 1 mEq/kg IV
Key Points/Considerations
Call Medical Control and begin transport to the closest hospital as soon as possible Do not interrupt compressions for placement of an advanced airway during the first 4 minutes of CPR Confirm asystole in more than 1 lead Consider and treat causes of PEA: Hypoxemia, Hypovolemia, Hypoglycemia, Hypothermia, Hyperkalemia, Hydrogen Ion (acidosis), Pulmonary Embolism, Tension Pneumothorax, Cardiac Tamponade, Tablets/Toxins (overdose)
STREMS PROTOCOLS 2012 34
Pediatric Cardiac Arrest: Ventricular Fibrillation / Pulseless V-Tach EMT INTERMEDIATE
CPR consistent with current AHA guidelines. EMT and INTERMEDIATE STOP
CCT
Vascular access Cardiac Monitor/SpO2 Epinephrine 1:10,000; 0.01mg/kg IV/IO CCT STOP
PARAMEDIC
Secure airway Repeat Epinephrine every 4 minutes Defibrillation at 4 J/kg between doses of medication Amiodarone 5 mg/kg bolus IV or IO; repeat twice as needed (Amiodarone 150 mg in 100ml, 1.5 mg/ml), or Lidocaine 1mg/kg) PARAMEDIC STOP
PHYSICIAN OPTIONS
Repeat Lidocaine, 1 mg/kg IV or IO
Key Points/Considerations
Call Medical Control and begin transport to the closest hospital as soon as possible Do not interrupt compressions for placement of an advanced airway during the first 4 minutes of CPR Treat V-Tach without a pulse as V-fib Consider “H’s & T’s”
STREMS PROTOCOLS 2012 35
Pediatric Cardiac: Bradycardia EMT
ABC and vital signs Airway management and appropriate oxygen therapy If heart rate is bradycardic and patient’s mental status and respiratory rate are decreased, ventilate with BVM If symptomatic bradycardia persists, start CPR EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 CCT STOP
PARAMEDIC
Secure airway as appropriate Epinephrine 1:10,000 dose 0.01 mg/kg IV or IO Repeat epinephrine every 4 minutes Atropine 0.02 mg/kg, with a minimum dose 0.1 mg IV, IO Repeat Atropine once in 5 minutes, to maximum total dose of 1 mg PARAMEDIC STOP
PHYSICIAN OPTIONS
Transcutaneous pacing Epinephrine 0.1-0.3 mcg/kg/minute IV drip
Key Points/Considerations
Call Medical Control as soon as possible Newborn/Infant bradycardic if pulse less than 80 bpm; child over 1 year of age bradycardic if pulse is less than 60 bpm Symptomatic includes poor systemic perfusion, hypotension, respiratory difficulty or altered level of consciousness If bradycardia is due to increased vagal tone or primary AV block give atropine before giving epinephrine Do not treat asymptomatic bradycardia. Contact Medical Control
STREMS PROTOCOLS 2012 36
Pediatric Cardiac: Tachycardia EMT
ABC and vital signs Airway management and appropriate oxygen therapy EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 12 Lead EKG Normal Saline 20 ml/kg bolus IV or IO; may repeat once CCT STOP
PARAMEDIC
UNSTABLE patient o Synchronized cardioversion 0.5 – 1 J/kg o Consider sedation if vascular access available (see Pediatric Procedural Sedation Protocol) PARAMEDIC STOP
PHYSICIAN OPTIONS
STABLE patient, wide QRS: o Adenosine 0.1 mg/kg IV, IO (max 6 mg) may repeat at 0.2 mg/kg, maximum 12mg or o Amiodarone 5mg/kg (Amiodarone 150 mg diluted in 100ml, 1.5 mg/ml) IV, IO; over 20 minutes or o Lidocaine 1 mg/kg IV STABLE patient, narrow QRS: o Adenosine 0.1 mg/kg IV, IO (max 6 mg) may repeat at 0.2 mg/kg, maximum 12mg
Key Points/Considerations
Call Medical Control as soon as possible Newborn/Infant SVT if pulse greater than 220 bpm; child over 1 year of age SVT if pulse greater than 180 bpm, with no discernable p-waves The most common causes of Sinus Tachycardia in children are fever and dehydration UNSTABLE includes cardio-respiratory compromise, hypotension, or altered level of consciousness Do not treat asymptomatic tachycardia. Contact Medical Control STREMS PROTOCOLS 2012 37
Pediatric: Acute Asthma EMT INTERMEDIATE
ABC and vital signs Airway management and appropriate oxygen therapy Determine if patient has been given their own asthma medications Implement BLS Albuterol Protocol EMT and INTERMEDIATE STOP
CCT
Albuterol 2.5 mg in 3 ml (unit dose) + Ipratropium 0.5 mg in 2.5 ml (unit dose) mixed together, via nebulizer; repeat to a total of three doses Cardiac Monitor/SpO2 CCT STOP
PARAMEDIC
Epinephrine 1:1,000 dose 0.01 mg/kg IM, if patient in severe distress; max 0.5 mg If patient not improving, vascular access PARAMEDIC STOP
PHYSICIAN OPTIONS
Methylprednisolone 1 mg/kg IV Epinephrine 1:1,000 dose 0.3 mg mixed with 3 ml Normal Saline, via nebulizer Magnesium sulfate 50 mg/kg over 10 minutes IV
Key Points/Considerations
Call Medical Control as soon as possible Absence of breath sounds can be indicative of status asthmaticus. Be prepared for imminent respiratory arrest
STREMS PROTOCOLS 2012 38
Pediatric: Anaphylaxis EMT
ABC and vital signs Airway management and appropriate oxygen therapy Patient previously prescribed Epinephrine auto injector with severe resp. distress, edema, hypotension o Administer appropriate Epinephrine auto injector or Epinephrine auto injector Jr if 55
STREMS PROTOCOLS 2012 50
Trauma: Pediatric Trauma Triage and Transport Pediatric Trauma Patient Characteristics – Physical Findings
Major trauma is present if: UNSTABLE PATIENT Glasgow Coma Scale is less than or equal to 13 Respiratory status: cyanosis or respiratory rate either low or high for patient’s age Capillary refill time greater than 2 seconds Pulse rate either low or high for patient’s age PHYSICAL FINDINGS Penetrating injuries to head, neck, torso, groin or proximal extremities Combined system trauma involving two or more body systems, or blunt trauma to the chest or abdomen Two or more suspected proximal long bone fractures Suspected flail chest Suspected spinal cord injury or limb paralysis Amputation (except digits) Suspected pelvic fracture Suspected open or depressed skull fracture Pediatric Trauma Patient Characteristics - Mechanism of Injury
Major trauma is present if mechanism of injury is: Ejection or partial ejection from an automobile Death in the same passenger compartment secondary to trauma Extrication time in excess of 20 minutes Vehicle collision resulting in 12 inches of intrusion into the passenger compartment Motorcycle crash >20 MPH or with separation of rider from motorcycle Falls from greater than 10 feet Vehicle rollover (90 degree vehicle rotation or more) with unrestrained passenger Vehicle vs. pedestrian or bicycle collision above 5 MPH High Risk Patients
If a patient does not meet the criteria for Major Trauma, but has sustained an injury and has one or more of the following criteria, they are considered a “High Risk Patient”. Consider transportation to a Trauma Center and/or consulting Medical Control Patients with bleeding disorders or patients on anticoagulant medications Patients with cardiac disease and/or respiratory disease Patients with insulin dependent diabetes, cirrhosis, or morbid obesity Immunosupressed patients (HIV disease, transplant patients and patients on chemotherapy treatment
STREMS PROTOCOLS 2012 51
Trauma: General Key Points/Considerations
Trauma Arrest patients go to the closest hospital UNSTABLE patients should be enroute to the hospital/landing zone within 10 minutes of disentanglement/extrication Patients with unmanageable airway go to the closest hospital or call for aeromedical or advanced airway assistance while enroute to closest hospital All other major trauma patients go to closest Trauma Center: o If more than 30 minutes from a Trauma Center consider aeromedical assistance. Refer to the Aeromedical Utilization Policy o If more than 45 minutes from Trauma Center and aeromedical assistance is not available, transport patient to closest hospital All times start at the time the EMS provider determined the patient to meet major trauma criteria Notify the receiving facility as early as possible giving brief description of mechanism of injury, status of patient(s), and estimated time of arrival Do not use MAST in pediatric patients (children 8 years of age or less)
STREMS PROTOCOLS 2012 52
Adult Trauma: Burns EMT
Stop the burning. Remove any clothing, jewelry, etc. ABC and vital signs Airway management and appropriate oxygen therapy Consider aeromedical intercept for direct transport to a Burn Center (See Trauma: Burn Center Transport Criteria) If the burn is less than 10% BSA use moist sterile dressings If the burn is more than 10% BSA use dry sterile dressings Burns to the eye require copious irrigation with Normal Saline for a minimum of 15 minutes. Do Not delay irrigation EMT STOP
INTERMEDIATE
Vascular access at 2 sites Normal Saline 500 ml bolus IV INTERMEDIATE STOP
CCT
Cardiac monitor/SpO2 If patient has signs of airway involvement be prepared to intubate Refer to PAIN MANAGEMENT protocol CCT STOP
PARAMEDIC
For burns to the eye(s): o Consider Tetracaine 0.5% 2 drops in affected eye, prior to irigation PARAMEDIC STOP
PHYSICIAN OPTIONS
Morphine IV or IM Fentanyl 0.5-1 mcg/kg slow IV, IM or atomized intranasal Additional fluid
STREMS PROTOCOLS 2012 53
Adult Trauma: Burn Care Considerations Key Points/Considerations
Be alert for other injuries, including cardiac dysrhythmias Be alert for smoke inhalation Assure 100% oxygen. Oxygen saturation readings may be falsely elevated If hazardous materials, notify the destination hospital immediately to allow for decontamination When considering total area of a burn, DO NOT count first degree burns Burns are only to be dressed with simple sterile dressings
Transportation Considerations
Burns associated with trauma should go to the closest appropriate trauma center If there is any question about the appropriate destination of a patient consult Medical Control Consider transport to a burn center if: o >10% BSA partial thickness burns o Involvement of face, hands, feet, genitalia, or major joints o Full thickness burns o Electrical burns, including lightning injuries o Chemical burns o Inhalation injury
STREMS PROTOCOLS 2012 54
Adult Trauma: Chest Trauma EMT
ABC and vital signs Airway management and appropriate oxygen therapy If sucking chest wound, cover with occlusive dressing; if dyspnea increases release the dressing momentarily during exhalation Contact receiving hospital as soon as possible EMT STOP
INTERMEDIATE
Vascular access; use the side opposite the injury if possible INTERMEDIATE STOP
CCT
Cardiac monitor/SpO2 Vascular access; use the side opposite the injury if possible Normal Saline per the Traumatic Hypoperfusion Protocol If patient in cardiac arrest; consider needle decompression bilaterally CCT STOP
PARAMEDIC
Needle decompression if patient has signs and symptoms consistent with Tension Pneumothorax AND hemodynamic compromise Pericardiocentesis: if patient shows signs of impending cardiac arrest secondary to pericardial tamponade, including narrowed pulse pressure, JVD, muffled heart sounds. Must be trained and service Medical Director Approved to perform this skill PARAMEDIC STOP
PHYSICIAN OPTIONS
Fentanyl 0.5-1 mcg/kg IV, IM or atomized intranasal
Key Points/Considerations
Begin transportation as soon as possible and perform ALS treatment enroute to the hospital Penetrating chest trauma is a contraindication for use of Anti-Shock Trousers (MAST) Signs and symptoms of Tension Pneumothorax: absent lung sounds on one side, extreme dyspnea, jugular vein distention (JVD), cyanosis (even with 100% oxygen), tracheal deviation AND hypotension Hemodynamic compromise is defined as hypotension, narrowed pulse pressures and tachycardia Thoracic decompression is a serious medical intervention that requires a chest tube in the hospital STREMS PROTOCOLS 2012 55
Adult Trauma: Crush Injuries EMT
ABC and vital signs every 5 minutes if possible Airway management and appropriate oxygen therapy EMT STOP
INTERMEDIATE
Vascular access at 2 sites Normal Saline (preferably warmed) 1 liter IV bolus INTERMEDIATE STOP
CCT
Cardiac Monitor/SpO2 12 Lead EKG repeated at 30 minute intervals CCT STOP
PARAMEDIC
If 1 complete extremity crushed more than 2 hours or 2 extremities crushed more than 1 hour: o Sodium Bicarbonate 50 mEq IV/IO bolus o Sodium Bicarbonate infusion (50 mEq in 1 liter NS), run at 1L every 40 minutes o One minute prior to extrication: Sodium Bicarbonate 50 mEq IV/IO bolus o Consider Midazolam 0.05 mg/kg IV, IM or atomized intranasal o Consider Morphine 0.05 mg/kg IV, IM PARAMEDIC STOP
PHYSICIAN OPTIONS
If hyperkalemia is suspected: o Calcium Chloride 1 g IV (over 5 minutes). Repeat in 10 minutes if no resolution o Albuterol 2.5 mg in 3 ml (unit dose) via nebulizer. Repeat as needed Additional Midazolam 0.05 mg/kg IV, IM or atomized intranasal Additional Morphine 0.05 mg/kg IV or IM Fentanyl 0.5-1 mcg/kg IV, IM, or atomized intranasal
Key Points/Considerations
Contact the Regional Trauma Center early and consider physician presence at scene if anticipated prolonged extrication Use one dedicated IV for Sodium Bicarbonate, the other IV for all other medications Hyperkalemia is indicated by PVCs, peaked T-waves or widened QRS complexes After extrication immobilize the extremity and apply cold therapy. Do not elevate the extremity STREMS PROTOCOLS 2012 56
Adult Trauma: Hypoperfusion / Hypovolemia EMT
ABC and vital signs every 5 minutes if possible Airway management and appropriate oxygen therapy Use appropriate splinting devices as available including MAST o If systolic BP less than 50 mmHg apply and inflate Anti-Shock Trousers (MAST) o If systolic BP less than 90 mmHg and pt has suspected pelvic fracture apply and inflate Anti-Shock Trousers (MAST) EMT STOP
INTERMEDIATE
Vascular access INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac monitor/SpO2 If COMPENSATED SHOCK: o Normal Saline, 1 liter, then 500 ml/hour IF DECOMPENSATED SHOCK: o Additional vascular access, infuse Normal Saline, 2 liters, then 500 ml/hour CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Additional Normal Saline Dopamine 5.0 micrograms/kg IV
Key Points/Considerations
COMPENSATED SHOCK is defined as significant mechanism of injury AND tachypnea, tachycardia, pallor, or restlessness, AND Systolic BP greater than 90 mmHg DECOMPENSATED SHOCK is defined as clinical picture of shock AND Systolic BP less than 90 mmHg A falling BP is a LATE sign of shock Contact receiving hospital early, with “Trauma Alert” call, giving brief description of mechanism of injury, status of patient and estimated time of arrival
STREMS PROTOCOLS 2012 57
Aeromedical Utilization Criteria to use when considering use of air medical services
Patient’s condition requires expeditious transport to a hospital capable of providing definitive care Patient’s condition requires specialized services offered by the air medical crew, prior to arrival at the hospital The patient’s condition is a “life or limb” threatening situation demanding intensive multi-disciplinary treatment and care Unstable trauma patients as defined by the physiologic criteria such as vital signs and physical findings Critical burn patients as defined in the Trauma: Burn Transport Criteria protocol Acutely ill, unstable medical patients as defined in the medical protocols
Destination
The destination facility will be determined by the air medical crew, based upon medical appropriateness, with consideration of patient preference and on-line medical direction Do not delay on the scene for the helicopter. If it is considered critical for the individual patient and the patient is packaged and ready for transport, start enroute to the hospital and reassign the Landing Zone either closer to the hospital or at the hospital’s designated Landing Zone; the helicopter can intercept with you
Key Points
This is a guideline and is not intended to specifically define every condition in which air medical services may be requested. Good clinical judgment should be used at all times Police, Fire, or EMS will evaluate the situation/patient condition and if necessary place the helicopter on standby The helicopter can be requested to respond to the scene when: o ALS personnel request the helicopter o BLS personnel request the helicopter, when ALS is delayed or unavailable o In the absence of an EMS agency, any emergency agency may request the helicopter if felt to be medically necessary
STREMS PROTOCOLS 2012 58
Airway management and Oxygen Delivery EMT
Oxygen therapy using nasal cannula, 2-6 1pm Oxygen therapy using non-rebreather mask 10-15 1pm Oxygen therapy using bag valve mask 15-25 1pm Nasopharyngeal airways Oropharyngeal airways EMT STOP
INTERMEDIATE
Oral endotracheal intubation in unresponsive ADULTS Alternative rescue airway device in unresponsive ADULTS INTERMEDIATE STOP
CCT
Continuous Positive Airway Pressure (CPAP) CCT STOP
PARAMEDIC
Portable transport ventilators, if trained Nasal endotracheal intubation in ADULTS Pediatric intubation Sedation assisted intubation Surgical airway PARAMEDIC STOP
STREMS PROTOCOLS 2012 59
Airway management (continued) Key Points
Agencies may only perform endotracheal intubation with wave form capnography Only paramedics may intubate pediatric patients Pediatric intubation is only to be performed if the EMS unit is equipped with continuous end-tidal capnography and it is working and appropriately connected to the patient Sedation assisted intubation is to be performed only by paramedics who have received specific training and are approved by the agency medical director, within agencies that have been approved by the Medical Advisory Committee Only aeromedical agencies may perform pediatric medication facilitated intubation on standing orders Reason for nasal cannula use must be documented Tidal Volume settings for portable transport ventilators: 5-7 ml/kg Always have a BVM available when using a portable transport ventilator Intubation may be attempted on a patient 2 times by one AEMT and one more time by a second AEMT. If unsuccessful utilize a rescue airway device or ventilate with BVM A cervical collar should be placed on all intubated patients to assist secure placement of the airway device Combitube is the “alternative airway” Contraindication for use of alternative airway device: o Patients with esophageal disease, pharyngeal hemorrhage, tracheostomy or laryngectomy o Patients who have ingested a caustic substance o Patients with known obstruction of larynx and/or trachea
STREMS PROTOCOLS 2012 60
Emergency Incident Rehab Guidelines - EMT Key Points
For events, including drills, fire ground operations, hazardous materials incidents, lengthy extrications and any other events where personnel are wearing protective gear and fluid loss is a concern When a person arrives in rehab with no significant complaints: o Encourage the person to drink at least 8 ounces of fluid o An EMT should do a visual evaluation for signs of heat exhaustion or fatigue. If the person exhibits any signs of heat exhaustion or fatigue, take their vital signs o If any vital sign is out of the range listed below, protective gear should be removed, and the person should rest for at least 15 minutes, with continued oral hydration. Blood Pressure: Systolic> 150 mmHg or Diastolic > 100 mmHg Respirations: >24 per minute Pulse: >110 per minute Temperature: >100.6 (if monitoring equipment available) o If vital signs return to within criteria limits, the person may be released o If vital signs are still beyond the limits, continue rehab for another 15 minutes and determine if further intervention may be needed o If after 30 minutes the vital signs are above the limits, transport to the hospital should be initiated If a person arrives at the rehab area with complaints of chest pain, shortness of breath, or altered mental status, follow the appropriate protocol. The person may not return to duty An irregular pulse mandates ALS intervention, cardiac monitoring, and removal from duty or the event Names and vital signs for each person evaluated should be recorded on a log sheet for the incident A PCR should be written on any person transported to the hospital or receiving any ALS care More aggressive treatment should be used during extremes of temperature Consider carbon monoxide poisoning during prolonged exposure to smoke If any questions exist regarding the treatment of a patient according to this protocol, consult Medical Control for advice For any ongoing event with high potential for injury to public safety personnel consider contacting Medical Control and requesting a physician to the scene Agency procedure may be used in place of these guidelines as appropriate if in developed from industry standard models such as the NFPA or USFA or others STREMS PROTOCOLS 2012 61
Smoke Inhalation - Symptomatic EMT
ABC and AED Apply carbon monoxide monitor if equipped Oxygen, 100% NRB EMT STOP
INTERMEDIATE
Airway management as appropriate Vascular access, Normal Saline 500 ml IV bolus INTERMEDIATE STOP
CCT PARAMEDIC
Cardiac Monitor/SpO2 12 Lead EKG CCT and PARAMEDIC STOP
PHYSICIAN OPTIONS
Draw bloods Hydroxycobalamin (CyanoKit) 5 grams IV over 15 minutes if suspected cyanide toxicity
Key Points/Considerations
Hydroxycobalamin (CyanoKit) is not available in all ambulances. It may be available for response to scenes Drawing bloods is of increased importance if CyanoKit maybe given, as it can alter laboratory test results Suspect cyanide toxicity in patients who were in enclosed spaces during a fire and have soot in their nares or oropharynx and exhibit altered mental status Disorientation, confusion, and severe headache are potential indications of cyanide poisoning IN THE SETTING of smoke inhalation Hypotension without other obvious cause IN THE SETTING of smoke inhalation increases the likelihood of cyanide poisoning Do not delay transport awaiting a responder with CyanoKit. It is available at most of the Regional Emergency Departments
STREMS PROTOCOLS 2012 62
Inter-Hospital Transport EMT
An EMT may transport stable patients with a secured saline lock device in place, as long as no fluids or medications are attached.
INTERMEDIATE CCT
An EMT-I may transport stable patients with simple IV fluids such as D5W, Normal Saline, or Lactated Ringers. The solution may not contain potassium or any medications. EMT, INTERMEDIATE, and CCT STOP
PARAMEDIC
Paramedics may transport a patient between hospitals with certain IV infusions, provided the medication is ordered, provided by the transferring physician and authorized by their service medical director. Be certain to clarify orders regarding medication titration prior to departure The IV medication must be run on an infusion pump
STREMS PROTOCOLS 2012 63
Specialty Care Transport
Paramedics that have attended regionally-approved supplemental training focused on Specialty Care Transports and have been credentialed by the agency’s Medical Director may transport a patient between hospitals with IV infusions, advanced modalities and blood products not specifically addressed in the regional formulary, provided the medication is ordered and supplied by the transferring physician or facility All medications and interventions utilized must be covered within Agency protocols Be certain to clarify orders regarding medication titration prior to departure The IV medications must be run on an infusion pump BLOOD OR BLOOD PRODUCTS MAY BE ADMINISTERED DURING TRANSPORT, CONSISTENT WITH DOH REGULATIONS.
Key Points/Considerations
Requests for inter-hospital transfer must be screened by appropriately trained personnel to determine the transport requirements After assessing the patient and reviewing the patient’s records and transfer orders, determine if the patient’s current condition is appropriate for the provider’s level of training, experience and available equipment Evaluate the patient’s airway status prior to departing the transferring facility. Secure the airway as indicated Prior to or during the transport, contact Medical Control, the agency’s medical director, the transferring/sending physician or the receiving physician for clarification, or to discuss any concerns If there are any changes in the patient’s condition that are not covered by the prescribed orders or agency protocols contact Medical Control. If a total failure of communications occurs and the patient is unstable and decompensating, follow standing orders and go to the closest hospital emergency department An appropriately trained nurse, respiratory therapist, physician assistant, nurse practitioner or physician from the sending facility must accompany the patient for any prescribed treatments or modalities for which the designated provider is not credentialed by their agency There must be an appropriate communication device in the transporting vehicle Specialty Care Transports (SCT) are a subset of Inter-Hospital Transports, and can only be done by Paramedics credentialed by the medical director of the agency performing the transport. Credentialing must include a Regionally approved training program in Specialty Care Transports Each Inter-Hospital transport must be reviewed by the agency as part of the QI program STREMS PROTOCOLS 2012 64
Medication and Medical Control Key Points/Considerations - Medications
Only medications listed may be carried by an ALS agency within the STREMS region. Medications not listed may not be carried without clearance from the Regional Medical Advisory Committee Local variations in concentration and volume may exist because of restocking necessity Medications must be kept locked in a secure environment when not being used Medications should be protected from extremes of temperature at all times Controlled substances carried must be in accordance with the Agency’s NYS Approved Controlled Substance Plan Medications are only to be carried in NYS DOH Approved Vehicles and cannot be carried in a private/personally owned vehicle at any time
Key Points/Considerations - Medical Consultation Communications
For the protection of the patient, the provider, and Medical Control, communication over recorded line is suggested If unable to contact Medical Control, utilize Standing Orders only. Describe the situation that prevented you from contacting Medical Control on the PCR If a communication breakdown occurs after Medical Consultation has been established, Standing Orders ONLY must continue to be utilized
STREMS PROTOCOLS 2012 65
Medication Formulary Medication Name Adenosine Amiodarone Albuterol Aspirin Atropine Calcium Chloride Dextrose 50% Dextrose 25% *D5W (Intermediate only) Diltiazem Diphenhydramine Dopamine Epinephrine 1:1,000 Epinephrine 1:10,000 Etomidate Fentanyl** Furosemide Glucagon Haloperidol Ipratropium bromide Lidocaine 2% (IV) Lidocaine Infusion Premix Magnesium Methylprednisolone Metoprolol Midazolam Morphine Naloxone Nitroglycerin (spray or tablets) Normal Saline 0.9% Ondansetron Phenylephrine Sodium Bicarbonate (8.4%) Tetracaine Ophthalmic Solution Vasopressin
Administration Method Rapid IV IV bolus, gtt Nebulized PO chewed IV bolus IV Bolus IV bolus IV bolus IV, gtt IV slow IV slow IV gtt IM, IV gtt IV IV IV, IM, atom IN IV IV, IM, atom IN IM, slow IV Nebulized IV, IV gtt IV drip IV, IV gtt IV IV slow IV, IM, atom IN IV, IM IV, IM, atom IN SL IV IV slow Intranasal IV, IV gtt ophthalmic IV/IO
*For Intermediate Agencies ONLY **Fentanyl requires updated agency Controlled Substance (CS) plan Atom IN=atomized intranasal using mucosal atomizer device only STREMS PROTOCOLS 2012 66
Medication Infusions Amiodarone: 150 mg in 100 ml Normal Saline = 1.5 mg/ml Infusion Rate Admin Set: 10 drops/ml Admin Set: 15 drops/ml 10 ml/min (over 10 min) 100 drops/min 150 drops/min Lidocaine: 4 mg/ml Infusion Rate 1 mg/min 2 mg/min 3 mg/min 4 mg/min
Admin Set: 60 drops/min 15 drops/min 30 drops/min 45 drops/ min 60 drops/min
Epinephrine: 1:10,000, 1 mg in 250 ml Normal Saline = 4 micrograms/ml Infusion Rate Admin set: Admin Set: Admin Set: 10 drops/ml 15 drops/ml 60 drops/ml 1 microgram/min 2.5 drops/min 3.5 drops/min 15 drops/min 2 micrograms/min 5 drops/min 7 drops/min 30 drops/min 4 micrograms/min 10 drops/min 15 drops/min 60 drops/min 6 micrograms/min 15 drops/min 22 drops/min 90 drops/min 8 micrograms/min 20 drops/min 30 drops/min 120 drops/min 10 micrograms/min 25 drops/min 37 drops/min 150 drops/min Magnesium: 2 g in 100 ml Normal Saline = 20 mg/ml Infusion Rate (over 20 min) Admin Set: 10 drops/ml 5 ml/min 50 drops/min
Admin Set: 15 drops/ml 75 drops/min
Dopamine: 400 mg in 250 ml Normal Saline = 1600 micrograms/ml Weight in kilograms Infusion Rate 50 55 60 65 70 75 80 85 90 95 100 105 Micrograms/kg/min) 5 9 10 11 12 13 14 15 16 17 18 19 20 10 18 20 22 24 26 28 30 32 34 36 38 39 15
28 31 34 37 39 42 45 48 51 53
56
59
20
38 41 45 49 53 56 60 64 68 71 Drip rates/min, using a 60 drops/ml administration set
75
79
Note: 800 micrograms/ml may be available within the region. Make sure to double your drip rates when using this concentration
STREMS PROTOCOLS 2012 67
Sedation Assisted Intubation_____________________________________ PARAMEDIC ONLY
I. IV, O2 monitor/SpO2 II. Assess Need for airway or Ventilatory Support III. Manage Airway as appropriate with initial BLS according to AHA/ARC/NSC standards IV. Ventilate with high concentration oxygen V. Assess/Re-Assess airway difficulty (level of consciousness, protective reflexes, anatomy, environment) VI. Consider sedation assisted intubation for the patient with compromised respiratory effort and partially intact airway reflexes a. Hypoxia despite high concentration supplemental oxygen b. Unable to protect airway c. Traumatic injury with GCS