Emergency Medical Services

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Aurora Health Care South Market Emergency Medical Services

Pre-Hospital Patient Care Protocols 2012 Aurora Lakeland Medical Center W3985 County Road NN Elkhorn, WI 53121 EMS Office: 262-741-2083 Fax: 262-743-2849

Aurora Memorial Hospital of Burlington 252 McHenry Street Burlington WI, 53105 EMS Office: 262-767-6101 Fax 262-767-6235

Aurora Medical Center Kenosha 10400 75th Street Kenosha, WI 53142 EMS Office: 262-948-5648 Fax: 262-767-6235

TABLE OF CONTENTS SECTION A ADMINISTRATIVE GUIDELINES Standard Operating Procedures Approval and Instructional Page

A-6

Scope of Practice – EMERGENCY MEDICAL RESPONDER / First Responder

A-8

Scope of Practice – EMERGENCY MEDICAL TECHNICIAN / Basic

A-9

Scope of Practice – ADVANCED EMERGENCY MEDICAL TECHNICIAN / INTERMEDIATE TECHNICIAN

A – 11

Scope of Practice – INTERMEDIATE

A - 13

Scope of Practice – PARAMEDIC

A - 15

Scope of Practice – REGISTERED NURSE

A - 17

Radio Report

A - 18

Withholding or Withdrawing of Resuscitative Efforts

A - 19

General Patient Assessment – Initial Medical Care

A - 21

Initial Medical Care

A - 22

IV Protocol

A – 23

IO Protocol

A - 24

Pain Management

A – 26

Dilaudid Dosing Chart

A – 27

Sedation

A - 28

Patient Restraint

A - 29

Use of Mark I Auto Injectors

A - 31

Physician Control at the Scene

A - 32

Statement of Release

A – 33

Advanced Life Support Response

A – 34

EtCO2 Monitoring/Capnography

A – 35

SECTION C - CARDIAC STEMI Acute Coronary Syndrome (ACS)/Chest Pain

C-1

Bradycardia

C–2

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 1

Supraventricular Tachycardia

C-3

Ventricular Tachycardia with a Palpable Pulse

C-5

Ventricular Fibrillation – Pulseless V-Tach

C-6

Amiodarone Infusion / Lidocaine Drip Guidelines

C-7

Pulseless Electrical Activity / Asystole

C-8

Conditions that Cause Pulseless Electrical Activity

C-9

Cardio Cerebral Resuscitation

C - 10

Pulmonary Edema (Due to Heart Failure)

C - 11

Cardiogenic Shock

C - 12

Induced Hypothermia

C – 13

STEMI ALERT WORKSHEET

C – 14

SECTION M - MEDICAL Diabetic / Glucose Emergencies

M–1

Syncope / Near Syncope

M–2

Unconscious – Unknown Etiology

M–3

Seizures

(Non-Traumatic Origin)

M–4

Hypertension (Stable Acute Crisis)

M–5

Suspected CVA

M–6

Acute Abdominal Pain

M–7

Nausea and Vomiting

M–8

Drug Overdose / Poisoning Narcotic or Synthetic Narcotic Tricyclic Antidepressant Organophosphate Beta Blocker/Calcium Channel Blocker Cyanide Cocaine Carbon Monoxide

M–9 M–9 M–9 M – 11 M – 12 M – 12 M – 13

Heat Emergencies

M - 14

Cold Emergencies (Frostbite)

M - 15

Cold Emergencies (Hypothermia)

M -16

Psychological Emergencies

M -17

EMS Neurologic Checklist

M -18

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 2

SECTION OB - OBSTETRICAL Emergency Childbirth – Phase I: Labor

OB - 1

Emergency Childbirth – Phase II: Delivery

OB - 2

Delivery Complications: Breech Birth

OB - 3

Delivery Complications: Prolapsed Cord

OB - 4

Newborn and Post-Partum Care – Care of Newborn,

OB - 5

APGAR Scoring Chart, Infant Patient Care Report

OB - 6

Newborn and Post-Partum Care – Care of the Mother

OB - 7

Neonatal Resuscitation (Newborns In Distress / Arrest, APGAR Score = 6 or Less)

OB - 8

Obstetrical Complications Bleeding Hypertension

OB – 10 OB – 11

SECTION P - PEDIATRICS General Pediatrics

P-1

Pediatric GCS (Glasgow Coma Scale)

P-2

CPR Modifications for Children and Infants

P-3

Resuscitation Medication Dosages

P-4

Pediatrics Bradyarrhythmias with Pulse

P-5

Pediatrics Asystole / Pulseless Electrical Activity (PEA)

P-6

Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia

P-8

Pediatric Airway Obstruction (Child / Infant)

P - 10

Pediatric Allergic Reaction / Anaphylactic Shock

P - 11

Pediatrics Asthma

P - 13

Pediatrics Croup / Epiglottitis

P - 14

Pediatrics Diabetic / Glucose Emergencies

P - 16

Pediatrics Drug Overdose / Poisoning Narcotic or Synthetic Narcotic Tricyclic Antidepressant Organophosphate Cyanide Carbon Monoxide Cocaine Pediatrics Seizures

P – 17 P – 17 P – 17 P – 18 P – 18 P – 18 P - 19

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 3

Pediatrics Syncope/Near Syncope

P – 20

Pediatrics Unconscious – Unknown Etiology

P – 20

Suspected Child Abuse or Neglect

P – 21

SECTION R - RESPIRATORY Adult Airway Obstruction

R-1

Rapid Sequence Induction and Intubation

R–2

Rapid Sequence Intubation Medications for Pediatric Patients

R-3

Acute Asthma / COPD

R–4

Allergic Reaction / Anaphylactic Shock

R–5

TB – Pneumonia

R–6

Continuous Positive Airway Pressure (CPAP)

R–7

Cricothyrotomy

R-8

SECTION T - TRAUMA Initial Trauma Care: Primary Survey

T-1

Initial Trauma Care: Secondary Survey

T-3

Glasgow Coma Scale GCS /

T-5

Trauma Definition – Level 1 Trauma Center Access Guidelines

T–6

Spinal Immobilization – Appropriate Omission

T-8

Hypovolemic / Hemorrhagic Shock

T–9

Tourniquet Application

T – 10

Use of Hemostatic Dressings

T - 11

Traumatic Arrest

T - 12

Head Injuries

T - 14

Spinal Injuries

T - 15

Chest Injuries

T - 16

Ophthalmic Emergencies

T - 17

Musculoskeletal Injuries

T - 18

Burns

T - 19

Near Drowning

T - 21

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 4

Trauma in Pregnancy

T - 22

Abuse – Domestic, Sexual, Elder

T – 23

SECTION X – EMERGENCY MEDICAL RESPONDER, EMERGENCY MEDICAL TECHNICIAN (BASIC), ADVANCED EMERGENCY MEDICAL TECHNICIAN (EMT-IV TECH) SPECIFIC PROTOCOLS 2012 Emergency Medical Care of the Pulseless Non-Breathing Patient Using Automated External Defibrillation (AED) Protocol

X-2

Emergency Medical use of the Esophageal Tracheal Combitube (ETC) and King LTS-D Airway Protocol Non-Visualized Airways

X-4

Assisted Administration of Epinephrine Utilizing a Patients Auto-Injector Protocol

X-6

Assisted Administration of Patient-Prescribed Nitroglycerine Protocol A – 8

X-7

Administration of Nebulized Albuterol / Atrovent for the Emergency Care of Severe Asthma Protocol

X- 8

Emergency Medical Treatment of Hypoglycemia with Glucose Monitoring and Administration of Glucagon Protocol

X-9

Drug Appendix / Protocols 2012 Table of Contents.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 5

Online Medical Control can be provided by any of the three (3) Aurora Hospitals in the South Market: Aurora Lakeland Medical Center, Aurora Memorial Hospital of Burlington, and Aurora Medical Center-Kenosha. In addition, if transporting the patient to another Aurora hospital, medical control may be obtained from that Aurora hospital. Additional medical control hospitals may be approved on a service specific agreement.

THEY SHALL BE UTILIZED: •

As written orders of a physician for treatment guidelines to be administered by authorized members of the South Market EMS System as circumstances allow for the treatment of the ill or injured patient.

•

As the prehospital standing medical orders to be initiated by South Market EMS Paramedic (P), Intermediate (I), Advanced Emergency Medical Technician/Intermediate Technician (IV), Emergency Medical Technician/Basic (B), Emergency Medical Responder/First Responder (FR) and/or Nursing personnel. Medical control must be contacted if patient condition is refractory to the initial treatment orders or at the point that the protocol states: “At discretion of Medical Control” and/or an “Δ is present in the protocol margin.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 6

•

The following symbols in the SOP’s indicate approval for specific providers: o FR-EMR/First responder o B-EMT/EMT Basic o V-ADVANCED EMERGENCY MEDICAL TECHNICIAN / INTERMEDIATE TECHNICIAN o I-Intermediate o P-Paramedic

It is recognized that these prehospital standing medical orders are intended to stabilize most patient care situations. If patient is stable or improves, EMS personnel need only to contact the receiving hospital directly. •

Medical care orders can only be initiated through these protocols or an authorized Medical Control Center. EMS personnel who are uncertain of a specific protocol or drug dosage to be used must contact Medical Control immediately.

•

In the event that communications cannot be established, prehospital personnel shall continue to provide treatment to the degree authorized by the EMS Medical Directors in these protocols.

•

In disaster situations, where immediate action to preserve and save lives supersedes the need to communicate directly with the hospital, the requirement for Medical Control orders may be lifted provided protocol recommendations are followed and/or sound medical judgment is used.

•

As the standing medical orders to be used by Medical Control when directing prehospital care.

UNDER NO CIRCUMSTANCES SHALL EMERGENCY PREHOSPITAL CARE BE DELAYED WHILE ATTEMPTING TO ESTABLISH CONTACT WITH MEDICAL CONTROL. It is recognized that hospice patients, patients with a valid DNR order, patients who have not responded to BLS/ALS procedures and/or require specialized care or patients involved in a multi casualty incident (MCI) present unique circumstance that may, in the medical opinion of the physician directing the call, justify deviation from these protocols, including bypassing the nearest hospital.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 7

Scope of Practice for Emergency Medical Responder/First Responder in the South Market EMS System Purpose:

To identify the scope of practice of Emergency Medical Responder in South Market EMS System.

A.

A Emergency Medical Responder (FR) may perform any activity identified in the scope of practice of First Responder as described in Wisconsin Administrative Code, Section HFS 110 (1/1/11) and in accordance with the following South Market EMS Standard Operating Procedures. These approved activities are identified with a “FR” in the margin of each protocol for your convenience.

AIRWAY / VENTILATION / OXYGENATION Airway - Lumen (Non-Visualized)*** Airway - Nasopharyngeal Airway - Oropharyngeal Bag - Valve - Mask (BVM) CO Monitoring** Cricoid Pressure (Sellick) Manual Airway Maneuvers Obstruction - Manual Oxygen Therapy - Nasal Cannula Oxygen Therapy - Non-rebreather Mask Oxygen Therapy - Regulators Pulse Oximetry Suctioning - Upper Airway (Soft & Rigid) ASSISTED MEDICATIONS – PATIENTS Auto-Injected Epinephrine *** Oral Glucose APPROVED MEDICATION by PROTOCOL Epinephrine for Anaphylaxis Auto-Injector Only*** Oral Glucose

CARDIOVASCULAR / CIRCULATION Cardiocerebral Resuscitation (CCR)*** Cardiopulmonary Resuscitation (CPR) Defibrillation - Automated / SemiAutomated (AED) Hemorrhage Control - Direct Pressure Hemorrhage Control - Pressure Point Hemorrhage Control - Tourniquet Trendelenberg Positioning IMMOBILIZATION Spinal Immobilization - Manual Stabilization Spinal Immobilization – C-Collar*** Spinal Immobilization - Long Board*** Spinal Immobilization – Seated Patient*** (KED) Splinting - Manual Splinting - Rigid Splinting – Soft Splinting - Traction Splinting – Vacuum

MISCELLANEOUS Assisted Delivery (childbirth) Blood Pressure -Manual / Automated Eye Irrigation Vital Signs - Obtain/ Monitor/Document (Pulse, BP, Respiration, Temperature) ***As long as the provider has been trained and approved AHC-SM EMS Approved__7/1/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 8

Scope of Practice for Emergency Medical Technician/EMT-B in the South Market EMS System Purpose:

To identify the scope of practice of Emergency Medical Technician in South Market EMS System.

A.

An Emergency Medical Technician may perform any activity identified in the scope of practice of EMT as described in Wisconsin Administrative Code, Section HFS 110 (1/1/11) and in accordance with the following South Market EMS Standard Operating Procedures. These approved activities are identified with a “B” in the margin of each protocol for your convenience.

AIRWAY / VENTILATION / OXYGENATION Airway – Lumen (Non-visualized) Airway – Nasal (Nasopharyngeal) Airway – Oral (Oropharyngeal) Bag-Valve-Mask (BVM) CO Monitoring** End Tidal CO2 Monitoring/ Capnometry*** CPAP Cricoid Pressure (Sellick) Capnography – (non interpretive)*** ITD or Impedance Threshold Device*** Manual Airway Maneuvers Obstruction – Forceps (Direct Visual) Obstruction - Manual Oxygen Therapy – Nebulizer Oxygen Therapy – Nasal Cannula Oxygen Therapy –Non-rebreather Mask Oxygen Therapy – Regulators Pulse Oximetry Suctioning –Upper Airway (Soft & Rigid) Ventilator – Automated Transport Ventilator – CPR ONLY** ASSISTED MEDICATIONS – PATIENTS Auto-Injected Epinephrine Medicated Inhaler – Prescribed Albuterol and/or Atrovent Nitroglycerin Oral Glucose

CARDIOVASCULAR / CIRCULATION ECG Monitor Impedance Threshold device 12-Lead ECG – (acquire)*** Cardiocerebral Resuscitation (CCR)*** Cardiopulmonary Resuscitation (CPR) CPR - Mechanical Device Defibrillation – Automated / SemiAutomated (AED) Hemorrhage Control – Direct Pressure Hemorrhage Control – Pressure Point Hemorrhage Control – Tourniquet Hemorrhage Control – Hemostatic agents*** Trendelenberg Positioning IMMOBILIZATION Spinal Immobilization – Cervical Collar Spinal Immobilization – Long Board Spinal Immobilization – Manual Stabilization Spinal Immobilization – Seated Patient (KED) Selective Spinal Immobilization Splinting – Manual Splinting – Pelvic Wrap / MAST / Splinting – Rigid Splinting – Soft Splinting – Traction Splinting – Vacuum

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 9

MEDICATION ADMINISTRATION ROUTES Aerosolized/Nebulizer Auto-Injector Intramuscular(IM) Oral Subcutaneous (SQ) Sub-Lingual (SL) Intra Nasal (IN) MISCELLANEOUS Assisted Delivery (Childbirth) Blood Glucose Monitoring Blood Pressure – Manual / Automated Eye Irrigation

Vital Signs - Obtain/ Monitor/ Document (Pulse, BP, Respiration, Temperature) Patient Physical Restraint Application

APPROVED MEDICATIONS BY PROTOCOL Albuterol Aspirin (ASA) Atrovent Epinephrine 1:1000 Glucagon Mark I Auto-Injector (For Self & Crew) Oral Glucose

***As long as the provider has been trained and approved

AHC-SM EMS Approved__7/01/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 10

Scope of Practice for Advanced Emergency Medical Technician/Intermediate Technician in the South Market EMS System Purpose:

To identify the scope of practice of Advanced Emergency Medical Technician / Intermediate Technician in South Market EMS System.

A.

An Advanced EMT / Intermediate Technician (V) may perform any activity identified in the scope of practice of an Advanced EMT / Intermediate Technician as described in Wisconsin Administrative Code, Section HFS 110 (1/1/11) and in accordance with the following South Market EMS Standard Operating Procedures. These approved activities are identified with a “V” in the margin of each protocol for your convenience.

AIRWAY / VENTILATION / OXYGENATION Airway – Lumen (Non-Visualized) Airway – Nasal (Nasopharyngeal) Airway – Oral (Oropharyngeal) Bag-Valve-Mask (BVM) End Tidal CO2 Monitoring/Capnometry*** CO Monitoring** CPAP Cricoid Pressure (Sellick) Manual Airway Maneuvers Obstruction – Forceps (Direct Visual) Obstruction - Manual Oxygen Therapy – Nebulizer Oxygen Therapy – Nasal Cannula Oxygen Therapy – Non-rebreather Mask Oxygen Therapy – Regulators Pulse Oximetry Suctioning – Upper Airway (Soft & Rigid) Ventilator – Automated Transport Ventilator – CPR ONLY** MEDICATION ADMINISTRATION ROUTES Aerosolized/Nebulizer Auto-Injector Intramuscular (IM) Intravenous (IV) Push Intraosseous (IO) Oral Subcutaneous (SQ)

Sub-Lingual (SL) Intra Nasal*** APPROVED MEDICATION BY PROTOCOL Albuterol Atrovent Epinephrine 1:1000 Aspirin (ASA) Atrovent Dextrose 50% Dextrose 25% Glucagon Mark I Auto Injector (For Self & Crew) Narcan Nitroglycerin (SL) Oral Glucose IV INITIATION/ FLUIDS IV Normal Saline Peripheral Initiation Intraosseous – Initiation (EZ-IO)*** CARDIOVASCULAR / CIRCULATION ECG Monitor ** 12-lead ECG (acquire)*** Cardiocerebral Resuscitation (CCR)*** Cardiopulmonary Resuscitation (CPR) Impedance Threshold Deice CPR Mechanical Device **

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 11

Defibrillation – Automated / SemiAutomated (AED) Hemorrhage Control – Direct Pressure Hemorrhage Control – Pressure Point Hemorrhage Control – Tourniquet Hemorrhage Control – Hemostatic agent*** Trendelenberg Positioning IMMOBILIZATION Spinal Immobilization – Cervical Collar Spinal Immobilization – Long Board Spinal Immobilization – Manual Stabilization Spinal Immobilization – Seated Patient (KED) Selective Spinal Immobilization

Splinting – Manual Splinting – Pelvic Wrap / MAST / PASG Splinting – Rigid Splinting – Soft Splinting – Traction Splinting – Vacuum MISCELLANEOUS Assisted Delivery (Childbirth) Blood Glucose Monitoring Blood Pressure – Manual / Automated Eye Irrigation Vital Signs - Obtain/ Monitor/ Document (Pulse, BP, Respiration, Temperature) Patient Physical Restraint Application

***As long as the provider has been trained and approved

AHC-SM EMS Approved__7/01/08 Revised __9/20/08, 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 12

Scope of Practice for Intermediate in the South Market EMS System Purpose: A.

To identify the scope of practice of Intermediate in South Market EMS System. An EMT-Intermediate (I) may perform any activity identified in the scope of practice of an EMT-I as described in Wisconsin Administrative Code, Section HFS 110 (1/1/11) and in accordance with the following South Market EMS Standard Operating Procedures. These approved activities are identified with an “I” in the margin of each protocol for your convenience.

AIRWAY / VENTILATION / OXYGENATION Airway – Lumen (Non-Visualized) Airway – Nasal (Nasopharyngeal) Airway – Oral (Oropharyngeal) Bag-Valve-Mask (BVM) Chest Decompression – Needle CO Monitoring** CPAP *** Cricoid Pressure (Sellick) End Tidal CO2 Monitoring/Capnometry*** Intubation - Orotracheal Manual Airway Maneuvers Obstruction – Forceps (Direct Visual) Obstruction – Manual Oxygen Therapy - Nebulizer Oxygen Therapy – Nasal Cannula Oxygen Therapy – Non-rebreather Mask Oxygen Therapy – Regulators Pulse Oximetry Suctioning – Tracheobronchial Suctioning – Upper Airway (Soft & Rigid)

Ventilator – Automated Transport Ventilator – CPR ONLY** CARDIOVASCULAR / CIRCULATION ECG Monitor 12 Lead ECG Cardiocerebral Resuscitation (CCR)*** Cardiopulmonary Resuscitation (CPR) Valsalva CPR Mechanical Device Impedance Threshold Device Defibrillation – Automated / SemiAutomated(AED) Defibrillation – Manual

Hemorrhage Control – Direct Pressure Hemorrhage Control – Pressure Point Hemorrhage Control – Tourniquet Hemorrhage Control – Hemostatic agents Cardioversion Transcutaneous Pacing Trendelenberg Positioning IMMOBILIZATION Spinal Immobilization – Cervical Collar Spinal Immobilization – Long Board Spinal Immobilization – Manual Stabilization Spinal Immobilization – Seated Patient (KED) Selective Spinal Immobilization Splinting – Manual Splinting-Pelvic Wrap/MAST/PASG Splinting – Rigid Splinting – Soft Splinting – Traction Splinting – Vacuum*** IV INITATION /FLUIDS IV Solutions- Normal Saline Intraosseous – Initiation Peripheral – Initiation Maintenance – Non-Medicated IV Fluids (D5W, LR, NS)

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 13

MEDICATION ADMINISTRATION Routes Aerosolized/Nebulized Auto-Injector Endotracheal Tube (ET) Intramuscular (IM) Intraosseous (IO) Intravenous (IV) Push Oral Rectal Subcutaneous (SQ) Sub-lingual (SL) Nasal***

APPROVED MEDICATIONS BY PROTOCOL Activated Charcoal Adenosine Albuterol Amiodarone (Bolus only) Aspirin Ativan 1 Atropine Atrovent (Nebulized) Dextrose 50%

Dextrose 25% Epinephrine Auto-Injector Epinephrine 1:1000 Epinephrine 1:10,000 Glucagon Lasix Lidocaine (Bolus Only) Mark I Auto Injector Morphine or Fentanyl, Dilaudid Choose one Narcan Nitroglycerin (SL only) Valium1 Versed1 Vasopressin Oral Glucose

MISCELLANEOUS Assisted Delivery (childbirth) Blood Glucose Monitoring Blood Pressure – Manual/Automated Eye Irrigation Vital Signs - Obtain/ Monitor/ Document (Pulse, BP, Respiration, Temperature) Pain Management Techniques Patient Physical Restraint Application

***As long as the provider has been trained and approved 1

Choose one for seizure control only.

AHC-SM EMS Approved__7/01/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 14

Scope of Practice for Paramedic in the South Market EMS System Purpose: A.

To identify the scope of practice of Paramedic in South Market EMS System. A Paramedic (P) may perform any activity identified in the scope of practice of an EMT-P Wisconsin Administrative Code, Section HFS 110 (1/1/11) and in accordance with the following South Market EMS Standard Procedures. These approved activities are identified with a “P” in the margin of each protocol for your convenience.

AIRWAY / VENTILATION / OXYGENATION Airway – Lumen (Non-Visualized) Airway – Nasal (Nasopharyngeal) Airway – Oral (Oropharyngeal) Bag-Valve-Mask (BVM) Chest Decompression – Needle CPAP Cricoid Pressure (Sellick) Cricothyrotomy – Surgical/Needle End Tidal CO2 Monitoring/Capnometry Intubation – Medication Assisted (paralytics/RSI) Intubation – Nasotracheal Intubation - Orotracheal Manual Airway Maneuvers Obstruction – Forceps (Direct Visual) Obstruction – Manual Oxygen Therapy - Nebulizer Oxygen Therapy – Nasal Cannula Oxygen Therapy – Non-rebreather Mask Oxygen Therapy – Regulators Pulse Oximetry Suctioning – Tracheobronchial Suctioning – Upper Airway (Soft & Rigid) Ventilator – Automated Transport Ventilator – CPR ONLY** CARDIOVASCULAR / CIRCULATION ECG Monitor 12 Lead ECG Cardiopulmonary Resuscitation (CPR) CPR Mechanical Device Impedance Threshold Device

Cardioversion – Electrical Valsalva Defibrillation – Automated / Semi-Automated (AED) Defibrillation – Manual Hemorrhage Control – Direct Pressure Perform Needle Pericardiocentesis Hemorrhage Control – Pressure Point Hemorrhage Control – Tourniquet Hemorrhage Control – Hemostatic agent*** Transcutaneous Pacing Trendelenberg Positioning IMMOBILIZATION Spinal Immobilization – Assessment Based Spinal Immobilization – Cervical Collar Spinal Immobilization – Long Board Spinal Immobilization –Manual Stabilization Spinal Immobilization – Seated Patient (KED) Selective Spinal Immobilization Splinting – Manual Splinting- Pelvic Wrap/MAST/PASG Splinting – Rigid Splinting – Soft Splinting – Traction Splinting – Vacuum

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 15

MEDICATIONS 25% and 50% dextrose Activated Charcoal Adenosine Albuterol Amiodarone Anzemet Aspirin Atropine sulfate Atrovent(Ipratropium) Calcium Chloride Compazine (prochlorperazine) Dexamethasone(Decadron) Diazepam(Valium) Diltiazem Diphenhydramine (Benedryl) Dopamine hydrochloride Etomidate (Amidate) Epinephrine Fentanyl Furosemide (Lasix) Glucagon Glucose Heparin Labetalol Lidocaine Hydrochloride Lorazepam(Ativan) Magnesium sulfate Morphine sulfate Naloxone Hydrochloride (Narcan) Norepinepherine Nitroglycerin preparations Plavix (clopidogogrel) oral only. Procainamide Prochlorperazine Reglan Succinylcholine Sodium Bicarbonate Solu-Medrol (methylprednisolone) Tetracaine Tenectaplace Valium Versed (midazolam) Vecronium Zofran (ondansetron) Cyanokit Dilaudid (hydromorphone)

Ketamine (Ketalar) 2-Pam Chloride (Pralidoxime)

IV INITATION / MAINTENANCE / FLUIDS Blood/ Blood By-Products (Maintenance only)*** Colloids – (Albumin, Dextran)*** IV Solutions- D5W, Normal Saline, Lactated Ringers Intraosseous – Initiation Peripheral – Initiation Maintenance – Medicated IV Fluids Maintenance – Non-Medicated IV Fluids (D5W, LR, NS) MEDICATION ADMINISTRATION Routes Aerosolized/Nebulized Auto-Injector Endotracheal Tube (ET) Intramuscular (IM) Intraosseous (IO) Intravenous (IV) Piggyback Intravenous (IV) Push Oral Rectal Subcutaneous (SQ) Sub-lingual (SL) Nasal MISCELLANEOUS Assisted Delivery (childbirth) Blood Glucose Monitoring Blood Pressure – Manual/Automated Eye Irrigation Initiation of IV at Central Line Port*** Thrombolytic Therapy – Monitoring*** Vital Signs - Obtain/ Monitor/ Document (Pulse, BP, Respiration, Temperature) Pain Management Techniques Patient Physical Restraint Application

***As long as the provider has been trained and approved Each department will identify medications currently used in their operating plan documents. They will document all training in the administration of these medications. AHC-SM EMS Approved__7/01/08 Revised __9/20/08, 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 16

Scope of Practice for Registered Nurse in the South Market EMS System Purpose:

Provide a guideline to assist South Market EMS providers for allowing registered nurses to perform advanced levels of care in the pre-hospital setting, thus promoting the optimal permissible pre-hospital advanced level of patient care and reducing the time it takes for the patient to receive advanced life support.

Nurse Qualification Requirements: 1. Wisconsin State Licensed Registered Nurse. 2. Wisconsin State Emergency Medical Technician License. • Active status on state E-Licensing roster for said provider. • Requires authorization by South Market EMS Medical Director. 3. ACLS and PALS Certified. • PALS only required if licensed under an ALS provider 4. Fulfillment of South Market EMS System Affiliation. Skills: All Registered Nurses meeting the above qualifications per above, can perform to the level achieved during system affiliation, not to exceed the level of care of the EMS service. . Continuing Education: 1. Registered Nurses providing pre-hospital care are required to maintain their EMT-Basic, System Affiliation, CPR and ACLS recertification. • PALS if applicable 2. Registered nurses recognized by medical control to provide pre-hospital care are required to present copies of current licensure and certification to the system EMS Coordinator on a bi-annual basis. 3. Maintenance of South Market EMS requirements. Pre-Hospital Care Approved nurses do not need to receive authorization from Medical Control prior to initiating any of the above except when specified by the appropriate South Market EMS System SOP where it says Î Contact Medical Control.

AHC-SM EMS Approved__7/01/08 Revised _12/5/08, 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 17

Radio Report Transmit the following, being concise as possible. Cell phone use is encouraged, due to additional levels of patient privacy. 1. Department name, EMS unit number. Transport priority. 2.

Patient age, sex (approximate weight when appropriate).

3.

Chief complaint: • Signs and symptoms, degree of distress, severity of pain on a scale of 0-10. • Mechanism of trauma/pertinent scene information. • Pertinent negatives/denials.

4.

Level of consciousness and orientation. • Note: Glasgow Coma Scale parameters for all patients with an altered mental status. Eye Opening Spontaneous In response to speech In response to pain None

Best verbal response 4 3 2 1

Oriented conversation Confused conversation Inappropriate words Incomprehensible sounds None

Best motor response 5 4 3 2 1

Obeys Localizes

6 5

Withdraws Abnormal flexion Abnormal extension

4 3 2

None

1

5.

History: • Current medications. • Allergies.

6.

Clinical findings: • Pertinent findings • Vital signs: communicate every 15 minutes as able – if patient condition changing. o Blood pressure: auscultated or palpated. o Pulse: rate, regularity, quality, equality. o Respirations: rate, pattern, depth. o Skin: color, temperature, moisture, turgor. • Blood glucose level, if indicated. • Pulse oximeter reading, if indicated. • End tidal CO2 reading, if indicated.

7.

Treatment initiated prior to calling and response to that treatment.

8.

ETA. Update ETA as necessary.

AHC-SM EMS Approved__7/01/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 18

Withholding or Withdrawing of Resuscitative Efforts 1. Use of this SOP MUST be guided by a physician. Contact should be established via radio or phone. 2. Provide emotional support to significant others. 3. Patient disposition according to local and county requirements. 4. Document date and time of pronouncement in the patient care report. 5. Document thoroughly all circumstances surrounding the use of this protocol. EMS personnel may withhold or cease resuscitative efforts in the following circumstances: • There is a risk to the health and safety of EMS personnel • Resources are inadequate to treat all patients (i.e., mass casualty situations) • Death has been declared by a physician, Medical Examiner or coroner • A child (< 18 years), where a Court Order is provided to EMS personnel indicating that CPR is not to be commenced • Patient w/ blunt trauma who, based on a thorough assessment, is found apneic, pulseless, normothermic, and asystolic upon arrival of EMS at the scene. DNR Orders Patients who are NOT in respiratory or cardiac arrest should receive supportive/comfort care enroute to the hospital. DO NOT WITHHOLD OXYGEN AND MEDICATIONS (e.g., analgesia, sedation, antiarrhythmics or vasopressors) unless these are included in the order. 1. Confirm the validity of the DNR: • An intact State of Wisconsin DNR Wrist Band on the patient. • ÎA State of Wisconsin DNR form properly filled out.- WITH MEDICAL CONTROL APPROVAL 2. If the DNR order is valid, withhold resuscitative efforts. Follow any orders found on the DNR order. If an original or photocopied DNR form is not presented or it is not appropriately executed, contact medical control. 3. If resuscitation was begun prior to the DNR form being presented, stop resuscitation after order validity is confirmed with medical control. 4. Contact medical control and explain the situation; follow any orders received. Injuries/presentations incompatible with life Irreversibly dead patients are those found to be non-breathing, pulseless, asystolic and have any of the following injuries and/or long term indications of death: • Decapitation • Decomposition • Thoracic/abdominal transection • Mummification/putrification • Rigor mortis without hypothermia 1. DO NOT start CPR for these patients. 2. Contact medical control; explain the situation. Follow any orders.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 19

Withholding or Withdrawing of Resuscitative Efforts, Cont Power of Attorney for Healthcare / Living Wills If someone represents themselves as having a Power of Attorney to direct medical care of the patient and/or a document referred to as a living will is presented; follow these procedures: 1. Begin or continue medical treatment. . 2. Living wills may not be honored by EMS personnel without a valid DNR order. 3. If a Power of Attorney for healthcare document is presented by the agent, confirm that the document is in effect and covers the current situation. If yes, honor the agent’s instructions. If there are any doubts concerning the living will or power of attorney, continue treatment, contact medical control, explain the situation and follow orders received. 5. Bring any documents received to the hospital. Hospice patients not in cardiac/respiratory arrest. If patients are registered in a hospice program, initiate BLS care and immediately contact medical control for orders on treatment and disposition. Inform medical control of the presence of written treatment and/or valid DNR orders.

AHC-SM EMS Approved__7/01/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 20

General Patient Assessment – Initial Medical Care Resuscitative interventions are to be performed during the initial assessment as impairments are found. General Patient Assessment: • Assure scene safety for all personnel. • Initiate universal blood and body secretion precautions on all patients. Apply appropriate equipment (PPE). Use special care in the handling of sharps/contaminated objects/linens per procedure. • In a HAZMAT incident, do not risk exposure of EMS responders. Follow department HAZMAT protocols. Primary/Initial Assessment: • Airway – Assess airway patency. Assess for possible spinal injury. • Breathing – Assess for ventilatory distress, bilateral chest expansion, rate, pattern, and depth of ventilations, adequacy of gas exchange, use of accessory muscles, and breath sounds. • Circulation – Assess rate, quality, regularity of pulses, hemodynamic status and neck veins. Evaluate and record cardiac rhythm if indicated (Chest Pain, SOB, Shock, Altered Mental Status, Drug Toxicity, Hypothermia, Electrocution, Chest Trauma, etc). • Disability – Mini-neurological exam to include brief pupil check and assessment of mental status: o A – Alert x 4. (Person, Place, Time and Events) o V – Not alert but responds to verbal stimuli. o P – Not alert but responds to painful stimuli. o U – Unresponsive to all stimuli. • Expose and examine as indicated. Transport Decision: Once the primary survey and/or resuscitative interventions are initiated, a decision must be made whether to complete the primary survey and/or continue with the secondary assessment and additional interventions on-scene or to transport rapidly with interventions en route. The unstable patient requires rapid interventions that may require expeditious transport. Secondary/Focused or Rapid Assessment: Chief complaint Review of Systems. General Exam. Head to Toe Exam. Mechanism of Injury Perform SAMPLE history and OPQRST history

AHC-SM EMS Approved__7/01/08 Revised

Vital Signs. Glasgow Coma Score Appropriate Interventions

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 21

Initial Medical Care LEVEL Initial Medical Care Airway: Establish and maintain a patent airway using appropriate patient FR B V I P 1.

FR B V I P

positioning and airway adjuncts (Combi-Tube, King LTS-D intubation, etc.) per Scope of Practice. Initiate spinal precautions if indicated. Suction as necessary. 2. Breathing: Provide or assist ventilations as necessary. Give supplemental oxygen to bring Pulse Ox Saturations to 94% or greater. 3. Circulation: Initiate CPR, if indicated. Establish IV or IO of Normal Saline (NS) as determined by patient condition and/or Provider Scope of Practice. IV Tubing and rate to be determined by patient condition or as specified by SOP or Medical Control. Attempt twice unless requested to continue attempts or situation demands. Control any external hemorrhage. 4. Loosen tight clothing, reassure patient. Do not provide any food or drink to the patient. 5. Place patient in semi-fowler’s position or position of comfort unless contraindicated. Patients with altered mental status should be placed on their back with head elevated 30 degrees, unless immobilized, to prevent aspiration. 6. Pain Management should be considered in the care of all patients unless contraindicated or ill advised. Ask patient to rate any pain on a scale of 0-10 with 0 indicating a pain free state and 10 being the worst pain imaginable. 7. Recheck and record Vital Signs and patient responses at least every 5 minutes for critical and 15 min for stable or as indicated and after each intervention, noting the times obtained. Attempt to repeat and record all abnormal vital signs. 8. Contact Medical Control if patient condition does not improve, worsens, or is refractory to the initial treatment orders, or at the point in which the protocol states: “At discretion of Medical Control” or “Δ. Transmit assessment and treatment information and follow orders. 9. Be certain to notify receiving hospital and/or Medical Control ASAP. In certain situations, a patient’s medical condition and the medical judgment of the EMT may require that treatment that would normally be administered on the scene be attempted en route to the hospital, in order to shorten the time taken to reach the hospital. Document the patient’s condition or behaviors, which necessitated expeditious transport.

In order to facilitate rapid and efficient resuscitation in cardiorespiratory emergencies, the EMT will use the primary/secondary survey patient care approach as below. Primary Survey (is CPR needed?) Secondary Survey (once CPR has been started) 1. First “C-A-B” 1. Second “A-B-C-D” • Circulation: Give chest compressions • Airway: Perform advanced airway. Defibrillation: Shock VF/Pulseless VT. • Airway: Open the airway. • Breathing: Assess bilateral chest rise and ventilation. • Breathing: Provide positive-pressure • Circulation: Gain IV access, determine ventilations rhythm, give appropriate agents. • Differential Diagnosis (THINK): Search.

AHC-SM EMS Approved__7/01/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 22

IV Protocol LEVEL VIP

VIP

IV Protocol General • An IV of 0.9% Normal Saline should be started if there is an anticipated use for IV medications or fluids. Providers should not be hesitant to initiate IV access • All IV infusions are to be run at TKO unless a different rate is specified by the appropriate protocol. • Start a second IV line when appropriate (i.e. major trauma, cardiac and burn cases), or when provider judgment deems appropriate • Macro (10/15gtt) should be used for all situations, except when medication calls for smaller tubing Adult/Peds Failed IV Access • If vascular access is deemed mandatory to immediately treat conditions with significant morbidity or death and two attempts at IV access have failed follow IO access protocol. Adult Fluid Resuscitation • 500 ml bolus - repeat up to 2000ml’s. If severe diarrhea or septic shock, may give additional 1000ml Normal Saline every 30 minutes. Pediatric Fluid Resuscitation • For fluid resuscitation use 20 ml/kg bolus – repeat 2x PRN for a total infusion of 60 ml/kg.

AHC-SM EMS Approved__7/01/08 Revised

08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 23

IO Protocol LEVEL

IO Protocol Use of this protocol is limited to Paramedics, Intermediates and IV Techs who are trained in its use and have current check off documentation on file with their EMS coordinator

VIP

VIP P VIP

INDICATIONS: • May be used for patients in Cardiac and/or Respiratory Arrest without an IV attempt, but generally should be used only if IV access not able to be obtained after at least 2 IV attempts. • In conscious patients in immediate life or limb threat where IV attempts unsuccessful. • In conscious patients with immediate need for fluids or medications and able to give IO lidocaine. • In unconscious patients with immediate need for fluids or medications. EZ-IO® 25mm (40 kg and over) and EZ-IO® 15mm (3-39 kg) EZ-IO® 45mm (40 kg and over with excessive tissue). Adults • Proximal humerus • Proximal tibia • Distal tibia Pediatrics • Proximal tibia • Distal tibia (Note: Proximal humerus can be used in pediatric patients when the landmarks can clearly be identified) CONTRAINDICATIONS: • Fracture of the bone Selected for IO infusion. (consider alternate sites) • Excessive tissue at insertion site with the absence of anatomical landmarks. (consider alternate sites) • Previous significant orthopedic procedures (IO within 24 hours, prosthesis – consider alternate sites • Infection at the site selected for insertion. (consider alternate sites)

VIP

PROCEDURE: If patient is conscious, explain procedure. • Cleanse site using antiseptic agent. • Connect appropriate Needle Set to driver. • Stabilize site. • Insert EZ-IO needle into selected site. IMPORTANT: Keep hand and fingers away from needle set. • Position the driver at the insertion site with the needle at a 90-degree angle to the bone surface • Gently pierce the skin with the Needle Set until the Needle set tip touches the bone. • Penetrate the bone cortex by squeezing drivers trigger and applying gentle, consistent, steady, downward pressure (allow the driver to do the work) • Do not use excessive force. In some patients insertion may take greater Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 24

LEVEL

IO Protocol

• • • • • • • IP • • • • • • •

than 10 seconds, if the driver sounds like it is slowing down during insertion; reduce pressure on the driver to allow the RPMs of the needle to do all the work. • In the unlikely event that the battery on the driver fails clinicians may manually finish inserting the EZ-IO Needle Set. Grasp the Needle Set and, rotate arm, while pushing the needle into the intraosseous space. This may take several minutes. Release the driver’s trigger and stop the insertion process when the sudden “give or pop” is felt upon entry into the medullary space or when desired depth is obtained. Remove EZ-IO Power Driver from Needle Set while stabilizing the catheter hub. Remove stylet from catheter by turning counter-clockwise and immediately dispose of stylet in appropriate biohazard sharps container. Secure site with EZ Stabilizer. Connect primed EZ-Connect to the exposed Luer-lock hub. Confirm placement If patient is responsive to pain, give 2% lidocaine (cardiac lidocaine) 2 – 5 ml Adult dose, or 0.1 -0.2 ml/kg up to 5 ml for pediatric patients for anesthetic effect prior to the 10 ml normal saline flush. Syringe bolus: flush the catheter with 10 ml normal saline Assess for potential IO complications. Disconnect 10 ml syringe from the EZ-Connect extension set. Connect primed IV tubing to EZ-Connect extension set. Begin infusion using pressure delivery system. Continue to monitor extremity for complications. Place EZ-IO armband on patient, document time and date.

AHC-SM EMS Approved__08/01/2012 Revised

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols A - 25

Pain Management LEVEL FR B V I P

IP

P

Pain Management 1. 2. 3. 4.

Assess pain 0-10 scale Assess for cause of pain. Remove cause if possible. Apply ice and elevate if applicable Narcotic Analgesia – Fentanyl • Adult: 50 to 100 mcg IV/IO/IM, repeat every 5 minutes for pain. • Peds: 1 mcg/kg IV/IO/IM, repeat every 5 minutes for pain. If no effect, may double dose to maximum 2 mcg/kg per dose. 5. Narcotic Analgesia – Morphine • Adult and Peds: 0.1 mg/kg IV/IO/IM; up to 10 mg per dose. May repeat every 5-10 minutes PRN pain. If no effect, may double dose to maximum 0.2 mg/kg per dose.

P

6.

P

7.

Narcotic Analgesia - Dilaudid • Adult: 1mg IV/IO/IM – May repeat every 15 min. • Pediatric: 0.15mg/kg IV/IO/IM – May repeat every 15 min. • •

Non - Narcotic Analgesia - Ketamine Adult: 20-30 mg IV/IO every 15 minutes Peds: 0.2 mg/kg IV/IO every 15 minutes

In elderly or chemically or otherwise impaired patients, give half dose of any narcotic medication. In moderate pain, (4 to 7) give half dose. This is cumulative – elderly patients with moderate pain – give quarter dose. 9. Adverse reactions: nausea, vomiting, respiratory depression, and hypotension. Consider anti nausea medication 10. If patient is Hypotensive (SBP 220 or Diastolic BP is > 130) with neurovascular and/or neurologic deficits due to the hypertension and/or those with chest pain and/or pulmonary edema. FR B V I P 1. BVIP

VIP P

Initial Medical Care – Special Considerations: • Oxygen titrated to keep O2 saturations at or above 94% • Elevate head of bed 15-30 degrees, keep head and neck midline. • Assess and record neuro signs as a baseline. • History: HTN and renal Dx. • Obtain 12-lead EKG and transmit EKG. • Assess for chest pain and/or pulmonary edema and treat per appropriate protocol. • Assess for other causes – Anxiety or pain – Treat per Protocol

2. If hypertensive-related neurologic deficits are present and DBP >130 mmHg: At discretion of Medical Control may give • ÆNitroglycerine 0.4 mg SL. Altered mental status: • ÆLabetalol 20 mg IV/IO slowly.

AHC-SM EMS Approved 7/01/08_Revised 12/5/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 5

Suspected CVA LEVEL Suspected CVA Initial Medical Care – Special Considerations: FR B V I P 1. • Titrate Oxygen to bring O2 saturations to 94% or greater. • Assist with BVM, if patient is not breathing adequately. • Protect airway, suction as needed. • If BP is greater than 90 mmHg: elevate head of bed 15-30 degrees. • Protect paralyzed limbs from injury. • Keep head neck and spine in neutral alignment. Do not flex neck. • Complete Neuro Alert checklist enroute to hospital. • IV access VIP • Obtain and record blood glucose levels. (If < 60 treat per protocols) BVIP • History: Length of time of symptoms/last known well time. • Obtain Glasgow Coma Scale and Cincinnati Prehospital Stroke Scale. Note any changes from known baseline • If Seizures occur, treat per Seizure protocol

Glasgow Coma Scale

Cincinnati Prehospital Stroke Scale Facial Droop: have patient show teeth or smile: • Normal – both sides of face move equally well. • Abnormal – one side of face does not move as well as the other side.

Eye Opening: Spontaneous In response to speech In response to pain None Best Verbal Response: Oriented conversation Confused conversation Inappropriate words Incomprehensible sounds None

5 4 3 2 1

Arm Drift: have patient close eyes and hold both arms out: • Normal – both arms move the same or both arms do not move at all (other findings, such as pronator grip, may be helpful). • Abnormal – one arm does not move or one arm drifts down compared with the other.

Best Motor Response: Obeys Localizes Withdraws Abnormal flexion Abnormal extension None

6 5 4 3 2 1

Speech: have patient say “you can’t teach an old dog new tricks”: • Normal – patient uses correct words with no slurring. • Abnormal – patient slurs words, uses inappropriate words or is unable to speak.

4 3 2 1

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 6

Acute Abdominal Pain LEVEL Acute Abdominal Pain Initial Medical Care – Special Considerations: FR B V I P 1. •

Apply full PPE if body fluids are present

•

VIP P

Consider cardiac/great vessel (aneurysm) in addition to GI etiologies and anticipate need for expeditious transport • Note and record jaundice. • Note nature and amount of vomiting/diarrhea. • Establish IV • Nausea/Vomiting, Zofran 4 mg IVP (may repeat after 10 minutes). • History: Onset, Provication Quality, Radiation, Severity on 1-10 scale, and Time. (OPQRST) • Obtain menstrual history in females of childbearing age. (10 to 59 years) • Last BM. STABLE: Alert, oriented, normotensive.

IP

1.

Consider pain management

BVIP

2.

Transport in position of comfort.

BVIP VIP IP BVIP

UNSTABLE: Altered sensorium, signs of hypoperfusion, guarding or rigidity of abdominal wall. 1. Initial Medical Care – Special Considerations: • Titrate Oxygen to bring Saturation to 94% or higher, or assist breathing with BVM if patient is not breathing adequately • 2 large bore IV’s on regular tubing with pressure infusers as available. • NS Wide open per Hypovolemic Shock SOP • Treat pain with appropriate pain protocols. If Hypotensive, Fentanyl is drug of choice. • Expeditious transport.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 7

Nausea and Vomiting LEVEL FR B V I P BVIP

Anti-emetic 1. Initial Medical Care – Special Considerations: • Obtain and transmit 12 lead EKG

BVIP

2.

Assess for cause of nausea and/or vomiting. Address underlying cause if possible.

P

3.

Zofran (Ondansetron) • Dose: Adult: 4 mg IV over 2 minutes Peds: 0.1 mg/kg IV (max dose 4 mg) • Adverse reactions: Headache, fever, constipation, diarrhea

P

P

P

P

Compazine, Phenergan, Droperidol and Reglan have similar adverse reactions: hypotension, dizziness, drowsiness, extrapyramidal reaction, motor restlessness (akathisia), dystonia. These medications will normally not be utilized, but will be allowed only in the event of shortages. • Dystonic reaction should be treated with Benadryl (Diphenhydramine) 25-50 mg IV (Pediatric: 1 mg/kg per dose up to adult dose). May give Benadryl prior to antiemetic to prevent dystonic reactions. 4. Compazine (Prochlorperazine) • Contraindications: Patient < 6 months old; Pregnancy – relative; History of dystonic or other adverse reaction - relative. • Dose: Adult: 5-10 mg IV/IM. Peds: 0.15 mg/kg/dose IV/IM not to exceed 10 mg. 5. Phenergan (Promethazine) • Contraindications: Narrow-angle glaucoma; Pregnancy – relative; Patient < 2 year olds • Dose: Adult: 12.5-25 mg IV/IM over 1-2 minutes Peds ≥ 2 y.o.: 0.25-0.5 mg/kg IV/IM (max 25 mg) 6. Droperidol (Inapsine) • Contraindications: Patient < 6 months old; Pregnancy – relative; History of dystonic or other adverse reaction – relative; Prolonged QT • Dose: Peds: 0.05-0.075 mg/kg IV/IM up to Adult dose maximum Adult: 0.625-2.5 mg IV/IM. 7. Reglan (Metoclopramide) • Contraindications: GI Obstruction/perforation • Dose: Adult: 10 mg IV over 1-2 minutes Peds : 0.1 mg/kg IV (max 10 mg) 8. Consider sedation with benzodiazepines. Anxiety can contribute to

nausea/vomiting and benzodiazepines have been shown to reduce symptoms. (See Protocol – Sedation) P

Alternative to Zofran (Ondansetron): Anzemet (Dolasetron) • Dose: Adult: 12.5 mg IV over 2 minutes Peds: 0.35 mg/kg IV (max dose 12.5 mg)

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 8

Drug Overdose / Poisoning LEVEL FR B V I P

BVIP BVIP VIP BVIP

Drug Overdose / Poisoning General Approach: 1. Initial Medical Care – Special Considerations: • Follow established hazmat protocols. Do not enter contaminated scenes without appropriate PPE. • Anticipate the possibility of respiratory distress, seizure activity, dysrhythmias or vomiting. • Place an advanced airway, if airway compromised, and no response to Narcan. • Oxygen – titrate oxygen saturations to 94% or higher. • Large bore IV. • Do NOT induce vomiting • Obtain and record blood glucose level. If < 60 treat per Protocol. • If Seizures occur, treat per protocols. • Be alert to and ask about suicidal ideation/attempt. 2.

VIP VIP VIP

P IP

IP

IP

If patient is stable, in most cases no further treatment is required, transport.

Narcotic or Synthetic Narcotic Overdose or unknown: 3. If weight is over 20 kg: Narcan 2 mg IV/IN/IO/IM If weight is under 20 kg: Narcan 0.1 mg/kg IV/IN/IO/IM • Consider restraints before Narcan is administered. Tricyclic Antidepressant Overdose 4. Sodium Bicarbonate 1 mEq/kg IV/IO for hypotension, deterioration of sensorium, dysrhythmias, or PEA. • If seizures occur: Follow Seizure protocol. Organophosphate Poisoning If unstable patient: 5. Atropine 2 mg rapid IV/IO. Repeat every 3 minutes until signs of Atropinization appear (dry mouth, dried secretions, flushed skin). Usual Atropine dose limitation does not apply. 4. Mark 1 Kit

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 9

LEVEL IP

Drug Overdose / Poisoning Patient Age Infant (0 - 2 yrs)

Mild/Moderate Symptoms²

Severe Symptoms³

Atropine: 0.05 mg/kg IM;

Atropine: 0.1 mg/kg IM;

2-PAM Cl: 15 mg/kg IM

Other Treatment

2-PAM Cl: 25 mg/kg IM

Child (2 - 10 yrs)

Atropine: 1 mg IM; 2-PAM Cl: 15 mg/kg IM

Atropine: 2 mg IM; 2-PAM Cl: 25 mg/kg IM

Adolescent (>10 yrs)

Atropine: 2 mg IM; 2-PAM Cl: 15 mg/kg IM

Atropine: 4 mg IM; 2-PAM Cl: 25 mg/kg IM

Adult

Atropine: 2 to 4 mg IM;

Atropine: 6 mg IM;

2-PAM Cl: 600 mg IM

2-PAM Cl: 1800 mg IM

Atropine: 1 mg IM;

Atropine: 2 to 4 mg IM;

Assisted ventilation should be started after administration of antidotes for severe exposures.

2-PAM Cl: 10 mg/kg IM

2-PAM Cl: 25 mg/kg IM

Repeat atropine (2 mg IM or 1 mg IM for infants) at 5 - 10 minute intervals until secretions have diminished and breathing is comfortable or airway resistance has returned to near normal.

Elderly, frail

Benzodiazepine for convulsions: See Protocol Seizures 1. 2-PAMCl solution needs to be prepared from the ampule containing 1 gram

of desiccated 2-PAMCl: inject 3 ml of saline, 5% distilled or sterile water into ampule and shake well. Resulting solution is 3.3 ml of 300 mg/ml. 2. Mild/Moderate symptoms include localized sweating, muscle fasciculations, nausea, vomiting, weakness, and dyspnea. 3. Severe symptoms include unconsciousness, convulsions, apnea, flaccid paralysis.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 10

LEVEL

VIP

VIP

Drug Overdose / Poisoning Beta Blocker or Calcium Channel Blocker Overdose If unstable patient • Patients can have varying degrees of hypotension, bradycardia (heart blocks), and lethargy and coma. • Patients may decompensate quickly, so be prepared. • Hypotension should initially be treated with a fluid challenge. Calcium Channel Blockers 1. Normal Saline Bolus 500 to 1000 ml.

P

2.

Calcium Chloride 5 ml to 10 cc IV/IO

IP

3.

Glucagon 2-5 mg IV/IO Anticipate nausea, bradycardia or hypotension – be prepared to give anti- emetic medications

P

If refractory, consider: 4. Dopamine infusion 5-20 mcg/min IV/IO.

P

5.

Repeat Calcium Chloride 5 - 10 ml IV/IO.

IP

6.

Consider transcutaneous pacing

VIP

Beta Blocker 7. Normal Saline bolus 500 – 1000 ml 8.

P

Glucagon 2–5 mg IV/IO Anticipate nausea, bradycardia or hypotension – be prepared to give anti-emetic medications If refractory consider: 9. Dopamine 5–20 mcg/min IV/IO, for SBP 90 mmHg. 4. FR B V I P

Initiate rapid cooling: • Remove as much clothing as possible to facilitate cooling • Cold packs to groin, axillae, carotid arteries, temples, and behind knees • Water mist that is body temperature on to body with source of rapid air movement over body.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 14

Cold Emergencies Frostbite LEVEL FR B V I P

IP

Frostbite: 1. Initial Trauma Care. • Move patient to a warm environment as soon as possible. • Cover with warm blankets and prevent re-exposure • Do NOT rub area. Do NOT thaw area if there is a chance of refreezing • HANDLE SKIN GENTLY. Protect with light, dry, sterile dressings. Anticipate severe pain when rewarming partial thickness frostbite: 2. Consider Pain Management.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 15

Cold Emergencies Hypothermia MILD/MODERATE HYPOTHERMIA: 86-95° F, Conscious or altered sensorium with shivering. Initial Trauma Care: FR B V I P 1. • Obtain temperature VIP • Use warm IV fluids LEVEL

2.

Rewarm patient: • Place in warm environment. Remove wet clothing and dry patient • Apply hot packs wrapped in towels to axillae, groin, neck, thorax. Wrap patient in blankets.

FR B V I P Severe Hypothermia: Temperature of 86° F or less. 3.

Initial Trauma Care • Assess rhythm before beginning CPR; check pulse for 30-60 seconds. If pulse/breathing are absent, start CPR. • Prevent further heat loss; remove wet clothing and dry patient

4.

May give only one round of IV drugs if body temperature < 86° or ordered by medical control.

5.

If rhythm V-fib/pulseless VT: Defibrillate x 1.

6.

Advanced airway, if indicated.

7.

Transport patient very gently to avoid precipitating V-fib.

FR B V I P CRITERIA FOR COLD DEATH 1. Frozen solid preventing chest from being compressed. 2 Ice in airway 3. Signs of Predation 4. Head underwater for more than 60 minutes in an adult or 90 minutes if a child.

AHC-SM EMS Approved 7/01/08_Revised 9/20/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 16

PSYCHOLOGICAL EMERGENCIES FR B V I P

1. Assess SCENE AND PERSONAL SAFETY. Call law enforcement personnel to scene, if needed. Above all, DO NOTHING TO JEOPARDIZE YOUR OWN SAFETY.

2. Initial Medical Care; special considerations: * Determine and document if patient is a threat to self or others; or if patient is unable to care or provide for self * Protect patient from harm to self or others * Do not touch a patient with a mental illness without telling them your intent in advance

3. Verbally attempt to calm and reorient the patient to reality as able. Do not participate in a patient's delusions or hallucinations.

4. If patient is combative: Refer to Patient Restraint Protocol, use physical restraints as necessary per Patient Restraint Protocol. Document reasons for use.

5. Consider medical etiologies of behavioral disorder and treat according to appropriate SOP: * Hypoxia * Substance Abuse/Overdose * Neurologic disease (CVA, intracerebral bleed, etc.) * Metabolic derangements (hypoglycemia, thyroid disease etc.)

6. Initial Medical Care as situation warrants. 7. Consult Medical Control from the scene in ALL instances where a refusal of transport is being considered.

8. If patient is an imminent threat to self or others, or is unable to care for themselves, and is refusing transportation: Have Police Department evaluate situation for Chapter 51.

AHC SR-EMS Approved 7/01/08_Revised 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols M - 17

EMS Neurologic Checklist Aurora Health Care – South Market EMS Program Date:

Patient:

BASIC DATA Witness Name: Witness Phone: Dispatch Time: EMS Arrival Time: Patient Last Known Normal/Without Symptoms Time: Date: Criteria Yes Head Trauma at Onset Seizure at Onset Taking Warfarin (Coumadin) History of Bleeding Problems Management

Age: BP Left Arm: Departure to ED Time:

No

EXAMINATION / BP Right Arm: ED Arrival Time: Additional History

Allergies: Medications: Past History: Last Meal: Events Prior: Cincinnati Prehospital Stroke Scale Mental Status •

Level of Consciousness

•

Do not treat hypertension without medical control direction.

•

Speech

•

Do not allow aspiration. o NPO, Head Up, O2

•

Questions (age, month, etc)

•

Commands Facial Droop

• •

Do not give glucose (unless glucose is less than 60). o IV NS, Blood Sugar ECG Rhythm o If AMI, 12-Lead and transmit to ED. “Stroke Specific” EMS to ED Report (Report Items)

Symptom Onset Time (Last time w/o S&S) Trauma Seizure GCS Score

Neurologic Exam Level of Consciousness Speech Language Motor Strength Witness (Name and Contact Info)

Sex:

•

On-Scene

On-Scene

/

Check if Abnormal Enroute

Enroute

Facial Droop

(Abnormal – one side does not move as well as other.)

Arm Drift •

On-Scene

Enroute

Motor-Arm Drift

(Close eyes and hold out both arms. Abnormal – arm can’t move or drifts down.)

•

Cincinnati scale is considered “Abnormal” for a positive-negative found during scale assessment.

Emergency Childbirth – Phase I: Labor LEVEL Phase I: Labor Obtain pregnancy history and determine if there is adequate time to transport: FR B V I P 1. • • • • •

FR B V I P 2.

BVIP

3.

Gravida (number of pregnancies); para (number of live births). Number of miscarriages, stillbirths, abortions or multiple births. Due date (EDC) or LMP. Onset and current duration of contractions. Frequency of contractions (time from beginning of one to beginning of the next). • Length of previous labors (in hours). • Status of membranes (intact or ruptured). o If ruptured or unsure, visually inspect for prolapsed cord and/or evidence of meconium. o Note time since rupture. Document any high-risk concerns: • Lack of prenatal care. • Drug abuse. • Teenage pregnancy. • Pre-term labor (less than 37 weeks). • Multiple fetuses. • Previous breech or C-section. • History of diabetes, hypertension, cardiovascular or other diseases that may compromise mother and/or fetus. Visually inspect for bulging perineum or crowning. Determine whether mother is involuntarily pushing or feels like she has to move her bowels with contractions. • If contractions are two minutes apart or less, or any of the above signs are present, prepare for delivery.

DO NOT ATTEMPT TO RESTRAIN OR DELAY DELIVERY UNLESS PROLAPSED CORD IS PRESENT. BVIP

4.

•

VIP BVIP BVIP

Initial Medical Care – Special Considerations:

5. 6.

If mother becomes hypotensive or lightheaded at any time: o Roll mother onto her left side o IV fluid challenge of Normal Saline in consecutive 500 mL increments to maintain systolic BP > to 90 mmHg.

If delivery is not imminent, transport. If delivery imminent: • Position mother supine on flat surface, if possible. • Put on full blood and body secretion barriers. • Prepare bulb syringe, cord clamps, scalpel, and chucks to warm infant. • Have neonatal BVM and oxygen supply ready.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 1

Emergency Childbirth – Phase II: Delivery LEVEL BVIP

Phase II: Delivery 1. Allow head to deliver passively. • Control rate of delivery by placing palm of one hand gently over occiput. • Protect perineum with pressure from the other hand. 2. If amniotic sac is still intact, gently tear the membrane. • If meconium present in amniotic fluid, gently suction infant’s mouth and nose as soon as head delivers. 3. Once head is delivered, allow it to passively turn to one side. This is necessary for the shoulders to deliver. 4. Feel around the infant's neck for the umbilical cord (nuchal cord). • If present, attempt to lift it over the baby's head. • If unsuccessful, double clamp and cut the cord between the clamps. • Suction mouth and nose after the anterior shoulder has delivered 5. To facilitate delivery of the upper shoulder: • Gently guide the head downwards. • Support and lift the head and neck slightly to deliver the lower shoulder. • DO NOT forcefully move or roll head sideways on to the shoulder 6. The rest of the infant should deliver quickly with the next contraction. • Firmly grasp the infant as it emerges. • Suction secretions from mouth and nose again 7. Note the date and time of the delivery. 8. Keep the newborn level with uterus or place on mother’s abdomen in a 15degree, head-down position until the umbilical cord stops pulsating. 9. Proceed to Newborn and Post-Partum Care Guidelines.

AHC-SM EMS Approved 7/01/08_Revised 9/20/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 2

Delivery Complications: Breech Birth LEVEL BVIP

Delivery Complications: Breech Birth A breech birth or breech presentation is when the position of the baby in the uterus is such that it will be delivered buttocks-first as opposed to the normal head-first position. Breech presentations occur in about 4% of all births. The two most common categories are: • The frank breech presentation (65-70% of breech babies) where the baby’s bottom comes first and their legs are flexed at the hip and extended at the knees (with the feet near the ears). • The footling breech presentation, where one or both feet come first, with the bottom at a higher position. This is rare with term babies, but relatively common with premature fetuses. • Single limb or other abnormal presentations may require C-section. Do not attempt field delivery.

BVIP

An infant in a frank breech or a double footling (both feet) breech presentation generally delivers in three (3) stages: • Legs to Abdomen • Abdomen to Shoulders • Head

BVIP

With respect to the risk of hypoxia, the two most dangerous times for the infant are: • After delivery of the Legs to Abdomen, when the umbilical cord can become compressed against the pelvic inlet as the head descends; and • After delivery of the Abdomen to Shoulders, awaiting delivery of the head.

BVIP

1.

Initial Medical Care – Special Considerations: • If birth is imminent, prepare for delivery per Emergency Childbirth guidelines.

BVIP

2.

Expeditious Transport with care enroute; if only the buttocks or lower extremities are delivered. • It is acceptable to stay on-scene for One Contraction Only if the baby is delivered to the shoulders, while attempting delivery of the head. • If the baby delivers to the shoulders while enroute, stop the vehicle to attempt delivery of the head. • Never attempt to pull the infant by the legs or trunk from the vagina.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 3

Delivery Complications: Prolapsed Cord LEVEL BVIP

Delivery Complications: Prolapsed Cord Assessment Priority: • Check for prolapsed cord whenever the patient states her bag of water has ruptured. 1.

If Prolapsed Cord is observed: Place gloved hand into vagina and place fingers between pubic bone and presenting part, with cord between fingers. Apply continuous steady pressure on the presenting part to keep the cord from being compressed and allow for blood flow.

2.

Cover the exposed cord with a moist dressing and keep warm. Palpate the cord frequently for pulsations, and if lost, reposition.

3.

Expeditious transport, with care enroute: • Oxygen 10-15 L/NRM. • Establish IV access, while enroute if possible.

4.

Transport with continued pressure on part to keep the cord free.

VIP

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 4

Newborn and Post-Partum Care – Care of Newborn, APGAR Scoring Chart, Infant Patient Care Report LEVEL BVIP BVIP

BVIP

BVIP

BVIP BVIP

BVIP

Care of Newborn 1. Assess the airway, breathing, and circulatory status of the neonate. • If in distress, refer to the Neonatal Resuscitation Guidelines. 2. Initial Medical Care – Immediately After Delivery: • Keep infant eye level with mother’s uterus; hold in a 15° head down position. • Note date and time of delivery. • Suction mouth and nose using the neonatal bulb syringe; repeat as necessary. Ultra vigorous suction will depress neonatal respirations. • Dry and warm the neonate, wrap in blanket or chucks. • Stimulate the infant by gently rubbing the back or flicking soles of the feet. • Spontaneous ventilations should begin in 30 seconds. • If no spontaneous ventilations, proceed to Neonatal Resuscitation Guidelines. 3. Clamp the cord at 6-inches and 8-inches from the infant’s body. • Cut between the clamps with the sterile scalpel from OB kit. Check the cord ends for bleeding. • If no sterile scalpel available, leave the cord clamped and uncut. Place infant on mother’s abdomen for transport. 4. Obtain 1 Minute APGAR Score (see APGAR Assessment Chart). If score is 6 or less, refer to Neonatal Resuscitation Guidelines. • If respiratory rate is less than 40, assist ventilations with 15 Liters of Oxygen/Neonatal BVM. Proceed to Neonatal Resuscitation Guidelines. • If the infant is dusky but breathing spontaneously at a rate of less than or equal to 40 breaths per minute: o Place a neonatal NRM 1-inch from infant’s face with oxygen at 10 Liters. 5. Obtain 5 Minute APGAR Score (see APGAR Assessment Chart). 6. Tag infant and mother with the same information, as follows: • Mother’s name. • Sex of infant. • Date and time of delivery. 8. Transport infant and mother together, if possible. • However, these are two separate patients, and if one should require resuscitation, a second ambulance should be requested.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 5

APGAR Scoring Chart APGAR Assessment 0 (Zero) 1 (One) 2 (Two) Appearance Blue or Pale Blue Hands or Feet Entirely Pink Pulse Absent Less than 100 Above or Equal to 100 Grimace (Reflex Irritability) Absent Grimace Cough or Sneeze Activity (Muscle Tone) Limp Some Extremity Flexion Active Motion Respirations (Respiratory Effort) Absent Weak Cry, Rate Less than 40 Strong Cry

Infant Patient Care Report LEVEL BVIP

Infant Patient Care Report 1. Document the following: • Date and time of delivery. • Whether or not umbilical cord was wrapped around the neck. If so, note how many times. • Appearance of amniotic fluid (if known), especially if green, brown, or tinged with blood. • APGAR scores at 1-minute and 5-minutes. • Any infant resuscitation initiated and response. • Time placenta delivered and whether or not it appeared intact.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 6

Newborn and Post-Partum Care – Care of Mother LEVEL BVIP

VIP

Newborn and Post-Partum Care – Care of Mother Care of Mother: 1. Placenta should deliver in 20-30 minutes. If delivered, collect in plastic bag from OB kit and transport to hospital for inspection. DO NOT pull on cord to facilitate delivery of the placenta. DO NOT delay transport awaiting placental delivery. 2. Mother may be shivering. Cover with blanket. 3. If perineum torn and/or bleeding, apply direct pressure with sanitary pads and have mother bring her legs together. Apply cold pack (ice bag) to perineum (over pad) for comfort and to reduce swelling. 4. If significant blood loss: • Fluid challenge of Normal Saline in consecutive 500 mL increments to maintain systolic BP > 90 mmHg. • Massage top of uterus (fundus) until firm. • Breast-feeding may increase uterine tone.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 7

Neonatal Resuscitation Newborns in Distress / Arrest (APGAR Score = 6 or Less) LEVEL BVIP

Neonatal Resuscitation – Newborns in Distress / Arrest Points to Remember: • The majority of newborn infants require no resuscitation beyond maintenance of temperature, mild stimulation and suctioning of the airway. • Of the small number who require intervention, most will respond to oxygen via NRM and/or BVM. • An even smaller number of severely asphyxiated infants require chest compressions, and • An even smaller number need resuscitative medications. • Expeditious transport is always indicated as soon as an airway is secured and resuscitative interventions have been initiated.

BVIP

1.

Leave at least 6 inches of umbilical cord when cutting the cord on an infant in obvious distress. One team member should note the 1-minute and 5-minute APGAR scores.

2.

Rapidly warm and dry the neonate and provide tactile stimulation by flicking the soles of the feet and/or rubbing the back.

3.

Place the newborn on his/her back in a head-down position, if possible. A 1" thick towel roll placed under the shoulders is helpful in maintaining a "sniffing" position for optimal airway opening.

4.

Suction the mouth and nose with a bulb syringe. Deep suctioning of the oropharynx using an 8 Fr. catheter, if indicated, should be limited to 10 seconds at a time.

NOTE: Infants born with meconium staining require thorough suctioning immediately upon delivery of the head and before initiation of artificial respirations. 5.

Ventilate the child between suctioning using 100% oxygen/neonatal BVM at a rate of 40-60/minute if adequate spontaneous ventilations do not begin in 30 seconds. • Use only enough tidal volume to see the chest rise. • The first breath will require a little more pressure to begin lung inflation. • Continue to suction the nose and oropharynx periodically to remove secretions that emerge from the lungs.

6.

Assess for bradycardia (heart rate less than 100 beats per minute).

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 8

LEVEL

IP

VIP IP IP

Neonatal Resuscitation – Newborns in Distress / Arrest 7. If apneic, bradypneic, or central cyanosis is present: • Continue to ventilate at 40-60/minute using 100% Oxygen/Neonatal BVM. 8.

If, despite adequate assisted ventilations for 30 seconds, the heart rate remains under 80 beats per minute: • Continue assisted ventilations. • Begin chest compressions at 120/minute.

9.

Intubate, as able, using a 3.0 ET tube and a size “0” (zero) straight laryngoscope blade. • If the ET attempt is unsuccessful, and the airway is compromised, expeditious transport.

10.

If heart rate remains under 80/minute despite warming, stimulation, 100% oxygen/BVM, and chest compressions: • Attempt peripheral IV for one attempt with a 22-gauge to 24-gauge catheter TKO. If unsuccessful, place IO. • Give Epinephrine (1:10,000) 0.01 mg/kg IV/IO. • Repeat Epinephrine (1:10,000) 0.01 mg/kg IV/IO every 3-minutes, if indicated.

USE BROSELOW TAPE FOR MEDICATION DOSES

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 9

Obstetrical Complications BLEEDING LEVEL Threatened Miscarriage/Placental Previa/Abruptio Placenta Initial Medical Care – Special Considerations: FR B V I P 1. • Position patient on left side if in 2nd or 3rd trimesters. • Raise right side of backboard if spinal immobilization necessary. • Do not obtain BP until patient positioned on left side. VIP • Anticipate need for 2 large bore IV’s. • If altered mental status or signs of hypoperfusion: o Fluid challenges in 500 cc increments titrated to patient response. BVIP • Obtain pregnancy history per Emergency Childbirth Protocol • Ask about the onset, duration, quality and severity of abdominal pain. 2.

Note type, color and amount of vaginal bleeding or discharge. If tissue is passed, collect and transport to hospital with the patient.

3.

Hemorrhaging – transport immediately do not wait for IV to be started.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 10

Obstetrical Complications HYPERTENSION IN PREGNANCY LEVEL

Preeclampsia or Hypertension of Pregnancy / Eclampsia Diastolic Blood Pressure > 90 mmHg with additional signs that include, but are not limited to: headache, Visual disturbances, and/or altered mental status. Signs and symptoms can occur any time in pregnancy, and up to 28 days past delivery. Initial Medical Care – Special Considerations: FR B V I P 4. • Position patient on left side if in 2nd or 3rd trimesters. • Do not obtain BP until positioned on left side. • Obtain pregnancy history per Emergency Childbirth Protocol • Minimal CNS stimulation. Do not check pupillary light reflex. P • If seizure occurs, give Magnesium Sulfate 4 gms in 100 cc of IV fluid slowly over 4 minutes for hypertension (BP > 160-110). Stop infusion if respiratory distress or loss of muscle tone. • If seizure continues, treat per seizure protocol

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols OB - 11

General Pediatric Care I.

Special Considerations: • Children have different responses to blood volume loss. They often maintain their systolic BP until a 30% volume loss has occurred, then, crash rapidly. • Children are also prone to heat loss and cold stress, which results in acidosis, hypoxia, and bradycardia. • Gastric dilation develops from crying, which leads to ventilatory impairment. • Conditions Requiring Rapid Cardiopulmonary Assessment and Potential Cardiopulmonary Support: o Respiratory Rate > 60 breaths/min o Heart rate ƒ Child 5 years of age or younger: < 80 beats/min or > 180 beats/min ƒ Child over 5 years of age < 60 beats/min or > 160 beats/min o Increased work of breathing (retractions, nasal flaring, grunting) o Cyanosis or a decrease in oxygen saturation o Altered level of consciousness (unusual irritability or lethargy, or failure to respond to parents or painful procedures) o Seizures o Fever with petechiae o Trauma o Burns involving more than 10% of body surface area • Use of Pediatric Measuring Tape (e.g. Broselow) along with the corresponding Pediatric Color coded supplies is encouraged for quick and easy identification of drug doses and supply sizes.

II.

Formula for Estimating Normal Weight in Children (kilograms) • Under 12 months (Age in months/2) + 4 = Weight in kg • 1 to 10 Years (Age in Years x 2) + 10 = Weight in kg Age*

Typical Systolic BP (Age x 2) + 90

Lower Limits of SBP (Age x 2) + 70

Neo to 3 months

90

70

3 mos.-2 yrs

90-92

70-72

2-10 yrs

94-110

74-90

Over 10 yrs

Over 110

90

Awake Pulse (Range) 140 (85-205 130 (100-190) 80 (60-140) 75 (60-100)

Asleep Pulse

Resp. Rate

80-160

30-60

75-160

24-40

60-90

18-30

50-90

12-20

Note: Age is all in years unless otherwise indicated. Typical Systolic Blood Pressure in children 1 to 10 years of age are: 90 mmHg + (Child’s age in years x 2) mmHg. Lower limits of Systolic Blood Pressure in children 1 to 10 years of age: 70 mmHg + (Child’s age in years x 2) mmHg Estimating Normal Weight in Children (Kg) 12 months [Age(months)/2 +4] 1 – 10 years [2 x age (years)] + 10 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 1

Suggested Sizes for ET Tubes, Blades, Suction Catheters Age Averages

Newborn

6 Months

18 Months

3 Years

5 Years

6 Years

8 Years

12 Years

ET Tube

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

Blade Size

0-1 Straight

1 Straight

1.5 Straight

2 Straight

2 Straight

2 Straight

2 Straight or Curved

3 Straight or Curved

Suction Cath

6 Fr

6 Fr

8 Fr

8 Fr

10 Fr

10 Fr

10 Fr

10 Fr

Notes: • Select tube size based on size of the child, not his/her chronological age. • Prepare additional tubes one size larger and one size smaller than the one you initially select. Fast References: • Match tube size to size of nail on patient’s little finger, or • Calculate using formula (16 + age in years) / 4.

Pediatric Glasgow Coma Scale Best Verbal Response Age older than 5 Yrs

Eye Opening

Best Verbal Response Age 2-5 Years

Best Verbal Response Age Less than 2 Years

Best Motor Response Moves Spontaneously/ Purposefully Localizes Pain/Withdraws to Touch

Spontaneous

4

Oriented / Converses

5

Appropriate Words/Phrases

5

Smiles/Coos/Cries Appropriately

5

To Speech

3

Disoriented / Converses

4

Inappropriate Words

4

Cries/Is Consolable

4

To Pain

2

Inappropriate Words

3

Cries/Screams

3

Persistent Screaming/Crying/ Inconsolable

3

Withdraws to Pain

4

None

1

Incomprehensible

2

Moans/Grunts to Pain

2

Moans/Grunts to Pain

2

Abnormal Flexion

3

None

1

None

1

None

1

Abnormal Extension

2

None

1

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 2

6

5

CPR Modifications for Children and Infants Technique

Child Age 1-8 Years

Infant Under 1 Year

Airway Opening

Modified Head Tilt/Chin Lift

Slight Head Tilt/Chin Lift

Breathing

Mouth-to-Mouth

Mouth-to-Mouth-and-Nose

Foreign Body Airway Obstruction

Abdominal Thrusts

Back Slaps/Chest Thrusts

Ventilation Rate without Compressions Ventilation Rate with CPR and Advanced Airway Circulation (Compression Point) Compress With

12-20 per minute/every 3-5 seconds 8-10 breaths per minute Lower 1/3 of Sternum (Same as adult) Heel of one hand, add second hand on top as needed to push fast and hard

Lower 1/3 of Sternum (Below nipple line) 2-3 fingers

Compression Depth

⅓ to ½ the depth of the chest

Compression Rate

At least 100 per minute

Compression-to-Ventilation Ratio Single Rescue Provider Multiple Rescue Providers

30 : 2 15 : 2

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 3

Resuscitation Medication Dosages Epinephrine Atropine 0.1mg/ml 1:10,000 0.01 mg/kg 0.02 mg/kg Age

Weight kg

IV/IO1

ET Size

lbs

mm

mg

Lidocaine 20 mg/ml 1 mg/kg

Amiodarone 50 mg/ml 5mg/kg/dose

IV/IO

IV/IO

IV/IO ml

mg

ml

mg

ml

mg

Newborn

3

7

3

0.03

0.3

0.1

1

3

0.15

15

0.3

1 month

4

8

3

0.04

0.4

0.1

1

4

0.2

20

0.4

3 months

5

11

3.5

0.05

0.5

0.1

1

5

0.25

25

0.5

6 months

7

15

3.5

0.07

0.7

0.14

1.4

7

0.35

35

0.7

1 year

10

22

4

0.1

1

0.2

2

10

0.5

50

1

2 years

12

26

4

0.12

1.2

0.24

2.4

12

0.6

60

1.2

3 years

14

31

4.5

0.14

1.4

0.28

2.8

14

0.7

70

1.4

4 years

16

35

5

0.16

1.6

0.32

3.2

16

0.8

80

1.6

5 years

18

40

5

0.18

1.8

0.36

3.6

18

1

90

1.8

6 years

20

44

5.5

0.2

2

0.4

4

20

1

100

2

7 years

22

48

6

0.22

2.2

0.44

4.4

22

1.1

110

2.2

8 years

25

55

6

0.25

2.5

0.5

5

25

1.25

125

2.5

9 years

28

63

6

0.28

2.8

0.5

5

28

1.4

140

2.8

10 years

34

75

6.5

0.34

3.4

0.5

5

34

1.7

170

3.4

Notes: 1

ml

IV/IO flush drugs with 5 cc Normal Saline.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 4

Pediatric Bradyarrhythmias with Pulse LEVEL FR B V I P

Pediatric Bradyarrhythmias with Pulse 1. 2. • •

P

•

Assess for cause. Initiate corrective resuscitative measures as necessary. Initial Medical Care – Special Considerations: 100% oxygen per Peds NRM or assist with Peds BVM If patient unconscious and unresponsive to pain: Assist breathing with BVM. Consider advanced airway only if unable to adequately ventilate with BVM. ÆIf unable to secure airway after assisting with BVM and attempted advanced airway insertion: Needle cricothyrotomy(Paramedic only) and expeditious transport Initiate CPR if heart rate: < 60/minute in an infant and < 60/minute in a child < 8 years Initiate peripheral IV or IO as able if signs of hypovolemia:

BVIP

•

VIP

•

VIP

• If signs of hypovolemia: Normal Saline 20 ml/kg IV. May repeat as needed to a max dose of 60 ml/kg. Check for pulse and rhythm changes after each intervention. Proceed to next step only if bradycardia with signs of hypoperfusion persists.

IP

3.

Epinephrine (1:10,000) 0.01 mg/kg (0.1ml/kg) IV/IO Repeat every 3-5 minutes

IP

4.

Atropine 0.02 mg/kg rapid IV/IO • Minimum dose 0.1 mg. • Maximum single dose is 0.5 mg (1 mg for adolescent). • If no response may repeat an additional dose (one) up to a maximum total of 0.04 mg/kg IV/IO. (Maximum dose of 3 mg)

P

5.

Initiate external pacing if available. MAY use standard size electrodes in children > 15 kg.

6.

If change in rhythm, proceed to appropriate PROTOCOL.

Notes: * Flush all IV/IO drugs with 5 ml NS * Attempt to keep child warm with protected hot packs/blankets as able

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 5

Pediatric Asystole / Pulseless Electrical Activity (PEA) LEVEL

Pediatric Asystole / Pulseless Electrical Activity (PEA)

FR B V I P

Ninety percent of pediatric arrests are secondary to inadequate respirations. Assess for causative factors: hypoxemia, acidosis, hypovolemia, tension pneumothorax, cardiac tamponade, shock, hypothermia, poisoning or ingestion, or severe infection and initiate corrective resuscitative measures as necessary.

FR B V I P

1. Initial Medical Care; special considerations: • • •

IP

• •

IP

•

P

•

BVIP

• • •

C-A-B: Compressions-Airway-Breathing Continuous chest compressions at least 100 per minute at all possible times. High quality CPR: Push hard & fast, minimize interruptions, allow full chest recoil, and avoid excessive ventilation Ventilate with 100% oxygen/peds BVM. Access airway through endotracheal intubation as soon as possible, if not able to adequately ventilate with BVM. Use straight blade on children < 8 years. Attempt X 2 if necessary If intubation unsuccessful, and good air exchange is achieved with Peds BVM: continue ventilations/BVM ÆIf unable to secure airway after assisting with BVM and attempted advanced airway insertion: Needle cricothyrotomy(Paramedic only) and expeditious transport Prepare Peds defib pads Confirm cardiac rhythm in more than one lead. Do not interrupt CPR for more than 10 seconds to check for pulse and rhythm.

Check for pulse and rhythm changes after each intervention. Proceed to next step only if Asystole/ PEA persists. VIP

2. Initiate peripheral IV or IO as able If signs of hypovolemia: NS 20 ml/kg IV/IO bolus. May repeat to a maximum of 60 ml/kg.

IP

3.

BV

4. If no Intermediate or Paramedic service available to scene and at least 20 minutes of resuscitation have occurred, contact medical control for permission to terminate resuscitation and not transport. If all the following present, medical control will likely terminate resuscitation: • Cardiac Arrest unwitnessed by EMS • No shock by automated defibrillator • No return of spontaneous circulation at any time during resuscitation

Epinephrine (1:10,000) 0.01 mg/kg (0.1 ml/kg) IV/IO. minutes.

Repeat every 3-5

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 6

IP

5. If no return of spontaneous circulation (ROSC) and at least 20 minutes of resuscitation have occurred, contact medical control for permission to terminate the resuscitation. Do not initiate transport without medical control consent.

AHC-SM EMS Approved 7/01/08 Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 7

Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia LEVEL FR B V I P

FR B V I P

FR B V IP

IP

IP

VIP

Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia Causes: Congenital heart disease, hypoxia, acidosis, electrolyte imbalance and ingestion (particularly cyclic antidepressants). 1. Initial care C-A-B: Compressions-Airway-Breathing Continuous chest compressions at least 100 per minute at all possible times. High quality CPR: Push hard & fast, minimize interruptions, allow full chest recoil, and avoid excessive ventilation Perform CPR for 5 cycles or 2 minutes prior to defibrillation or AED per scope of practice. Ventilate with 100% oxygen/Peds BVM. Maintain a compression to ventilation ratio of 30:2, unless 2 rescuers then it should be 15:2 Follow appropriate BLS skills as outlined in Section X. 2. Defibrillate at 2 Joules/kg. • Perform CPR for 5 cycles or 2 minutes. • Check ECG rhythm and pulse. • proceed to next step only if VF/Pulseless VT persists • if rhythm changes, follow appropriate PROTOCOL • Anytime V-fib converts to an SV: administer Lidocaine 1 mg/kg IVP. • Rebolus with Lidocaine 0.5 mg/kg 10 minutes after initial bolus if not contraindicated 3. Continue CPR for 5 cycles or 2 minutes; • Access airway through endotracheal intubation as soon as possible. Use straight blade on children < 4 yrs. Attempt X 2 if necessary. • Ventilate at 8-10 breaths per minute. • If intubation unsuccessful, and good air exchange is achieved with Peds BVM: continue ventilations/BVM • Do not interrupt CPR for more than 10 seconds. 4. Initiate peripheral IV or Intraosseous line as able. If dehydrated or hypovolemic: fluid bolus NS 20 ml/kg IV/IO. Repeat as needed to a Maximum of 60 ml/kg.

IP

5. Epinephrine first dose (1:10,000) 0.01 mg/kg (0.1ml/kg) IVP/IO or (1:1000) Note: Perform CPR and Defibrillate at 4 Joules/kg after each time a drug is given. The sequence should be: Drug/CPR-Shock-Drug/CPR-Shock Perform CPR for 5 cycles or 2 minutes after each drug or shock given. 6. Perform CPR and Defibrillate at 4 Joules/kg

IP

7. Amiodarone 5mg/kg IVP

IP

8. Perform CPR and Defibrillate at 4 Joules/kg

IP

9. Epinephrine second and subsequent doses (1:10,000) 0.01 mg/kg (0.1ml/kg) IVP/IO repeated every 3 to 5 minutes.

IP

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 8

IP

10. Perform CPR and Defibrillate at 4 Joules/kg

IP

11. Lidocaine 1mg/kg IV/IO

IP

12. Perform CPR and Defibrillate at 4 Joules/kg

IP

13. Expeditious transport with further interventions enroute. • May repeat Lidocaine 1 mg/kg IV/IO • Defibrillate 4J/kg 30 to 60 seconds after each medication • Total of all Lidocaine boluses not to exceed 3 mg/kg • Flush all IV/IO drugs with 5 ml NS • Attempt to keep child warm with blankets/protected hot packs as able

BV

14. If no Intermediate or Paramedic service available to scene and at least 20 minutes of resuscitation have occurred, contact medical control for permission to terminate resuscitation and not transport. If all the following present, medical control will likely terminate resuscitation: • Cardiac Arrest unwitnessed by EMS • No shock by automated defibrillator • No return of spontaneous circulation at any time during resuscitation

IP

15. If no return of spontaneous circulation (ROSC) and at least 20 minutes of resuscitation have occurred, contact medical control for permission to terminate the resuscitation. Do not initiate transport without medical control consent.

AHC-SM EMS Approved 7/01/08_Revised 08/01/2012 _

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 9

Pediatric Airway Obstruction (Child/Infant) LEVEL FR B V I P

Pediatric Airway Obstruction (Child/Infant) 1. Determine responsiveness and ability to speak. 2.

Position patient to open airway: • If unconscious: use head tilt/chin lift. • If possible C-Spine injury: use modified jaw thrust.

3.

Assess breathlessness/degree of airway impairment.

LEVEL FR B V I P

Pediatric Airway Obstruction (Child/Infant) – Conscious 1. Able to Speak: Child 1-8 years • Strong cry, effective cough: Less than 1 year of age

FR B V I P

2.

Initial Medical Care: • Do not interfere with patient’s own attempt to clear airway by coughing or sneezing. If patient is breathing or resumes effective breathing, place in the recovery position.

FR B V I P

3.

Cannot Speak: • Children over 1-year:

FR B V I P

LEVEL

•

Infants under 1-year:

•

Repeat if no response.

Five (5) abdominal thrusts (Heimlich maneuver) with patient standing or sitting. Five (5) back blows followed by five (5) chest thrusts.

4.

Still Obstructed: • Continue Step 3 until foreign body expelled or patient becomes unconscious (see below). • Monitor for cardiac dysrhythmias and/or arrest. Pediatric Airway Obstruction (Child/Infant) – Unconscious

FR B V I P

1. 2.

Initial Medical Care. Start CPR

BVIP

3.

FR B V I P

4.

Perform a tongue-jaw lift. Attempt to ventilate. • If obstructed, visualize airway with laryngoscope and attempt to clear using forceps and/or suction. Open airway and try to ventilate. • If still obstructed, reposition head and try to ventilate again.

BVIP

5.

IP

6.

Still obstructed: Intubate and push foreign body into right mainstem bronchus, then pull back tube and ventilate left lung.

P

7.

ÆStill obstructed:

Still obstructed:

Attempt forced ventilation with Pediatric BVM

Perform cricothyrotomy.

AHC-SM EMS Approved 7/01/08_Revised 9/20/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 10

Pediatric Allergic Reaction / Anaphylactic Shock LEVEL FR B V I P

P

Pediatric Allergic Reaction / Anaphylactic Shock 1. Initial Medical Care – Special Considerations: • Do not start IV or give medications into same extremity as a bite to injection site. • Apply venous constricting band (not arterial) proximal to bite or injection site if swelling is increasing rapidly. • Apply cold pack to bite or injection site. Allergic Reaction 1. Benadryl 1mg/kg IM/IV 2.

Solumedrol 2mg/kg IV/IO (max125mg) or Decadron 0.2mg/kg IV/IO (max 10 mg)

P

BVIP

FR B

BVIP IP P

VIP

IP

If extensive hives (urticaria), throat or tongue swelling, shortness of breath or history of systemic reaction in past consider:

Epinephrine (1:1000) 0.01 mg/kg IM (maximum of 0.3 mg) Repeat once in 20 minutes if minimal response Or Epi-pen Jr 0.15mg DO NOT DELAY TRANSPORT while waiting for response. Anaphylaxis 1. Initial Medical Care – Special Considerations: • If airway obstructed due to edema, attempt advanced airway. • If unsuccessful, perform needle cricothyrotomy • 100% Oxygen by Peds NRB or Assist with BVM. Titrate Oxygen to bring O2 saturations to 94% or greater. • If signs of hypoperfusion: o IV fluid challenge 20 ml/kg IV/IO. o Do not delay transport while waiting for response. 2.

BV

Epinephrine (1:10,000) 0.01 mg/kg (0.1 ml/kg) IV/IO Epinephrine (1:1000) 0.01 mg/kg IM (maximum of 0.5 mg) Repeat as needed every 10 minutes if minimal response Or Epi-pen Jr 0.15mg

FR B P

3.

Benadryl 1 mg/kg IV/IO/IM.

P

4.

Solumedrol 1mg/kg IVP/IO (max 125 mg) or Decadron 0.2 mg/kg IV/IO, max 10 mg

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 11

LEVEL IP

Pediatric Allergic Reaction / Anaphylactic Shock 5. If no response after 10 minutes, Epinephrine (1:10,000) 0.01 mg/kg(0.1ml/kg) IVP/IO or (1:1000) 0.1 mg/kg (0.1ml/kg)ET.

IP

6.

May repeat Epinephrine (1:10,000) 0.01 mg/kg (0.1ml/kg) IVP/IO or (1:1000) 0.1 mg/kg (0.1ml/kg) ET every 5 minutes x 2 total. DO NOT DELAY TRANSPORT WHILE WAITING FOR RESPONSE.

BVIP

7.

If wheezing: Albuterol 2.5 mg in 2-3cc NS via nebulizer

AHC-SM EMS Approved_7/01/08 Revised 9/20/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 12

Pediatric Asthma LEVEL

FR B V I P

BVIP BVIP BVIP

BVIP

BVIP

P

Pediatric Allergic Reaction / Anaphylactic Shock Pediatric asthma may manifest itself somewhat differently from the adult form. Children may not present with wheezing, but may continuously cough for 20-30 minutes after excitement or exercise; or they may abruptly vomit. Due to the small diameter of their airways, even incremental edema/bronchoconstriction may cause severe air exchange problems. The inability of peds patients to increase their tidal volumes often results in markedly increased respiratory rates which rapidly dehydrate the airways and accelerate the development of mucous plugs. The resulting hypoxemia leads to acidosis and bradycardia. Treat aggressively. 1.

Initial Medical Care; special considerations: • If mild to moderate ventilatory distress: oxygen 4-6 L/nasal cannula to bring patients O2 saturation to 94% or greater • If moderate to severe ventilatory distress: Oxygen by Peds NRB or assist ventilations with Peds BVM • If mild to moderate distress: do not start IV • if dehydrated or in moderate to severe distress: IV NS • If moderate to severe distress: monitor ECG • bradycardia signals deterioration of patient status: consider intubation • ETCO2 monitoring if available

2.

Obtain past medical history including triggers for attacks; usual severity of attacks; current asthma meds (inhalers, prednisone, theophylline); time and amount of last dose; duration of current episode.

Mild to Moderate Distress 3. Albuterol 2.5mg, 0.5mg Atrovent via nebulizer • Do not delay transport waiting for response. 4. Partial Response: repeat Albuterol 2.5mg via nebulizer At discretion of Medical Control - (I & P do not have to call) 5. Epinephrine (1:1000) 0.01 mg/kg IM (max of 0.5 mg IM). (66 lbs), administer 0.3 mg IM. Severe Distress 6. Albuterol 2.5mg, 0.5mg Atrovent via nebulizer • Do not delay transport waiting for response.

For patients > 30 kg

At discretion of Medical Control - (I & P do not have to call) 7. ÆEpinephrine (1:1000) 0.01 mg/kg IM (max of 0.5 mg IM). (66 lbs), administer 0.3 mg IM.

For patients > 30 kg

8.

Decadron 0.2 mg/kg IV/IO (max 10 mg) or Solumedrol 2mg/kg – Max 125mg.

AHC-SM EMS Approved_7/01/08 Revised 08/01/2012__ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 13

Pediatric Croup/Epiglottitis Signs & Symptoms Age in years/months Onset of distress Presence of stridor Voice Drooling Fever Retractions Ventilatory distress

Croup 6 months to 4 years Gradual, days Loud Hoarse, raspy voice/cry Absent Low grade Absent Usually mild to moderate

Epiglottitis Usually older than 2 years Rapid – within hours Muffled, softer if obstruction almost complete Muffled/quite speech/cry. No hoarseness Often present Elevated, above 102° Often present Usually moderate to severe

Cough

Barking like a seal

Quiet, not usually coughing; without severe sore throat

LEVEL FR B V I P

Pediatric Croup/Epiglottitis 1. Initial Medical Care – Special Considerations: • Keep patient calm Allow parent/guardian to hold upright in position of comfort. • Do not place anything in mouth to visualize pharynx. • MONITOR ECG FOR CHANGES - Bradycardia signals deterioration. • Do not start IV unless child presents in impending arrest. 2.

BVIP IP P LEVEL BVIP

IP

If ventilatory distress: • Expeditious transport • Prepare intubation/suction equipment. • Paramedic only, consider cricothyrotomy.

Pediatric Croup No cyanosis, mild to moderate respiratory distress. 1. Six (6) cc Normal Saline in nebulizer by mask or aim mist at child’s face with oxygen at 6-Liters. 2. If wheezing, Albuterol 2.5mg, Atrovent 0.5mg via nebulizer Cyanosis, Severe stridor at rest, or severe respiratory distress. 1. Consider possibility of epiglottitis and treat as below if airway obstruction progresses. 2. Epinephrine (1:1000) 3 mL (3 mg) via nebulizer mask or aim mist at child’s face

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 14

LEVEL BVIP

Pediatric Epiglottitis STABLE 1. Blow by Oxygen at 6-Liters at child’s face. Avoid agitation/crying. 2. Transport Bradycardic, altered mental status, marked stridor/ventilatory distress, retractions, cyanosis, ineffective air exchange, and/or actual or impending respiratory arrest. 1. Position supine in sniffing position. Ventilate with 100% Oxygen/Pediatric BVM. • If unable to ventilate: o Temporarily stop ambulance and attempt one oral endotracheal intubation by the most experienced/skilled provider. UNSTABLE:

BVIP

IP IP P

•

Be prepared for airway status to worsen if intubation attempt is unsuccessful.

2. If intubation unsuccessful, and unable to ventilate: Cricothyrotomy.

ÆPerform Needle

AHC-SM EMS Approved_7/01/08 Revised 9/20/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 15

Pediatric Diabetic/Glucose Emergencies LEVEL FR B V I P

VIP BVIP

BVIP VIP

BVIP

VIP

Pediatric Diabetic/Glucose Emergencies: 1. Initial Medical Care – Special Considerations. • Obtain medical history including medications – last medication dose and last oral intake • Vomiting and seizure precautions: Be ready with suction • IV or IO Access 2.

Obtain and record blood glucose level.

If Blood Sugar less than 60 or signs and symptoms of Hypoglycemia, give: 3. Consider using 1 tube of Oral Glucose, if not contraindicated 4. If IV/IO access established, give: Older than 2-years of age: Dextrose 50% 2 ml/kg IV. 1-2 years of age: Dextrose 25% 4 ml/kg IV. Younger than 1 year of age: Dextrose 12.5% (dilute D25 1:1 with NS) 8 ml/kg IV 3.

If unable to establish IV access: • Less than 20 kg: Glucagon 0.5 mg IM/IN • Over 20 kg: Glucagon 1 mg IM/IN

4.

Observe and record response to treatment; may repeat if necessary.

6.

Blood Sugar > 300, or Signs and Symptoms of Hyperglycemia/Ketoacidosis: • Fluid challenge 20 ml/kg IV unless contraindicated. • May repeat x1. Stop fluid challenge if crackles noted.

PREHOSPITAL PROVIDERS SHALL NOT ASSIST ANY PATIENT IN ADMINISTERING ANY INSULIN PRODUCTS PRIOR TO ARRIVAL AT THE HOSPITAL.

AHC-SM EMS Approved 7/01/08 Revised 11/20/08. 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 16

Pediatric Drug Overdose/Poisoning LEVEL FR B V I P

IP

FR B V I P VIP BVIP

Pediatric Drug Overdose/Poisoning: 1. Initial Medical Care – Special Considerations: • Follow department hazmat protocols. Do not enter contaminated scenes until appropriate PPE are applied • Anticipate the possibility of respiratory arrest, seizure activity, dysrhythmias, or vomiting • Supplement oxygen to keep O2 saturation at 94% or greater using a nasal cannuala, 100% oxygen/Peds NRB or assist with Peds BVM • Consider intubation if airway compromised and unable to ventilate with BVM. • Do NOT induce vomiting: especially in cases of caustic substance ingestion Bring substance or drugs to the hospital • IV 20-22 g. on regular drip tubing. Maintain flow at KVO rate. Do not fluid overload. • Monitor ECG in all cases/Consider 12 Lead EKG. Transmit to Medical control if unable to interpret • Be alert to and ask about suicidal ideation/attempt 2. If patient is stable, in most cases no further treatment is required, transport. 3. If altered mental status, seizure activity, or focal neurologic deficit; obtain and record blood glucose. If < 60 follow Pediatric Diabetic protocol. 4. If seizures occur, follow appropriate seizure protocol.

VIP VIP

Narcotic or Synthetic Narcotic Overdose or unknown: 1. If weight is over 20 kg: Narcan 2 mg IV/IO/IN and/or, 2. If weight is under 20 kg: Narcan 0.1 mg/kg IV/IO/IN

VIP

TriCyclic Antidepressant Overdose: 1. Fluid challenge 20 ml/kg IV/IO. May repeat x1

P

2.

Sodium Bicarbonate 1 mEq/kg IV for hypotension, deterioration of sensorium, or dysrhythmias.

Organophosphate Poisoning:

SLUDGEM + RESPIRATION + AGITATION. S – Salivation (excessive drooling). L – Lacrimation (tearing). U – Urination. D – Defecation. G – GI upset (cramps). E – Emesis (vomiting). M – Muscle (twitching, spasm, “bag of worms”). IP

1.

P

2. 3.

Atropine 0.02 mg/kg (minimum 0.1 mg) IV/IO Repeat every 3-minutes until signs of Atropinization appear (dry mouth, dried secretions, flushed skin, dilated pupils, tachycardia). Usually Atropine dose limitation does not apply. Sodium Bicarbonate 1 mEq/kg IV/IO for hypotension, deterioration of sensorium, or dysrhythmias. PRALIDOXIME (2 PAM CHLORIDE)

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 17

LEVEL

FR B V I P VIP P

FR B V I P

FR B V I P

Pediatric Drug Overdose/Poisoning: PEDIATRIC CYANIDE POISONING 1. Initial Medical Care per Peds Drug Overdose/Poisoning Protocol. 2. Establish hospital contact ASAP. 3. If hypotensive or pulseless: IV bolus 20 ml/kg May repeat to a total of 60 ml/kg. CPR as indicated. 4. Consider Cyanide kit if available. (Paramedic only) 70 mg/kg over 15 minutes. Note: Chances of recovery using this regimen are good even in the presence of respiratory arrest as long as the heart is still beating. PEDIATRIC CARBON MONOXIDE POISONING 1. Initial Medical Care; special considerations: • Advanced airway, if airway compromised. • Oxygen by Peds NRB or assist with Peds BVM. Ensure tight seal of mask to face. Remember Pulse Oxymetry is not an accurate indicator in the presence of CO. Patient needs High flow Oxygen even if the Pulse oxymetry is reading at 100% • Vomiting precautions; ready suction • Monitor ECG continuously • Keep patient as quiet as possible to minimize tissue oxygen demands • Consider hyperbaric medical needs in determining transport. 2. Treat patients with airway impairment or those in respiratory/cardiac arrest per appropriate Protocol and expeditious transport to nearest appropriate hospital by time travel. COCAINE OVERDOSE: 1. Treat dysrhythmias, chest pain, hypertensive crisis per appropriate protocols. 2. Treat Seizures per appropriate protocols.

AHC-SM EMS Approved_7/01/08 Revised 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 18

Pediatric Seizures LEVEL

Pediatric Seizures: Consider that seizures in children may be triggered by many causes including, but not limited to: trauma, fever, toxic ingestion/overdose, meningitis, electrolyte abnormality or hypoxia. Rapidly assess patient and environment for possible causes of seizure. Treat known causes per Medical Control instructions.

FR B V I P

1.

Initial Medical Care – Special Considerations: • Suction excess secretions. Do not place anything in mouth. • During total motor (grand mal) seizure activity: protect patient from injury and aspiration. Prepare suction and oxygen delivery. • Position patient on side unless contraindicated. • Obtain and record blood glucose, treat as needed

2.

If total motor (grand mal) seizure activity lasts more than 2-minutes: • IV access (do not wait to establish IV to give medications. IM Versed is preferred over IV.) • Versed 0.1 mg/kg IV/IO/Nasal/IM, max 5 mg/dose, o < 13 kg 0.2mg/kg o >13 to 40 kg is 5 mg dose • Ativan 0.05 – 0.2 mg/kg IV/IO/IM, max 4 mg/dose • May repeat these medications every 5 minutes

BVIP

VIP IP

P

LEVEL FR B V I P LEVEL P

Febrile Seizures: 3. Contact Medical Control before giving anything orally. INTRARECTAL VALIUM( Diastat): Special circumstances may exist that require administration of Valium to be given RECTALLY to pediatric patients in status epilepticus. • • • • •

Implement above protocols Attempt at IV must be unsuccessful or there are no sites available Valium 0.5 mg/kg rectally (maximum of 10mg) Lubricate syringe tip with K-Y jelly and insert 4-5 cm into the rectum Hold the buttocks together to avoid leakage after instillation of the medication

AHC-SM EMS Approved 7/01/08 Revised 11/20/08, 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 19

LEVEL FR B V I P

PEDIATRIC SYNCOPE/NEAR SYNCOPE NON-TRAUMATIC LOSS OF CONSCIOUSNESS 1. • • • 2. • • • • •

Initial Medical Care – Special Considerations: Monitor ECG continually enroute Document changes in GCS Obtain and record Blood Glucose Level. Treat to appropriate Protocol. Anticipate underlying etiologies and treat according to appropriate Protocol Cardiac Dysrhythmia Protocol's Hypovolemia Hypovolemic/Hemorrhagic Shock Protocol; consider dehydration CNS Disorder See appropriate Medical or Trauma Protocol; consider Meningitis Vasovagal Supportive Medical Care Metabolic Diabetes Protocol if blood glucose abnormality, Poisoning/overdose Protocol; consider electrolyte disturbance

Pediatric Unconscious – Unknown Etiology LEVEL Unconscious – Unknown Etiology FR B V I P Possible etiology mnemonic AEIOU TIPS-V: A: Alcohol, arrhythmias, ingestions; E: Endocrine, exocrine, electrolyte imbalance; I: Insulin shock, DKA; O: Oxygen deficit, opiates, overdose; U: Uremia, renal problems including hypertension; T: Trauma, temperature (hypothermia/hyperthermia); I: Infection; P: Psychological; S: Space occupying lesion (SAH), stroke, shock, seizures; V: Vascular FR B V I P 1. Initial Assessment & General Standing Orders. 2. Consider possible causes and treat. • Evaluate for hypoxia/hypercarbia and give oxygen and establish an airway as indicated. • If the patient is in SHOCK, attempt to determine the etiology and refer to the appropriate protocol, give IV fluids by IV protocol. • Consider Hypoglycemia- See Protocol - Hypoglycemia. VIP 3. If spontaneous ventilations inadequate, give Narcan 2 mg slow IV/IO/IN, if patient weight > 20 kg. For patient weight < 20 kg give Narcan 0.1 mg/kg IV/IO/IN. May repeat every 5 min. as needed, if transient response is seen. Remember to restrain the patient before giving Narcan.

AHC-SM EMS Approved 7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 20

Suspected Child Abuse or Neglect LEVEL Suspected Child Abuse or Neglect: FR B V I P 1. Initial Medical Care – Special Considerations: • Environmental factors that could adversely affect a child's welfare. • The child’s interactions with parents/guardians. • Discrepancies in the history obtained from the child and caregivers. • Injury patterns that do not correlate with the history or anticipated motor skills based on the child’s growth and developmental stage. • Any signs of intentional injury or neglect. 2.

Treat obvious injuries per appropriate SOP.

3.

Prepare to transport. If parent/guardian refuses to allow removal of the child, remain at the scene and contact law enforcement for assistance. Request law enforcement take the child into secure custody for medical evaluation at the hospital.

3.

If law enforcement refuses to take the child into secure custody, request that they remain at the scene. Contact local Child Protective Services (see numbers below) and request they respond to the scene and take the child into custody. If EMS remains unsuccessful in removing child, contact a medical control physician and seek guidance. If law enforcement or Child Protective Services assists in securing custody of the child, transport the child against the parent/guardian wishes. CPS contact numbers for respective counties are as follows: ƒ • • •

Kenosha County (262) 605-6582 (After hours, weekends and holidays call Crisis Intervention: (262) 657-7188) Racine County (262)-638-6321 or (800)-924-5137 Walworth County DHS (262)-741-3200 Waukesha County (262) 548-7212 or 211

5.

Children suffering from suspected abuse or neglect should not remain in an environment of suspected abuse unless #4 of the protocol has been pursued in vain to remove the child.

6.

Notify the receiving physician or nurse of the suspected abuse upon arrival to the hospital.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 21

LEVEL

Suspected Child Abuse or Neglect: 7.

Suspicions of child abuse or neglect must be reported to the local law enforcement agency having jurisdiction OR the Department of Children and Family Services (DCFS) per State Law. Reports must be filed, even if the EMT is aware that the hospital will also be reporting the incident. This includes both living and deceased children encountered by prehospital personnel. An EMS Provider who has reasonable cause to suspect that a child seen by the person in the course of professional duties has been abused or neglected or who has reason to believe that a child seen by the person in the course of professional duties has been threatened with abuse or neglect and that abuse or neglect of the child will occur is required to report.,

8.

Thoroughly document the child’s history and physical exam findings on the run sheet. Note relevant environmental/circumstantial data in the comments section of the run sheet or supplemental reports.

AHC-SM EMS Approved__7/01/08 Revised _08/01/2012_______ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

P- 22

Adult Airway Obstruction 8 Years of Age and Older LEVEL Adult Airway Obstruction (8 Years of Age and Older) FR B V I P 1. Initial Medical Care • Determine responsiveness and ability to speak. • Position patient to open airway: 2. Assess breathlessness/degree of airway impairment. 3. Monitor for cardiac dysrhythmias and/or arrest. BVIP Conscious and Able to Speak: FR B V I P Do not interfere with patient’s own attempts to clear airway by coughing or sneezing. FR B V I P Conscious and Cannot Speak: 1. Five (5) abdominal thrusts with victim standing or sitting. Five (5) chest thrusts if patient in 2nd-3rd trimester of pregnancy or morbidly obese. REPEAT IF NO RESPONSE. 2. If successful, complete Initial Medical Care and transport. 3. Still obstructed: Continue Step 1 while enroute until foreign body expelled or patient becomes unconscious. Unconscious: 1. Perform a tongue-jaw lift. BVIP Attempt to ventilate. If obstructed, visualize airway with laryngoscope and attempt to clear using forceps and/or suction. FR B V I P 2. Still obstructed: • Reposition head and try to ventilate again. If remains obstructed: • Start CPR VIP 3. Still obstructed: • Attempt forced ventilation. IP 4. Still obstructed: • Intubate and push foreign body into right mainstem bronchus, then pull back tube and ventilate left lung. P 5. Still obstructed: • Perform cricothyrotomy. 6. Rapid transport to closest appropriate facility. Note: Anytime the efforts to clear the airway are successful: • Complete Initial Medical Care • Transport

AHC-SM EMS Approved__7/01/08 Revised __9/20/08, 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-1

Rapid Sequence Induction and Intubation (RSI) LEVEL P

P P P

Rapid Sequence Induction and Intubation (RSI) – 2 Paramedic Only 1. Initial Medical Care. • Apply pulse oximeter, monitor and ETCO2 monitoring • Pediatric Patients: Use cuffed ETT whenever possible. Peds Cuffed ETT size = (age years/4) + 3. Peds Uncuffed ETT size = (age years/4) + 4. Premedicate: At discretion of Medical Control 2. Premedicate children < 5 years old with Atropine 0.02 mg/kg. • Minimum dose is 0.1 mg. Maximum dose is 1 mg IV. 3. ÆEtomidate 0.3 mg/kg slow IV/IO Max 40 mg. or Ketamine 1.5 – 2 mg/kg IV 4. Wait 30 seconds prior to administration of paralytic.

P

Paralyze: At discretion of Medical Control 5. ÆSuccinylcholine 1.5 mg/kg IV/IO Max 200 mg. • children < 10 years: 2 mg/kg IV/IO Max 200 mg.

P

Intubate: 6. Intubate 45 to 60 seconds after administration of Succinylcholine. 7. If unable to intubate trachea after 2 attempts, use Combitube, King LTS-D, basic airways or consider Cricothyrotomy. 8. Sedation with Midazolam (Versed) 2-5 IV/IO. May repeat as needed for sedation 9. Vecronium 0.1 mg/kg IV/IO, max 10mg, for prolonged transports or patients that need prolonged paralytics 10. Consider Pain Management.

P P

Do not perform rapid sequence intubation or administer agents for induction to patients who you cannot effectively ventilate with a bag-valve-mask (BVM). Contraindications for Succinycholine • Burns > 96 hours • History of Malignant Hyperthermia • Spinal cord injury with deficits > 48 hours • Hypersensitivity

ALWAYS HAVE A BACK-UP AIRWAY READIED IN THE EVENT THAT RSI FAILS!

AHC-SM EMS Approved__7/01/08 Revised 03/01/2009, 08/01/2012 PEDIATRIC MEDS FOR RSI Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-2

Age

Broselow

newbrn

3kg 4kg 5 kg

3-5 kg

6 mo

PINK

6-7 kg

9 mo

RED

8-9 kg

PURPLE

2 yrs

YELLOW

4 yrs

WHITE

6 yrs

BLUE

8 yrs

ORANGE

10 yrs

GREEN Atropine 0.02 mg/kg Versed 0.1 mg/kg (max 5) Ketamine 1-2 mg/kg IV (max 200 IV) 45mg/kg IM Succinylchol 1.5-2 mg/kg .......(max 200 mg IV) Dilaudid 0.015 mg/kg

1 yr

Kilos

Pounds

Versed 10mg/2mL

Atropine 1mg/10mL

mg

mL

mg

mL

mg

mL

mg

mL

0.5

0.1

0.1

1

10

0.5

10

0.1

1

0.2

0.14

1.4

14

0.7

14

1

0.2

0.18

1.8

18

0.9

1

0.2

0.2

2

20

1.5

0.3

0.26

2.6

2

0.4

0.34

2.5

0.5

0.4

3

0.6

3.5

0.7

4 4.5 5 5 5

0.8 0.9 1 1 1

10-11 kg 12-14 kg 15-18 kg 19-23 kg 24-29 kg 30-36 kg 40 kg 45 kg 50 kg 55 kg 60 kg

6 - 11 lbs 13 - 15 lbs 16 - 20 lbs 21 - 24 lbs 25 - 31 lbs 32 - 40 lbs 41 - 48 lbs 49 - 66 lbs 67 - 80 lbs 88 lbs 99 lbs 110 lbs 121 lbs 132 lbs

70 kg

154 lbs

5

1

80 kg

176 lbs

5

1

90 kg

198 lbs

5

1

100+ kg

220+ lbs

5

1

Succinylcholine 200mg/10mL

Ketamine 500mg/5mL

Dilaudid 2mg/mL mg

mL

0.14

0.1

0.1

18

0.18

0.1

0.1

1

20

0.2

0.2

0.1

26

1.3

26

0.26

0.2

0.1

3.4

30

1.5

30

0.3

0.3

0.2

4

40

2

40

0.4

0.3

0.2

60

3

60

0.6

0.4

0.2

70

3.5

70

0.7

0.5

0.3

80 90 100 110 120

4 4.5 5 5.5 6

80 90 100 110 120

0.8 0.9 1 1.1 1.2

140

7

140

1.4

160

8

160

1.6

180

9

180

1.8

200

10

200

2

0.6 0.7 0.8 0.8 0.9 12 12 12 12

0.3 0.4 0.4 0.4 0.5 0.51 0.51 0.51 0.51

ATROPINE NOT INDICATED FOR 5YR OLDS OR OLDER

RAPID SEQUENCE INTUBATION

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-3

Acute Asthma / COPD LEVEL Acute Asthma / COPD FR B V I P 1. Initial Medical Care • If minimal distress: Oxygen at 2-6 Liters/nasal cannula. • If moderate/severe distress: 100% Oxygen/NRM or BVM. • ETCO2 monitoring if available 2. Obtain history of patient’s current asthma/COPD meds; time and amount of last dose. 3. Consider possibility of CHF/pulmonary edema if crackles present, especially in patients without a history of COPD/Asthma. Treat per cardiac protocols

BVIP

BVIP VIP

VIP P P

BVIP

Age > 12 Years: as per Pediatric Asthma Protocol 1. Albuterol 2.5mg, 0.5mg Atrovent via nebulizer Do not delay transport waiting for response. Document response 2.

Partial response: Immediately repeat Albuterol 2.5mg via nebulizer.

No response to treatments or Severe Distress – Breath sounds are initially absent or diminished due to severe bronchoconstriction or patient is hypoxic and/or exhausted: 3. Albuterol 2.5 mg/Atrovent 0.5 mg via nebulizer 4. Solumedrol 125 mg IVP 5. Decadron 10 mg IV/IO. 6. If Age50 Epinephrine is at discretion of Medical Control 7. Consider CPAP for severe respiratory distress, See CPAP protocol.

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-4

Allergic Reaction / Anaphylactic Shock LEVEL Allergic Reaction / Anaphylactic Shock FR B V I P 1. Initial Medical Care – Special Considerations: • Do not start IV or give medications into the same extremity as a bite or injection site. • Expeditious transport 2. Apply cold pack to bite or injection site 3. Apply venous constricting band proximal to bite or injection site if swelling is increasing rapidly. Allergic Reaction: Alert and oriented, localized signs, normotensive, skin warm/dry Benadryl 50 mg IM or IV/IO If extensive hives (urticaria), throat or tongue swelling, shortness of breath, or history of systemic reaction in past, consider: Solumedrol 125 mg IV/IO or Decadron 10 mg IV/IO/IM Epinephrine (1:1000) IM 0.5 mg Dose may be repeated in 20 minutes (10 minutes if conditions appear to be life-threatening) with physician authorization Or Adult Epi-pen 0.3mg At discretion of Medical Control ÆAdult Epi-pen 0.3mg (if trained and approved)

P

P BVIP BVIP FR

FR B V I P IP P VIP IP BV IP

P P

Anaphylaxis: • Initial Medical Care – Special Considerations: • If airway obstructed due to edema, attempt ET. • Consider RSI, if rapidly deteriorating • Signs of hypoperfusion: IV fluid challenges in 500 ml increments • Expeditious transport Epinephrine (1:10,000) 0.5 mg (3 cc) IV/IO Epinephrine (1:1000) 0.5 mg IM Dose may be repeated in 20 minutes (10 minutes if conditions appear to be life-threatening) with physician authorization Or At discretion of Medical Control ÆAdult Epi-pen 0.3mg Benadryl 50 mg IV/IO Solumedrol 125 mg IV/IO/IM or Decadron 10 mg IV/IO/IM If wheezing, give Albuterol 2.5 mg via nebulizer DO NOT DELAY TRANSPORT WHILE WAITING FOR RESPONSE TO MEDICATIONS.

AHC-SM EMS Approved__7/01/08 Revised _3/19/09, 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-5

TUBERCULOSIS/PNEUMONIA LEVEL POSSIBLE TUBERCULOSIS FR B V I P Mycobacterium tuberculosis has made a resurgence, particularly in the AIDS, homeless, nursing home and drug abusing communities. In an effort to provide a safe environment for all prehospital personnel, measures shall be instituted to control and limit the spread of this infection. FR B V I P

1. Initial Medical Care: special considerations: • Immediately place a TB filtration masks on all care givers first; then on the patient if any of the following signs or symptoms are present: chronic pneumonia which may be suggestive of TB, cough, fever, night sweats, weight loss, and/or hemoptysis; or if the patient tells you that he/she has TB. • Attempt to assure a complete seal by forming the mask on the face. Avoid all air leaks around the sides of the mask if possible. • Dispose of any tissues or handkerchiefs into which the patient has coughed or sneezed per contaminated waste protocols. 2. Follow the individual department policy to facilitate appropriate follow-up.

PNEUMONIA

FR B V I P

FR B V I P

VIP FR B V I P

1. Initial Medical Care; special considerations: • Listen carefully to lung sounds over all lung fields. Identify area(s) of isolated wheezes, crackles or sounds of consolidation • Obtain patient temperature • Assess state of overall hydration 2. If fever, dehydration, localized (isolated) crackles or wheezes, and/or dyspnea; • apply surgical masks to rescuers to initiate respiratory isolation • titrate oxygen to keep patients oxygen saturations at 94% or higher • fluid challenge 500cc increments titrated to patient response. Reassess breath sounds after each 500cc 3. If cardiac history and/or risk factors present and crackles or wheezes diffuse and present bilaterally: consider presence of Pulmonary Edema. Do not give Lasix if dehydrated or patient has possible pneumonia. 4. If history of Asthma/COPD and bilateral wheezing present: refer to Asthma/COPD Protocol 5. Consider CPAP if patient is in severe respiratory distress. See CPAP Protocol.

AHC-SM EMS Approved__

Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-6

Continuous Positive Airway Pressure (CPAP) LEVEL BVIP

BV IP

P BVIP

Continuous Positive Airway Pressure (CPAP) Continuous Positive Airway Pressure (CPAP) rapidly improves vital signs and gas exchange. It decreases the work of breathing and alleviates dyspnea, CHF, COPD, and Pneumonia. 1. Indications: • Patient awake, cooperative having clinical signs of mild to severe respiratory distress. • Age over 12-years and able to fit mask. • Able to maintain open airway. • SBP is greater than 90 mmHg. • At least two of the following: o Respiratory rate is greater than 25. o Pulse oximeter reading is less than 94% not being relieved by other interventions. o Retractions or accessory muscle use. 2. Contraindications: • Respiratory arrest. • Pneumothorax. • Tracheostomy. • Unresponsive patient. 3. Precautions: • Impaired mental state (can’t cooperate). • Vomiting. • Excessive secretions. • Poor respiratory drive. • Facial deformity or problem preventing tight-fitting mask. 4. Procedure: • Explain procedure to patient. • Ensure adequate oxygen supply (100%). • Place mask over mouth and nose; secure with straps. • Use 5 cm H2O of PEEP • May Use 10 cm H2O of PEEP – titrate to effect. o 7.5 cm H2O of PEEP if less than 16 years old. • Check for air leaks. • Monitor patient’s response. • Check and record vital signs every 5 minutes. • Consider Sedation 5. Removal Procedure: • CPAP therapy should be discontinued ONLY if patient; o Can not tolerate it o Patient deteriorates

AHC-SM EMS Approved__7/01/08 Revised _9/20/08, 06/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-7

Cricothyrotomy LEVEL P

P

Cricothyrotomy Initial Medical Care • CONTACT MEDICAL CONTROL IF POSSIBLE BEFORE PROCEEDING • When ALL airway management measures have failed and the patient needs an advanced airway immediately consider cricothyrotomy with surgical cricothyrotomy for adults, needle cricothyrotomy for pediatric patients, if trained and approved by medical control. • If the time necessary to contact medical control may compromise the patient's chance of survival in the paramedics judgment - AND - it is not possible/practical to ventilate the patient with Bag-Valve-Mask during transport, cricothyroidotomy may be performed without Medical Control Adult Cricothyrotomy • Perform adult surgical cricothyrotomy

P Pediatric Needle Cricothyrotomy • Perform pediatric needle cricothyrotomy Procedure will be outlined by individual squad.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-8

AHC-SM EMS Approved__7/01/08 Revised _9/20/08, 06/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols

R-9

Initial Trauma Care LEVEL FR B V I P

Initial Trauma Care: Primary Survey/ Initial Assessment GENERAL: 1. Assess and secure scene safety. 2. Anticipate potential injuries based on the mechanism of energy transfer. 3. Refer to current SERTAC Trauma Field Triage Protocol for Definition of Major Trauma.

FR B V I P

PRIMARY SURVEY/ INITIAL ASSESSMENT: Assess for immediate life threats and treat as they are found. 1. AIRWAY/C-SPINE: Assess, establish, and/or maintain an effective airway. • C-spine immobilization as indicated by mechanism of injury and/or clinical presentation. • Reposition airway and suction as needed. • Airway adjuncts as needed. o If intubation required: in line or nasotracheal technique unless contraindicated. o If unable to secure airway by any other means, consider cricothyrotomy 2. BREATHING/VENTILATORY STATUS: Expose chest, inspect/palpate rate, depth, pattern, quality of ventilations, neck veins, use of accessory muscles, retractions, flail segments, unequal movements, open wounds, position of trachea, auscultate sounds. • Oxygen as needed to bring O2 saturation to 94% or greater. If ineffective breathing pattern, impaired gas exchange, or altered sensorium: 100% Oxygen/NRB or BVM. • If tension pneumothorax, or flail chest see Chest Trauma Protocol. 3. CIRCULATION/CARDIAC STATUS: Assess: • Pulses for presence, rate, quality, regularity, and equality. If no carotid pulses Traumatic Arrest Protocol. • Color, moisture, temperature of skin. • Heart sounds if chest trauma. See Chest Trauma Protocol Management: • Control all external hemorrhage with direct pressure/pressure dressings. Consider early use of Tourniquets or Hemostatic agents in massive or severe external hemorrhage which is not controlled with direct pressure/ pressure dressings (Refer to appropriate Protocol) • IV’s: Determine necessity of IV access based on mechanism of injury and patient presentation. Follow IO protocol as needed • If patient is critical: IV 14-16g, TWO attempts enroute. Pressure infusers if indicated. • Infusion rate based on clinical presentation, run wide open if hypotensive up to 2000 cc’s. • Monitor ECG. • Apply PASG for pelvic/femur fracture, or pelvic binder for pelvic fracture. Inflate as required, if no signs of chest trauma

FR B V I P

IP P FR B V I P

FR B V I P

FR B V I P

VIP

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 1

BVIP

4.

DISABILITY/MINI-NEUROLOGICAL EXAM: • Assess level of consciousness using AVPU or GCS. • Assess pupil size, shape, equality, and reactivity to light management. • If GCS is less than 9, intubate per Head Injury Protocol. • Vomiting/seizure precautions. • If altered sensorium: obtain and record blood glucose. o If less than 60, Treat per Hypoglycemia Protocol • Complete spinal immobilization, if indicated

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 2

Initial Trauma Care LEVEL FR B V I P

Initial Trauma Care: Secondary Survey/ Rapid or Detailed Assessment TRANSPORT DECISION: Once the primary survey/ Initial Assessment and resuscitative interventions are initiated, a decision must be made whether to complete the primary survey and/or continue with the secondary survey and additional interventions on-scene, or to transport rapidly with interventions enroute. THE UNSTABLE PATIENT REQUIRES EXPEDITIOUS TRANSPORT TO APPROPRIATE HOSPITAL. 1. Attempt to limit on-scene time to less than 10 minutes. Document any reasons for delay. 2. Refer to SERTAC Trauma Field Triage Protocol for Transport Decisions. REVISED TRAUMA SCORE: In addition to routine history and physical exam findings, the following should be relayed to Medical Control, include any changes from normal if known: • Glasgow Coma Scale parameters: o Best eye opening o Verbal response o Motor response • Systolic BP • Respiratory rate SECONDARY SURVEY/ DETAILED AND DEFINITIVE INTERVENTIONS: 1. 2. 3.

Full set of vital signs; reassess and record at least ever 5 minutes in unstable patients as possible. SAMPLE – History: Perform SAMPLE history and OPQRST history. Rate pain on a scale of 0-10. Review of Systems: complete physical exam based on mechanism, nature and type of injury, and patient’s condition. • HEAD, EYES, EARS, NOSE (HEEN): Inspect/palpate the head and face. Note any alterations from normal including drainage from any facial orifice. Reinspect pupils for size, shape, equality, and reactivity. Note gross visual and any trauma to eyes, lids, or orbits. Note extraocular movements and any deviations from normal. • NECK: Reinspect/palpate presence of carotid pulses, status of neck veins (flat or distended), subcutaneous emphysema, bleeding, location of trachea and cervical spines. May need to temporarily remove anterior aspect of C-collar to reassess neck. Check posterior neck for blood/wound by blind palpation. • CHEST: Reinspect/palpate/auscultate for ventilatory distress, impaired gas exchange, or signs of injury. • ABDOMEN: Inspect/palpate for signs of injury or peritoneal irritation. Note abdominal contour, visible pulsations, wounds/bruising patterns, pain referral sites, localized tenderness, guarding, and rigidity. Note in which quadrant they occur. If eviscerated abdomen: do not touch bowel. Cover with sterile dressing moistened with sterile saline. • PELVIS/G.U.: Inspect for bleeding, soft tissue injury, edema, and ecchymosis. Palpate for crepitus/instability.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 3

LEVEL

Initial Trauma Care: Secondary Survey/ Rapid or Detailed Assessment • EXTREMITIES: Inspect for position, deformities, false motion, wounds, skin color and signs of injury. Palpate for pain, paralysis (motor deficit), paresthesias (sensory deficit), pulselessness (circulatory deficit) distal to injury. Splint/immobilize per procedure manual. • BACK: Palpate accessible areas of spine; note any tenderness, deformities, and muscle spasms. • SKIN/SOFT TISSUE: Inspect/palpate for color, temperature, moisture; wounds, bruising edema, subcutaneous emphysema, and thermal/chemical/electrical burns. 4. Report significant positive and/or negative signs to Medical Control; including any changes

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 4

Glasgow Coma Scale GLASGOW COMA SCALE Spontaneous To Voice To Pain None

4 3 2 1

Verbal Response

Oriented Confused Speech Inappropriate Words Incomprehensible Sounds None

5 4 3 2 1

Motor Response

Obeys Commands Localizes Pain Withdraws to Pain Abnormal Flexion to Pain Abnormal Extension None

6 5 4 3 2 1

Eye Opening

TOTAL GLASGOW COMA SCORE: (3-15)

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 5

Trauma Definition – Level I Trauma Center Access Guidelines Patients meeting the listed definitions/indicators warrant air medical or ground transport to a Level I Trauma Center. If dispatch information indicates the need for air medical transport, request for helicopter should be made prior to EMS scene arrival and/or patient contact; this request may be initiated enroute to the scene based on dispatch info.

Follow Current SERTAC Trauma Field Triage Protocol flow chart on next page.

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 6

The State of Wisconsin Trauma Field Triage Protocol

1 2

Assess Airway: Patient has a protected airway or able to insert a functioning advanced airway NO

Transport to the closest appropriate Hospital or ALS/Air Medical Intercept for RSI/Definitive Airway Treatment

YES

Measure Vital Signs and Assess Level of Consciousness Glasgow Coma Scale 18 in. any site Ejection (partial or complete) from automobile Death in same passenger compartment Vehicle telemetry data consistent with high risk of injury Auto v. Pedestrian/Bicyclist Thrown, Run Over, or with Significant (>20 MPH) Impact Motorcycle Crash >20 MPH FALLS

4 YES

Transport to closest appropriate trauma care facility, which depending on the trauma region, need not be the highest level trauma center.

NO

Assess special patient or system considerations

Older Adults: Risk of injury death increases after age 55 Children: Consider transport to a pediatric trauma center within region BURNS Without other trauma mechanism: Triage to burn facility With trauma mechanisms: Triage to trauma center Anticoagulation and Bleeding Disorders Time Sensitive Extremity Injury End-Stage Renal Disease Requiring Dialysis Pregnancy >20 Weeks EMS Provider Judgment AGE

5 YES

Contact medical control and consider transport to a trauma care facility or a specific resource hospital.

NO

Transport according to protocol

When in Doubt, Transport to a Level I or II Trauma Center

Spinal Immobilization – Appropriate Omission LEVEL BVIP

Selective Spinal Immobilization 1. Patients with traumatic injuries may have spinal immobilization omitted if ALL of the following conditions apply: • They are conscious, cooperative and able to communicate effectively with provider. • There is no major mechanism for severe injury. ¾ ejection from vehicle ¾ death of another occupant ¾ fall greater than 20 feet • Have no history of new or temporary neurologic deficit such as numbness or weakness in an extremity. • Have no evidence of intoxication or altered mental status. • Have no evidence of a distracting injury such as ¾ fractures ¾ major burns ¾ crush injuries • Have no midline, or other causes of back or neck pain or tenderness upon palpation. If all the above criteria are met, have patient move their neck 45° to either side of midline and if still no pain, no immobilization is indicated.

•

If at any time provider feels the patient needs spinal immobilization despite these guidelines, immobilization is warranted. The above findings must be documented on PCR NOTE: Immobilization consists of C-collar or other neck immobilization procedure and maintaining the rest of the patient’s body in alignment. Backboards are only indicated for extrication and backboards may be removed if able to safely remove patient off them. Evaluation for evidence of intoxication: Ask "What medications did you take today? Have you had any alcohol? Have you had any recreational drugs?" Is there slurring of speech, dilated or constricted pupils, unsteady gait? Do they smell like alcohol or marijuana? AHC-SM EMS Approved__7/01/08 Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 8

Hypovolemic/Hemorrhagic Shock LEVEL

Hypovolemic/Hemorrhagic Shock

Definition: Class II - IV hemorrhage with signs and symptoms including a sustained respiratory rate ≥ 20; sustained pulse ≥ 100 (unless elderly or on beta blockers or digitalis); cool, moist, pale skin; narrowed pulse pressure, and or a falling BP. This presentation is almost always associated with internal or external bleeding/volume loss and requires definitive treatment. If MVC and still in vehicle: rapid extrication FR B V I P 1. 1. Consider C-Spine Immobilization BVIP

FR B V I P 2.

VIP

Initial Trauma Care. Oxygen by nasal cannula, NRB or assist ventilations with BVM. Deliver Oxygen to bring O2 Saturations to 94% or greater. • Identify and control any Hemorrhage with appropriate protocol • Expeditious transport.

VIP

3.

Attempt to complete Initial Trauma Care enroute as time and manpower permits • Start 2 (two) large bore (14-16 gauge) IV if veins appear accessible. • Consider IO with pressure infuser bag. • Do not delay transport attempting to start IV.

VIP

4.

IV Bolus 500 ml as needed to keep SPB > 90 mmHg. Give up to 2000 ml

AHC-SM EMS Approved__7/01/08 Revised 09/20/2008, 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 9

Tourniquet Application in Trauma PURPOSE Stop rapid hemorrhage associated with extremity trauma. First line use in the tactical and disaster environment EQUIPMENT A Commercially available and approved tourniquet device (example: C.A.T® or SOF-T®) or a manual blood pressure cuff. LEVEL BVIP

1. Verify the patient has sustained an injury that may benefit from tourniquet application (rapid external blood loss, traumatic amputation or visualized extremity distension with the presence of shock (ex. bilateral femur fractures) 2. Ideally the tourniquet should be applied approximately 2-3 inches above the point of injury on bare skin. In a dynamic tactical environment, the tourniquet can be applied as high on the extremity as possible over the clothing if necessary. • Remember: Direct Pressure may be appropriate, but if it cannot be firmly and consistently applied, default to tourniquet application. 3. The windlass of the device must be tightened enough to visibly see the cessation of bleeding (Ideally the distal pulse of the effected extremity should be absent). Do not forget to secure the windlass to prevent unwanted loosening of the device. 4. If using a BP cuff, inflate only to the point of restricting the blood flow to the extremity. 5. The application of the tourniquet can be very painful; consider ALS pain control (see Pain Management Protocol). 6. Early notification of receiving hospital is REQUIRED. 7. Constant assessment of the bleeding site must be done and documented. 8. If Bleeding is not successfully controlled with one tourniquet, consider the application of a second right next to the first, making sure to offset the windlass as to not tangle the devices. 9. Tourniquet removal is allowed, if: • Dressing applied to wound controls bleeding. (pressure dressing, hemostatic agent or other) • Release pressure of the tourniquet slowly. If bleeding continues reapply appropriate pressure to control bleeding.

AHC-SM EMS Approved 08/01/2012 Revised Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 10

Use of Hemostatic Dressing in Trauma PURPOSE Stop massive hemorrhage associated with trauma Second line agent for the control of Massive Hemorrhage not controlled by or anatomically amenable to application of a tourniquet Especially important consideration in the Tactical and Disaster Environment Hemostatic Dressings have been designed to control massive bleeding at the site of the vessel either through +/- charges or by literally using their chemical make-up to create a clot. EQUIPMENT Commercially available Hemostatic Dressings: Combat Gauze®, Celox gauze® or Quick Clot ACS® are currently recommended. LEVEL BVIP

1. Verify patient has sustained a traumatic injury that may benefit from the use of a Hemostatic Dressing (i.e. penetrating trauma, severe lacerations, scalp lacerations and hemorrhage that cannot be controlled by conventional means, direct pressure and or pressure dressings). 2. Hemostatic dressings should also be considered for wounds that are not amenable to tourniquet application (i.e. High Groin or Armpit wounds). 3. Gauze-type Hemostatic agents work well for superficial injuries and deep penetrating injuries. 4. Once wound is identified, apply immediate firm direct pressure while preparing your Hemostatic Agent 5. Remove direct pressure, and wrap or pack the wound. If a cavity is identified, the agent must be deeply packed to reach the site of bleeding. 6. Very firm direct pressure must be applied for 3 minutes, at which time the wound should be assessed for cessation of bleeding. If bleeding continues, remove Hemostatic agent and reapply. (Repeat steps 4-7). 7. Once bleeding is controlled, the wound should be dressed with a pressure-type dressing. 8. Assess and treat the patient for signs of shock (see Hypovolemia/Hemorrhagic Shock Protocol). 9. The process for addressing a wound with a Hemostatic Agent should NOT delay transport time.

AHC-SM EMS Approved_08/01/2012_ Revised

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 11

Traumatic Arrest LEVEL

Traumatic Arrest There are a number of studies that show that attempts at resuscitation of traumatic arrests are futile in certain situations. In these futile situations a patient should be considered dead and there should be no further resuscitation efforts. All traumatic pulseless non-breathers will undergo full resuscitation efforts unless: 1. All trauma with a significant mechanism of injury – If on the first arrival of EMS that patient is pulseless, apneic, and without other signs of life (pupil reactivity, spontaneous movement) or is asystolic, then the patient is not resuscitatable. If the injuries are incompatible with life (e.g.. Decapitation), the patient is not resuscitatable. 2. Blunt trauma – Despite a stable airway, the patient develops asystole or agonal wide complex rate 90. • Atropine: if bradycardic: o 0.5 mg rapid IV (adults), or o 0.02 mg/kg rapid IV (children) • May repeat Atropine every 3 minutes to a maximum total dose: o 3 mg in adults o 0.04 mg/kg in children

AHC-SM EMS Approved__7/01/08 Revised09/20/2008, 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 15

Chest Injuries LEVEL Chest Injuries FR B V I P 1. Initial Trauma Care. •

IP

Supplement oxygen to bring O2 saturation to 94% or greater by using Nasal cannula, NRB or assist with BVM • If patient is suspected of having internal chest trauma: 2 large bore (14/16 gauge) IVs NS. Attempt ENROUTE. If hypotensive, run consecutive fluid challenges of 500 ml. See hypovolemic trauma protocol. Use pressure infusers if indicated. • Consider pain management protocol. TENSION PNEUMOTHORAX: Unilateral absence of breath sounds, JVD; decreased BP, extreme dyspnea, resistance to BVM ventilations, “increased airway resistance, tracheal deviation (late sign). 1. Needle pleural decompression. 2nd-3rd intercostal space (above 3rd or 4th rib), midclavicular line on affected side.

2.

If patient stabilizes, continue Initial Trauma Care; follow other protocols as required. Expeditious transport.

3.

Monitor for PEA.

BVIP

OPEN PNEUMOTHORAX: Sucking Chest Wound 1. Immediately apply occlusive dressing 2. Monitor/note VS and ventilatory/circulatory status after procedure. 3. If patient stabilizes, continue Initial Trauma Care; follow other protocols as required. Expeditious transport. 4. If patient develops signs of tension pneumothorax, temporarily release side of dressing to allow air to escape. Recover wound.

BVIP

FLAIL CHEST: 8. If ventilatory distress: ventilate with CPAP or Assist with BVM to provide internal splinting. Do not apply external splinting.

VIP

PERICARDIAL TAMPONADE: 9. Expeditious transport. IV wide open up to 2000 cc’s while enroute.

VIP

10.

Monitor for PEA

P

11.

PNB Patient: Perform Needle Pericardiocentesis

P

Pulses Present: At discretion of Medical Control Æ Perform Needle Pericardiocentesis

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 16

Ophthalmic Emergencies LEVEL

Ophthalmic Emergencies General Approach: FR B V I P 1. Initial Trauma Care – Special Considerations: • Assess visual acuity • Assess pain scale 0 – 10. • Assess cornea, conjunctiva, and sclera for signs of injury. • Discourage patient from sneezing, coughing, straining, or bending at waist. • Vomiting precautions P

2.

0.5% Tetracaine 2-3 drops each affected eye if not an open globe injury. May repeat until pain relief is achieved.

IP

3.

Consider Pain Management.

BVIP

Chemical Splash/Burn: 1. Thoroughly and continuously irrigate affected eye(s) using copious amounts of saline instilled through IV tubing. Start irrigation as soon as possible and continue while enroute to the hospital.

BVIP

Corneal Abrasions: Observe for profuse tearing, severe pain, redness, and spasm of eyelid.

BVIP

Penetrating Injury/Ruptured Globe: Observe for signs of penetration: peaked pupil, excessive edema of conjunctiva (chemosis), subconjunctival hemorrhage, blood in anterior chamber (hyphema) or foreign body/impaled object. 1. Do not remove impaled objects; do not irrigate eye.

IP

2.

Avoid all pressure on injured eye. Cover with metal or plastic protective patch or paper cup. May patch injured eye or both eyes depending on patient's ability to tolerate bilateral patches.

3.

Elevate head of stretcher to 45-degree angle.

4.

Consider Pain Management per Protocol

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 17

Musculoskeletal Injuries LEVEL Musculoskeletal Injuries FR B V I P 1. Initial Trauma Care – Special Considerations: • Assess/document CMS: before and after splinting. • Control bleeding with pressure (direct). 2. Attempt to place extremities into axial alignment following long-bone fractures unless an open fracture, resistance is encountered or patient complains of extreme pain. Splint joint injuries as found. 3. Apply cold pack over injury site. 4. Immobilize/splint – If pulses are lost after applying a traction splint, release traction until pulses have returned. 5. Elevate extremity injuries if possible after splinting. IP 6. Consider Pain Management. 7. If long bone fracture with displacement/muscle spasm and hemodynamically P stable; consider Ativan 1mg slow IVP. (0.2 mg/kg Peds) (May repeat every 10 minutes until muscle spasms subside or adequate sedation; not to exceed a total of 4 mg). Watch for respiratory depression; protect airway. BVIP AMPUTATION/DEGLOVING INJURIES: 8. If amputation incomplete, attempt to stabilize with bulky dressing. DO NOT complete amputation. 9. If uncontrolled bleeding continues, apply tourniquet above amputation as close as possible to the injury. See tourniquet protocol. 10. Care of amputated parts: • Wrap in saline-moistened gauze or towel. • Place in plastic bag and seal. • DO NOT immerse tissue directly in water or saline. • Place plastic bag in second container filled with ice or cold water; or place in cold packs. • Bring with patient to hospital. BVIP IMPALED OBJECTS: 11. Never remove an imbedded or impaled object from the body unless it extends through the cheek into the mouth and poses impairment to the airway. 12. Stabilize object with bulky dressings to minimize further injury. 13. If penetrating injury is to head or extremity, elevate injured part if possible.

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 18

Burns LEVEL FR B V I P

VIP

IP BVIP

Burns 1.

Initial Trauma Care – Special Considerations: • Assess depth of burn • Consider Transport to Burn Center Burn. Injuries that should be sent directly to a burn center include: ¾ Partial thickness burns greater than 10% total body surface area (TBSA). ¾ Burns that involve the face, genitalia, or perineum. Circumferential burns of the hands, feet or major joints. ¾ Third degree burns of more than 1% size in any age group. ¾ Major Electrical burns, including lightning injury. ¾ Major Chemical burns. ¾ Inhalation injury. ¾ Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality • Assess extent of burns using Rule of Nine’s or use patient’s palmar surface = 1%. Note location of burns. • Supplement Oxygen to bring O2 saturation to 94% or greater using Nasal cannula, NRB or BVM • IV: may need to start IV through burned tissue if no other access sites. o Minor Burn: 18 g TKO if IV needed for pain management. o Moderate or Severe Burn: 14-16 g – Calculate Parkland formula: 4 x kg x %BSA = 1st half given during first 8 hrs. Contact Medical Control if unsure. • Assess ECG: treat all dysrhythmias per appropriate Protocol • Consider Pain Management.

THERMAL 1. Remove burned clothing, jewelry, belts, shoes, etc. Do not pull away clothing that is stuck to underlying skin. 2. WOUND CARE: • Cool with water or saline if burn occurred within last 15 minutes. Do not overcool or use ice. • Cover BSA < 10% with sterile saline soaked dressings or dry dressing. • Cover BSA > 10% with dry sterile dressings. 3. Open sterile sheet/burn pads on stretcher before placing patient for transport. Cover patient with dry, sterile sheets and blanket to maintain body warmth.

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 19

INHALATION 1. Assess for the presence of stridor, wheezing, carbonaceous sputum, cough, hoarseness, singed nasal or facial hair, dyspnea, or facial burns. 2. Oxygen via NRB or BVM. Humidify oxygen if able. 3. Consider RSI if severe respiratory distress or progressive compromise of airways.

BVIP P LEVEL BVIP

BVIP

Burns ELECTRICAL/LIGHTNING 1. Establish scene safety. Shut off/remove electrical source. 2. Immobilization/splint if any fall or loss of consciousness. 3. Assess for entrance/exit wounds. Apply dry, sterile dressings. No cooling necessary. 4. Assess neurovascular function of all extreities 5. ECG monitoring. Treat dysrhythmias per appropriate Protocol. CHEMICAL 1. Irrigate burn with copious amounts of water or saline unless a contraindication exists, i.e., sodium metals, dry chemicals (especially alkaline). Brush off as much of the agent as possible before irrigating. 2. If burn occurred in an industrial setting, bring in MSDS sheets if possible.

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 20

Near Drowning LEVEL Near Drowning FR B V I P Notes: • All persons submerged one hour or less must be vigorously resuscitated. • The essential survival mechanism for these patients is hypothermia; one focus of resuscitation must be appropriate rewarming. FR B V I P 1.

VIP

2. 3. 4.

Initial Trauma Care – Special Considerations: • C-Spine precautions as indicated. • Contact destination ED early • Remove wet clothing and dry patient as much as possible. Assess for hypothermia: If Normothermic – Treat dysrhythmias per appropriate Protocol Establish IV/IO access, per protocol. DO NOT DELAY TRANSPORT TO ESTABLISH IV.

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012 Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 21

Trauma in Pregnancy LEVEL Trauma in Pregnancy FR B V I P 1. Initial Trauma Care – Special Considerations: • Aggressively resuscitate patient. • Supplement Oxygen to bring O2 saturation to 94% or greater using Nasal cannula, NRB or BVM

• • • 2.

Presence of potential for shock: IV fluid challenges 500 cc NS. Repeat as necessary. If 2nd or 3rd trimester, tilt patient to left supporting body with blanket rolls. The fetus may be in jeopardy while the mother's vital signs remain stable.

Assess for uterine contractions, rigidity of uterine versus abdominal wall, vaginal bleeding, leaking of amniotic fluid (presence of meconium/blood), and/or presence (absence) of fetal movements.

If any of the above abnormalities are present, expeditious transport to appropriate facility. 1.

If contractions present: time duration of contractions and length of time between contractions.

2.

If mother is in shock; refer to Hypovolemic/Hemorrhagic Shock Protocol.

3.

Prepare for emergency childbirth if mother in labor due to trauma and signs of imminent birth are present.

AHC-SM EMS Approved__7/01/08 Revised 08/01/2012

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 22

ABUSE: DOMESTIC, SEXUAL, ELDER LEVEL FR B V I P

FR B V I P

Incidents of abuse include: • Person abused by a family or household member. • High-risk adult with disabilities who is abused, neglected, or exploited by a family or household member. • Minor child or dependent adult • Person residing or employed at a private home or public shelter that is sheltering an abused family or household member. EMT's shall provide immediate, effective assistance and support for victims and witnesses of domestic violence. If any form of abuse, maltreatment, harassment, intimidation, or neglect is suspected: 1. Assess the scene for rescuer safety.DO NOT ENTER UNLESS THE SCENE IS SAFE. Law Enforcement should be present before EMS enters if: • if the offender is present • weapons are involved • the offender is under the influence of drugs and/or alcohol • and/or there are children present. 2. Initial Medical Care;(Refer to A-20) In addition to general patient care, be aware of special considerations: • Provide psychological support. • Discourage patients from changing clothes, urinating, or washing away signs of the abuse. • Treat obvious injuries per appropriate SOP • Collaborate with the police to use all reasonable means to prevent further abuse or neglect. 3. Report your suspicions to the receiving hospital. Clearly document all scene factors and physical signs and symptoms that would support your suspicions of abuse/violence. 4. There are no mandatory reporting laws for adult victims of sexual, domestic or elder abuse. However, EMS can still voluntarily report their suspicions to either the local law enforcement agency having jurisdiction or the appropriate Department of Child and Family Services number listed below. If the victim is a child (under 18 years of age), mandatory reporting is required. Refer to Suspected Child Abuse and Neglect (P-24). • • • •

Kenosha County (262) 605-6582 o After hours, weekends and holidays call Crisis Intervention: (262)657-7188 Racine County 262-638-6321 or 800-924-5137 Walworth County DHS 262-741-3200 Waukesha County (262) 548-7212 or 211

AHC-SM EMS Approved 08/01/2012 Revised Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols T - 23

Aurora Health Care South Market EMS

EMERGENCY MEDICAL RESPONDER, EMERGENCY MEDICAL TECHNICIAN (BASIC), ADVANCED EMERGENCY MEDICAL TECHNICIAN (EMT-IV TECH) Protocols 2012

Emergency Medical Care of the Pulseless Non-Breathing Patient Using Automated External Defibrillation (AED) Protocol I. AED Use General Considerations A. Take body substance isolation precautions en route to the scene B. Initiate immediate ALS backup as appropriate C. The patient should be transported when one of the following has occurred: 1. The patient regains a pulse 2. Per medical control recommendation D. All contact with the patient must be avoided during analysis of rhythm and delivery of shock(s) E. A pediatric capable AED is preferred for age 0-8 years. However, a standard AED may be used if it is the only one available. F. 2010 AHA guidelines do not restrict AED use in a moving vehicle. G. It is acceptable to continue using the public access defibrillator (PAD) if it has already been applied so as not to interrupt CPR to apply EMS AED. H. WALWORTH COUNTY PROVIDERS ARE TO FOLLOW CCR PROTOCOL AS WELL. II. AED Application by Age A. Age 0 through 8 years 1. Perform CPR for 5 cycles (about 2 minutes) before undertaking other actions 2. Apply AED, using a pediatric capable AED if available a. If PAD is the only pediatric capable AED available, continue using it b. If only standard AED available, it may be applied. It is recommended to place the patches in anterior-posterior positions to avoid arcing. B. Age > 8 years 1. Apply standard AED III. Resuscitation (EMS Provider) A. Arrive on scene and perform initial assessment B. Stop CPR if in progress C. Verify pulselessness and apnea D. If no CPR (or poor quality CPR) performed prior to your arrival and response interval from time of collapse is: 1. Less than 5 minutes, the immediate priority is defibrillation 2. More than 5 minutes, perform two (2) minutes of CPR prior to defibrillation. E. If no Intermediate or Paramedic service available to scene and at least 20 minutes of resuscitation have occurred, contact medical control for permission to terminate resuscitation and not transport. If all the following present, medical control will likely terminate resuscitation: • Cardiac Arrest unwitnessed by EMS • No shock by automated defibrillator • No return of spontaneous circulation at any time during resuscitation

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 2

F. AED Activation and Use 1. Attach and activate defibrillator 2. Stop CPR 3. Clear patient 4. Initiate analysis of rhythm a. If AED advises shock: i. Deliver shock ii. Immediately begin CPR. 1. After 2 minutes, stop CPR assess ABC’s 2. If no return of carotid pulse, allow AED to re-analyze 3. If shock advised, deliver shock and perform two minutes of CPR 4. The sequence of two (2) minutes of CPR followed by one shock may be repeated a maximum of three times. 5. After two shocks contact medical control and determine time to Advanced Life Support. iii. If after shock patient exhibits signs of life (spontaneous respirations, purposeful motor activity) stop CPR and assess ABC’s. 1. If breathing adequately, titrate supplemental Oxygen to bring O2 saturation up to 94% or greater. 2. If not breathing adequately, artificially ventilate with oxygen, transport promptly (consider insertion of advanced airway here). b. If AED advises no shock: i. Resume CPR and determine time to Advanced Life Support ii. After two minutes of CPR allow re-analysis 1. If shock advised, deliver shock. 2. If no shock advised for the second time, resume CPR and contact medical control. 5. Consider insertion of an advanced airway when appropriate a. Airway should be inserted while chest compressions continue b. Once airway is in place, ventilations should be made at the rate of 8-10 per minute and CPR should be performed for two minutes between reanalyzing or pulse check. 6. If at any time pulses are lost, restart protocol. 7. Medical Control should be contacted as soon as possible to discuss further treatment option including termination of resuscitation. Document • Clinical assessment • Whether arrest was witnessed or un-witnessed • Presence of by-stander CPR • Defibrillator use, including PAD • Resuscitative measures and response • Communication with medical control AHC-SM EMS Approved 7/01/08 Revised 9/20/08, 11/20/08, 08/01/2012 _ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 3

Emergency Medical use of the Esophageal Tracheal Combitube (ETC) and King LTS-D Airway Protocol Non-Visualized Airways I.

II.

III.

IV.

Indications: A. Cardiac arrest from any cause. B. Respiratory arrest. C. Unconscious patient with inadequate respirations and no gag reflex. Contraindications – DO NOT use on patient if: A. Patient is under five (5) feet in height for Combitube, under four (4) feet tall for Combitube SA, and under four (4) feet tall for the King LTS-D airway (always comply with manufacturer’s recommendations for sizing) B. Active gag reflex. C. Patient has ingested a caustic substance. D. Patient has known or suspected foreign body obstruction of the larynx or trachea Prepare for Insertion of the non-visualized airway: A. Take appropriate body substance isolation precautions. B. Prepare the non-visualized airway. 1. Choose the correct size device based on the patients height. 2. Determine cuff integrity per manufacturer's directions. 3. Lubricate as necessary. 4. Insure all necessary components and accessories are at hand C. Prepare the patient. 1. Reconfirm original assessment. 2. Inspect upper airway for visual obstructions and remove. 3. Position the patient's head in a neutral position. Airway Insertion (ETC): Esophageal Tracheal Combitube A. Insert with ETC curvature in same direction as natural curvature of pharynx. 1. Grasp the tongue and lower jaw between index finger and thumb and lift upward (jaw-lift maneuver). 2. Insert the ETC gently but firmly until black rings on the tube are positioned between the patient's teeth. a. DO NOT USE FORCE. If tube doesn't insert easily, withdraw and reattempt. 1) Maximum of three twenty (20) second attempts with appropriate ventilation between each attempt. 3. Inflate pharyngeal cuff through line #1 (blue) with 100 mL of air (85ml for SA) and distal cuff through line #2 (white) with 15 mL of air (12ml for SA). 4. Ventilate through primary (blue) tube. 5. Confirm tube placement by auscultating breath sounds (high axillary and bilaterally) and auscultating over stomach. a. Esophageal placement: breath sounds are present bilaterally with epigastric sounds absent. 1) Continue to ventilate through primary (blue) tube. b. Tracheal placement: breath sounds are absent and epigastric sounds are present. 1) Ventilate through secondary (clear) tube 2) Reassess placement by auscultation and, if confirmed, a) Continue to ventilate through secondary (clear) tube c. Unknown placement: breath and epigastric sounds are absent. 1) Immediately deflate cuffs (blue then white). 2) Slightly withdraw tube then reinflate cuffs (blue/white). 3) Ventilate and reassess placement. Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 4

4)

VI.

VII.

VII.

If breath sounds and epigastric sounds are still absent, immediately deflate cuffs and remove. a) Suction as necessary. b) Insert oropharyngeal or nasopharyngeal airway. c) Ventilate with BVM. 6. Continue ongoing respiratory assessment and treatment. Airway Insertion: King LTS-D A. Normal Insertion 1. Hold the King LTS-D at the connector with dominant hand 2. With non-dominant hand, hold mouth open and apply chin lift unless contraindicated by C-Spine precautions or patient position. 3. Using a lateral approach, introduce the tip into the corner of the mouth a. A chin lift or laryngoscope and tongue depressor can be used to lift the tongue anteriorly to allow easy advancement. 4. Advance the tip behind base of the tongue while rotating the tube back to midline so that the blue orientation line faces the chin of the patient. a. Important that the tip of the device be maintained at the midline to assure that the distal tip is properly placed in the hypopharynx/upper esophagus. 5. Without exerting excessive force, advance tube until base of connector is aligned with teeth or gums a. Depth of insertion is important to patent airway 1) Ventilatory openings of the device must align with the laryngeal inlet for adequate oxygenation/ventilation. 2) Deeper placement and subsequent retraction is preferred 3) Withdrawal of the King LTS-D with the cuffs inflated results in a retraction of tissue away from the laryngeal inlet. 4) Deeper placement eliminates obstruction by epiglottis or other tissue during spontaneous ventilation. 6. Inflate Cuffs a. Inflate cuffs to volume sufficient to seal the airway. b. Typical inflation volumes 1) Size 3 – 45 to 60 ml. 2) Size 4 – 60 to 80 ml. 3) Size 5 – 70 to 90 ml. 7. Attach ventilation device to the connector of the King LTS-D. 8. At the same time, gently bag the patient and withdraw the King LTS-D 1cm per breath attempt until ventilation is easy and free flowing. 9. Readjust cuff inflation to “just seal” volume. 10. Check breath sounds and chest rise and fall. Tube Removal: A. Indications: 1. Patient regains consciousness. 2. Protective gag reflex returns. 3. Ventilation is inadequate. B. Position patient on side, using spinal injury precautions as necessary. C. ETC: Deflate cuffs (blue then white) and withdraw airway. King LTS-D, remove per manufacturers directions. D. Remove in smooth, steady motion, suctioning as needed. E. Monitor airway and respirations closely, suction as needed. Provide prompt transportation.

AHC-SM EMS Approved_7/01/08 Revised 3/01/09, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 5

Assisted Administration of Epinephrine Utilizing a Patient’s Auto-Injector Protocol The clinical picture of anaphylactic shock is tachycardia, hypotension and dyspnea, together with any or all of the following: wheezing, itching, hives, edema of the facial and neck area. It is not necessary that the EMT identify the antigen responsible for the condition; however, all suspected antigens should be reported to the medical control physician. Standard Dose:

Adults: Greater than 60 pounds – 0.3 mg Epinephrine 1:1000 IM • One EpiPen Adult Children: Under 60 pounds – 0.15 mg Epinephrine 1:2000 IM • One EpiPen Junior Contraindications: None in true anaphylactic shock. I. Patient-prescribed Epinephrine Auto Injector: Patient has come in contact with substance that caused past severe allergic reaction and complains of respiratory distress or exhibits signs and symptoms of shock (hypoperfusion): A. Perform initial assessment. B. Obtain patient history and perform physical exam. 1. History of allergies? 2. What was patient exposed to and how was patient exposed? 3. Effects and progression? 4. Interventions (previous injection)? C. Assess baseline vital signs and SAMPLE history. D. Administer Oxygen. E. Determine if patient has prescribed pre-loaded Epinephrine auto-injector available. F. Verify patient’s own medication. Check to make sure medication has not expired. G. Describe procedure to patient and obtain consent, if possible. H Press auto-injector firmly into lateral thigh and hold for several seconds I Record actions and reassess patient in two minutes. J. If ALS not enroute/available, transport immediately. K. Dose may be repeated in 20 minutes (10 minutes if conditions appear to be lifethreatening) with physician authorization. II. Patient has contact with substance that causes allergic reactions without signs of respiratory distress or shock (hypoperfusion). A. Continue with focused assessment. B. A patient not wheezing and/or without signs of respiratory compromise or hypotension should not receive Epinephrine. C. Transport. Perform ongoing assessment and record actions. D. Report any changes to Medical Control.

AHC-SM EMS Approved 7/01/08 Revised _12/5/08, 08/01/2012_

Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 6

Assisted Administration of Patient-Prescribed Nitroglycerine Protocol I.

II.

Nitroglycerine A. Contraindications: 1. Hypotension or blood pressure below 100 mmHg systolic. 2. Infants and children. 3. Patient has already taken the maximum prescribed dose prior to EMT arrival. 4. Patient takes medications for penile erection (Viagra, Cialis, Levitra or similar medications). Perform Patient Assessment: A. Perform initial assessment. B. Perform focused history and physical exam for cardiac patient. 1. History of chest pain? History of heart disease? 2. Onset of chest pain and progression since onset? 3. Interventions (previous nitroglycerin taken)? C. Assess baseline vital signs and SAMPLE history. 1. Assure BP above 100 mmHg systolic. D. Administer Oxygen (if not done previously). Titrate supplemental oxygen to bring oxygen saturation up to 94% or greater. E. Verify patients' own medication, medication not expired. Assure right patient, right medication, right route and patient is alert: 1. Ask patient to lift tongue and place tablet or spray dose under tongue (wear gloves) or have patient place tablet or spray under tongue. 2. Ask patient to keep mouth closed with tablet under tongue (without swallowing) until dissolved and absorbed. F. Record actions and continue to monitor and reassess. 1. Monitor blood pressure. 2. Record effect on pain relief. 3. Record any reported side affects (headache, hypotension, pulse rate changes). G. Doses may be repeated in 3-5 minutes if: 1. No relief. 2. Blood pressure > 100 mmHg. H. If ALS not enroute/available, transport. ALS should be requested for all suspected cardiac patients.

AHC-SM EMS Approved_7/01/08 Revised 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 7

Administration of Nebulized Albuterol/Atrovent for the Emergency Care of Severe Asthma Protocol I.

DuoNeb: For treatment of patient with known asthma or COPD who is found to be wheezing and in respiratory distress. A. Perform initial assessment. B. Perform focused history and physical exam. 1. History of asthma? 2. Onset and progression since onset? When was last attack? 3. Interventions (previous inhaler or injection)? When? 4. Is the patient hypersensitive/allergic to Albuterol or Atrovent? 5. Is the patient taking steroids or Theophylline? C. Assess baseline vital signs and SAMPLE history. 1. Auscultate the chest, listening for diminished air movement and/or wheezing. 2. Has the patient ever been intubated for asthma or COPD? D. Administer oxygen (if not done previously) and assist with ventilation as needed. E. Verify correct medication and that medication has not expired. F. Describe procedure to patient and obtain consent. G. Administer Albuterol 2.5mg and Atrovent 0.5mg via nebulizer. 1. Advise patient to inhale and encourage to breathe as deeply as possible. H. Record actions and continue to closely monitor patient and vital signs. I. Transport if ALS not enroute/available. J. Additional treatment with Albuterol 2.5mg may be repeated.

AHC-SM EMS Approved 7/01/08 Revised _08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 8

Emergency Medical Treatment of Hypoglycemia with Glucose Monitoring and Administration of Glucagon Protocol Blood glucose monitoring should be done anytime symptoms which present may be due to hypoglycemia. Caution must be used at all times, as EMT’s will have the possibility of direct blood contact. Use appropriate BSI protection when performing blood glucose monitoring. I. Glucagon: A. Side effects are rare but Glucagon can cause hypotension, dizziness, headache, nausea, and vomiting. II. Perform Patient Assessment: A. Perform initial assessment. B. Perform focused history and physical exam. 1. Facts surrounding the episode? 2. Onset? Duration? 3. Associated symptoms? 4. Evidence of trauma? 5. Interventions? Effects? 6. Seizures? Fever? 7. Check for medical alert tags/jewelry. C. Obtain baseline vital signs and SAMPLE history. 1. Including blood glucose level on any patient when any of the following are noted: a. Unconscious. b. Altered level of consciousness. c. Apparent stroke. d. Seizure. e. Suspected diabetic emergency. f. As otherwise directed by Medical Control. 2. Determine last meal, last medication dose (including insulin type, time, and how much), and any related illness. D. Where hypoglycemia is found to exist (blood sugar less than 60). 1. Oral Glucose, if patient can swallow and protect their own airway. 2. Glucagon, 1 mg IM. (EMT-B and higher) E. Administer IM Glucagon. (EMT-B and higher) 1. Must be reconstituted before using. 2. Add the diluent to the powdered medication. 3. Gently shake to mix thoroughly. 4. Draw up 1 mg of the medication and administer intramuscularly (subcutaneous administration will lengthen time to absorption). 5. Count to 10 seconds after administration of Glucagon before withdrawing needle to ensure complete absorption into muscle. F. Record actions and continue to monitor. G. Transport if ALS not enroute/available.

AHC-SM EMS Approved__7/01/08 Revised _9/20/08, 08/01/2012_ Aurora Health Care – South Market | Pre-Hospital ALS/BLS Patient Care Protocols X - 9

Aurora Health Care South Market EMS

Drug Appendix / Protocols 2012

Drug Appendix Drug Name Activated Charcoal

Adenocard (Adenosine)

Albuterol

Adult Dose/Route •

50 grams

• •

First Dose: 6mg IVP Second Dose: 12 mg IVP

•

2.5 mg via NEBULIZER

•

• •

•

Pediatric Dose/Route 1 gram/kg

Indications •

Contraindications •

• •

Altered Mental Status Concern for airway maintenance Vomiting High degree AV block Sick Sinus Allergy to drug

•

Allergy to drug

•

Asthma Bronchitis COPD Croup (racemic preferred) Emphysema

First Dose: 0.1 mg/kg/IVP Second Dose: 0.2 mg/kg/IVP

•

2.5 mg via NEBULIZER

• • • •

Toxic overdose within an hour of ingestion

•

Symptomatic SVT

• •

Atrovent (ipratropium bromide)

•

0.5 mg via NEBULIZER

•

0.5mg via NEBULIZER

• • • •

Asthma Bronchitis COPD Emphysema

•

Allergy to drug

Amiodarone (Cordarone)

• •

300 mg IV/IO push if pulseless 150 mg IV/IO push; repeat if pulseless 150 mg IV/IO over 10 minutes if pulse

•

5 mg/kg IV/IO push if pulseless 5 mg/kg added to 100 cc D5W IV/IO over 10 minutes if pulse

•

V-FIB/VTACH

• •

Allergy Severe bradycardia Incompatible with Bicarbonate

•

Aspirin

•

324 mg – Chewed and held in mouth if able

Ativan (Lorazepam)

• •

0.5 mg – 2.0 mg IV/IM/IO 4mg IV/IO/IM (seizure)

•

•

0.05-0.20 mg/kg IV/IM/IO

•

•

Cardiac – Chest Pain

•

Allergy to drug

• •

Seizure control Anxiety

•

Hypersensitivity to drug

Side Effects •

Concern to avoid aspiration

• • • • • • • • • • • • • • • • • • • • • •

Facial flushing Headache SOB Dizziness Nausea Palpitations Anxiety Headache Dizzy Sweating Hypertension Nausea Palpitations Anxiety Headache Dizzy Sweating Hypertension Nausea Hypotension Bradycardia Nausea

• • • • •

Heartburn Nausea Vomiting Decrease BP Respiratory depression 08/01/2012

Drug Name Atropine Sulfate

Adult Dose/Route Symptomatic Bradycardia • 0.5 mg IV every 3-5 minutes; up to 3 mg Arrest • 1 mg IV/IO up to 3 mg total Organophosphate • 2 mg rapid IVP/IO, no max.

Pediatric Dose/Route Symptomatic Bradycardia • 0.02 mg/kg IV every 3-5 minutes

Indications • • •

Symptomatic Bradycardia PEA less than 60 Organophosphate poisoning

Contraindications • •

Hypersensitivity to atropine Asystole

Arrest • 0.02 mg/kg IV/IO

Side Effects • • • • • • • •

Palpitations Anxiety Tachycardia Headache Dizziness Dry mouth Blurred vision Pupil dilation

• • • • • • •

Sedation Blurred vision Headache Palpitations Bradycardia Asystole Hypertension

Organophosphate • 0.02 mg/kg rapid IVP/IO, no max.

Benadryl (Diphenhydramine)

•

25-50 mg IV/IM/PO

•

1 mg/kg (max 50 mg) slow IV/IM

• •

Allergic Reaction Anaphylaxis

Calcium Chloride

•

10 mL IV/IO over 2-5min

• •

0.75 ml/kg, max 10 ml. 20 mg/kg IV/IO

• • •

1st dose 0.25 mg/kg slow IV over 2 minutes (typically 20 mg) 2nd dose 0.35 mg/kg slow IV over 2 minutes

•

N/A

• • •

5 – 10 mg IV/IM

•

Hyperkalemia PEA Calcium Channel Blocker OD SVT Refractory to Adenocard A-Fib with rapid ventricular rate Nausea and vomiting

Cardizem (Diltiazem)

• •

Compazine (prochlorperazine)

•

• 0.15 mg/kg IV/IM not to exceed 10 mg

•

•

Patient on Digitalis

• •

Hypotension High degree AV block WPW

• • • •

Nausea Vomiting Hypotension Dizziness

Those with dystonic or other reactions to medication Patients less than 6 months

• • • • • •

Hypotension Dizziness Dizziness Drowsiness Motor restlessness Dystonia/akathesia

• •

•

08/01/2012

Drug Name Cyanokit (cyanide antidote package

Adult Dose/Route •

5 grams IV infused over 15 minutes

•

Pediatric Dose/Route 70 mg/kg IV infused over 15 minutes

Indications •

Decadron (dexamethasone)

•

10 mg IV

•

0.2 mg/kg IV

• •

Dextrose

•

D-50: 25 gm/50 mL/IV

•

Peds older than 2 years old: 2 mL/kg D-50 IV 1-2 years old: 4 mL/kg D-25 IV Under 1 year old: 8 mL/kg D-12.5 IV o To make D12.5, dilute D-25% 1:1 NS

•

0.015 mg/kg IV/IM/IO

•

• •

Dilaudid (Hydromorphone)

Dopamine (Intropin)

• •

• • • •

1mg IV/IM/IO Half dose for elderly or patients with altered mentation

400 mg/250 mL, or 800 mg/500 mL (1600 mcg/mL) 5-20 mcg/kg/min IV/IO Mini drip tubing only

•

• •

Hypotension unresponsive to fluid Use as second line for refractory bradycardia

•

• • • •

Known or suspected Cyanide poisoning

Contraindications •

Asthma Severe Anaphylaxis Hypoglycemia

•

Analgesic for severe pain Use half dose for moderate pain (47/10)

•

Symptomatic Hypotension Cardiogenic Shock Beta Blocker OD Calcium Channel Blocker OD

•

• •

•

Known allergic reaction to medication

None in emergency setting None in emergency

Respiratory depression or breathing difficulty Hypersensitivity to medication Hypovolemia when fluid resuscitation has not occurred Severe tachycardia

Side Effects • • • • • • • • •

Transient chromaturia Erythema Rash Increased Blood Pressure Nausea Headache Infection Prolonged wound healing Local venous irritation

• • •

Hypotension Nausea / Vomiting Respiratory depression

•

Ventricular irritability Hypertension Palpitations Tachycardia

• • •

08/01/2012

Drug Name

Adult Dose/Route

DuoNeb (albuterol and atrovent)

•

2.5 mg Albuterol and 0.5 mg Atrovent

•

Epinephrine 1:1000

•

Allergic Reaction, Anaphylaxis, Asthma 0.3-0.5 mg IM

•

•

• • • • •

Pediatric Dose/Route 2.5 mg Albuterol and 0.5 mg Atrovent

Allergic Reaction Asthma 0.01 mg/kg SQ Max 0.5 mg Unstable Croup 3 mL (3 mg) Nebulizer-6L O2 Arrest 0.01 mg/kg IV/IO Anaphylaxis 0.05 mg IVP repeat every 3 minutes 0.3 mg/kg IV/IO

Indications

Contraindications

• • • • •

Asthma Bronchitis COPD Croup Emphysema

•

Allergy to drug

• • • • •

Allergic Reaction Anaphylaxis Asthma COPD Croup

•

Cardiac Disease Hypertension Pregnancy Tachycardia

• • • •

Cardiac Traumatic Arrest Anaphylaxis Symptomatic bradycardia

•

•

RSI – Induction agent

•

• • •

• • • • • • • • • • • •

Palpitations Anxiety Headache Dizzy Sweating Hypertension Nausea Palpitations Tachycardia Anxiety Headache Tremors

None in emergency

• • • •

Palpitations Anxiety Nausea Vomiting

Allergy to drug

• • • • • • • • •

Myoclonic muscle movement Apnea Laryngospasm Dizziness Altered LOC Bradycardia Dyspnea Hypotension Vomiting

•

bleeding

• •

Arrest 1 mg IV/IO Anaphylaxis 0.1 mg IVP repeat every 3 minutes

• •

0.3 mg/kg IV/IO (RSI) 5-10 mg IV/IO (sedation)

•

Fentanyl (Sublimaze)

•

25-100 mcg IV/IM/IN

•

0.5-1 mcg/kg IV/IM/IN

•

Pain management

•

Drug allergy

Glucagon (GlucaGen)

• •

Hypoglycemia: 1 mg IM/IN Beta Blocker/Calcium Channel Blocker OD: 1-2 mg IV (may repeat x 2)

•

• •

Hypoglycemia Beta Blocker Overdose Calcium Channel Blocker Overdose

• •

Allergy to drug Starvation

•

60 units/kg, Max 5000 units.

•

Hypoglycemia: 0.03 mg/kg IM/IN Beta Blocker/Calciu m Channel Blocker OD: 0.03 mg/kg IV (may repeat x 2) None

STEMI

•

active bleeding

Epinephrine 1:10000

Etomidate (Amidate)

Heparin

•

•

•

•

Side Effects

08/01/2012

Drug Name Ketalar (Ketamine)

Adult Dose/Route • •

4-5 mg/kg IM 1-2 mg/kg IV/IO

• •

Pediatric Dose/Route 4-5 mg/kg IM 1-2 mg/kg IV/IO

Indications • •

Analgesia Profound Sedation

Contraindications • •

known active coronary disease pregnancy

Side Effects • •

•

Labetalol (Normodyne)

•

20 mg IV – slow over 2 minutes

•

N/A

•

Unstable hypertensive crisis

• • •

Lasix (Furosemide)

•

20-80 mg-slow IVP

•

1mg/kg

•

Congestive Heart Failure with fluid overload

• •

Lidocaine (Xylocaine)

•

V-Fib Pulseless V-Tach: 1-1.5 mg/kg IV/IO. Repeat dose ½ of first (may repeat x2). EZIO-Conscious Patient: 20-50 mg IO Premix Drip: 1 gm/250 mL or 2 gm/500 mL – run at 2-4 mg/minute (30-60 mcg/min)

•

V-Fib Pulseless VTach: 1 mg/kg IV/IO. Repeat dose ½ of first (may repeat x2). Drip: 20-50 mcg/kg/minute ET Admin: 2x dose EZIOConscious Patient: 0.5 mg/kg IO

• • •

V-Tach V-Fib Pain Management with EZIO

• • •

• •

• • •

Bradycardia AV Block Cardiogenic Shock Dehydration Hypotension

• • •

Allergy to drug AV blocks PVC’s with Bradycardia

• • • • • •

• • •

Emergence reaction 5-30% Increased sympathomimetic output which may cause: hypertension, increase cardiac output and myocardial oxygen consumption. Tonic-clonic movements (including laryngospasm) with rapid infusion Bradycardia Hypotension AV Block Dizziness Hypotension Electrolyte depletion Anxiety Dizziness Nausea Vomiting Confusion Convulsions

08/01/2012

Drug Name Magnesium Sulfate

Adult Dose/Route • • •

Morphine Sulfate

•

Seizure/Pregnancy Eclampsia: 4 gms in 100 cc of IV fluid slowly over 4 minutes. Torsades: 1-2 gms IV Severe asthma: 2gms IV over 4 minutes.

•

0.1 mg/kg or 2-10 mg IV/IM

•

Pediatric Dose/Route 25-50mg/kg IV

Indications • • • •

0.1 mg/kg IV/IM up to 5 mg

• •

Narcan (Naloxone)

Nitroglycerine

•

•

2 mg IV/IM/IN – may repeat every 5 minutes if transient response

0.4 mg Sublingual Tablet

•

•

0.1 mg/kg IV/IM/IN up to 2 mg – may repeat every 5 minutes if transient response N/A

• •

• • • •

Norepinepherine

Oral Glucose (Glutose 15) Plavix

Start at 8 mcg/min IV and titrate to effect (maximum 3 mcg/kg/min) (Levophed: mix 4 mg in 500 mL)

•

•

1 Tube Orally

•

600mg PO

•

Contraindications

Side Effects

Seizure Pregnancy Eclampsia Torsades Severe Asthma

• • • •

Shock AV Block Caution with patient on Digitalis Hypocalcemia

Severe pain (greater than 7) Moderate pain (47/10) use half dose Chest Pain Overdose of Synthetic, Narcotics, Opiate drugs, unknown Altered LOC

• •

Hypotension Allergy to drug

• • • •

Altered LOC Dizziness Hypotension Decreased respiratory rate

•

None in emergency

•

Withdrawal symptoms

Chest Pain, Cardiac Pulmonary Edema Hypertensive Crisis Shock unresponsive to fluids

• • •

Hypotension Hypovolemia Hypersensitivity to medication

• • • •

Headache Hypotension Dizziness Flushing feeling

•

Severe Tachycardia Hypersensitivity to medication

• • •

Unable to swallow Hypersensitivity to the drug Active bleeding

•

Hypertension Tachycardia Extravasation can cause local tissue necrosis None

•

Bleeding

0.05-0.1 mcg/kg/min IV to maximum 3 mcg/kg/min

•

•

1 Tube Orally

•

Hypoglycemia

•

•

none

•

STEMI

•

•

•

• • • •

Respiratory depression Hypotension Bradycardia Cardiac/Respiratory Arrest

08/01/2012

Drug Name Procainamide

Adult Dose/Route •

Pediatric Dose/Route 15 mg/kg over 30-60 minutes only for ventricular tachycardia with pulses

Indications

•

•

•

0.1 mg/kg IV/IO over 1 to 2 minutes

•

Nausea Vomiting

Hyperkalemia Acidosis Cyclic Antidepressant OD Asthma Allergic Reaction

Reglan (metoclopramide)

•

50-100 mg IV bolus over 5 minute period until: o QRS is 50% wider than at start of medication administration o Maximum dose of 17 mg/kg has been given o Effect on dysrhythmia achieved 10 mg IV/IO over 1 to 2 minutes

Sodium Bicarbonate

•

1 mEq/kg IV/IO

•

1 mEq/kg IV/IO

• • •

SoluMedrol (methylprednisolone)

•

125 mg IV/IO

•

2 mg/kg IV/IO

• •

• •

Ventricular tachycardia Ventricular fibrillation Tachycardias including Atrial Fibrillation

Contraindications •

Side Effects

Allergy to the drug Heart block Torsades des pointes

• • •

Hypotension Bradycardia Heart block Nausea, vomiting

•

GI obstruction or bleeding

• • • •

•

None when used as indicated

•

Hypotension Bradycardia Nausea / Vomiting Respiratory depression Alkalosis

•

None in emergency setting

• •

• •

•

• Succinylcholine (Anectine)

•

1.5 mg/kg IV/IP

•

2 mg/kg IV/IP

•

Tetracaine

•

1-2 drop of 0.5% solution in affected eye(s)

•

1-2 drop of 0.5% solution in affected eye(s)

•

Under 2 years old 0.2mg/kg 2-5 years old 0.5 mg/kg rectal not to exceed 10 mg 6-11 years old 0.3mg/kg

•

Valium (Diastat)

•

0.2 mg/kg rectal not to exceed 10 mg

• •

•

RSI – Achieve paralysis for intubation Eye Pain

Seizures

• • • • • •

Allergy to drug Malignant hyperthermia Allergy to drug Penetrating eye injury Known hypersensitivity to Valium Patients experiencing shock or coma

• • • • • • • • • •

Increased appetite Lowered response to infections Altered moods

Prolonged paralysis Hypotension Bradycardia Eye-stinging, 30 seconds Urticaria Skin rash Respiratory depression or arrest Agitation Tremors Use lower doses in elderly, caution if ETOH or drug intoxication 08/01/2012

Drug Name Vecuronium (Norcuron)

Versed (Midazolam)

Zofran (Ondansetron)

Adult Dose/Route •

0.1 mg/kg IV/IO

•

2-5 mg IV repeat Q 5 min (Sedation)

•

10 mg IM/IV (Seizure)

•

4 mg IV may be repeated

•

•

Pediatric Dose/Route 0.1 mg/kg IV/IO

0.1 mg/kg IV (Sedation or Seizure)(max single dose 10 mg) may repeat dose Q 5 min Seizure • 0.2 mg/kg IM < 13 kg • 5 mg IM if 13 to 40 kg • 10 mg IM if > 40 kg • May repeat IM every 10-15 min • 0.1 mg/kg IV (max dose 4 mg) may be repeated

Indications •

Contraindications

RSI – Prolonged paralysis

•

•

•

Sedation prior to Cardioversion Pacing Seizure Chemical restraint RSI

• •

treat Nausea treat Vomiting

•

• • • •

Allergy to drug

Allergy to drug

allergic to Ondansetron

Side Effects •

•

Respiratory insufficiency Apnea Hypotension Bradycardia Drowsiness Hypotension Respiratory depression Apnea

• •

blurred vision feeling light-headed

• • • • • •

08/01/2012

TABLE OF CONTENTS (ALPHABETICAL) Standard Operating Procedures Approval and Instructional Page Abuse – Child, Suspected, Reporting Abuse – Domestic, Sexual, Elder Acute Abdominal Pain Acute Asthma / COPD Administration of Nebulized Albuterol / Atrovent for the Emergency Care of Severe Asthma Protocol Adult Airway Obstruction Advanced Life Support Response Allergic Reaction / Anaphylactic Shock Amiodarone Infusion / Lidocaine Drip Guidelines APGAR Scoring Chart, Infant Patient Care Report Assisted Administration of Epinephrine Utilizing a Patients Auto-Injector Protocol Assisted Administration of Patient-Prescribed Nitroglycerine Protocol Bradycardia Burns Cardio Cerebral Resuscitation Cardiogenic Shock Chest Injuries Cold Emergencies (Frostbite) Cold Emergencies (Hypothermia) Conditions that Cause Pulseless Electrical Activity Continuous Positive Airway Pressure (CPAP) CPR Modifications for Children and Infants Cricothyrotomy Delivery Complications: Breech Birth Delivery Complications: Prolapsed Cord Diabetic / Glucose Emergencies Drug Overdose / Poisoning:Beta Blocker/Calcium Channel Blocker Drug Overdose / Poisoning:Carbon Monoxide Drug Overdose / Poisoning:Cocaine Drug Overdose / Poisoning:Cyanide Drug Overdose / Poisoning:Narcotic or Synthetic Narcotic Drug Overdose / Poisoning:Organophosphate Drug Overdose / Poisoning:Tricyclic Antidepressant Emergency Childbirth – Phase I: Labor Emergency Childbirth – Phase II: Delivery Emergency Medical Care of the Pulseless Non-Breathing Patient Using Automated External Defibrillation (AED) Protocol Emergency Medical Treatment of Hypoglycemia with Glucose Monitoring and Administration of Glucagon Protocol

A-6 P -22 T – 23 M-7 R–4 X- 8 R-1 A – 34 R–5 C-7 OB - 6 X-6 X-7 C–2 T - 19 C - 10 C - 12 T - 16 M - 15 M -16 C-9 R–7 P-3 R-8 OB - 3 OB - 4 M-1 M – 11 M – 13 M – 12 M – 12 M–9 M–9 M–9 OB - 1 OB - 2 X-2 X-9

Emergency Medical use of the Esophageal Tracheal Combitube (ETC) and King LTS-D Airway Protocol Non-Visualized Airways EMS Neurologic Checklist EtCO2 Monitoring/Capnography General Patient Assessment – Initial Medical Care General Pediatrics Glasgow Coma Scale GCS / Head Injuries Heat Emergencies Hypertension (Stable Acute Crisis) Hypovolemic / Hemorrhagic Shock Induced Hypothermia Initial Medical Care Initial Trauma Care: Primary Survey Initial Trauma Care: Secondary Survey IO Protocol IV Protocol Musculoskeletal Injuries Nausea and Vomiting Near Drowning Neonatal Resuscitation (Newborns In Distress / Arrest, APGAR Score = 6 or Less) Newborn and Post-Partum Care – Care of Newborn, Newborn and Post-Partum Care – Care of the Mother Obstetrical Complications:Bleeding Obstetrical Complications:Hypertension Ophthalmic Emergencies Pain Management Patient Restraint Pediatric Airway Obstruction (Child / Infant) Pediatric Allergic Reaction / Anaphylactic Shock Pediatric GCS (Glasgow Coma Scale) Pediatric Ventricular Fibrillation / Pulseless Ventricular Tachycardia Pediatrics Asthma Pediatrics Asystole / Pulseless Electrical Activity (PEA) Pediatrics Bradyarrhythmias with Pulse Pediatrics Croup / Epiglottitis Pediatrics Diabetic / Glucose Emergencies Pediatrics Drug Overdose / Poisoning:Carbon Monoxide Pediatrics Drug Overdose / Poisoning:Cocaine Pediatrics Drug Overdose / Poisoning:Cyanide Pediatrics Drug Overdose / Poisoning:Narcotic or Synthetic Narcotic Pediatrics Drug Overdose / Poisoning:Organophosphate Pediatrics Drug Overdose / Poisoning:Tricyclic Antidepressant Pediatrics Seizures Pediatrics Syncope/Near Syncope Physician Control at the Scene

X-4 M -19 A – 35 A - 21 P-1 T-5 T - 14 M - 14 M–5 T–9 C – 13 A - 22 T-1 T-3 A - 24 A – 23 T - 18 M-8 T - 21 OB - 8 OB - 5 OB - 7 OB – 10 OB – 11 T - 17 A - 26 A - 29 P - 10 P - 11 P-2 P-8 P - 13 P-6 P-5 P - 14 P - 16 P – 18 P – 18 P – 18 P – 17 P – 17 P – 17 P - 19 P – 20 A - 31

Psychological Emergencies Pulmonary Edema (Due to Heart Failure) Pulseless Electrical Activity / Asystole Radio Report Rapid Sequence Induction and Intubation Rapid Sequence Intubation Medications for Pediatric Patients Resuscitation Medication Dosages Scope of Practice – ADVANCED EMERGENCY MEDICAL TECHNICIAN / INTERMEDIATE TECHNICIAN Scope of Practice – EMERGENCY MEDICAL RESPONDER/ First Responder Scope of Practice – EMERGENCY MEDICAL TECHNICIAN/ Basic Scope of Practice – Intermediate Scope of Practice – Paramedic Scope of Practice – Registered Nurse Sedation Seizures (Non-Traumatic Origin) Spinal Immobilization – Appropriate Omission Spinal Injuries Statement of Release STEMI Acute Coronary Syndrome (ACS)/Chest Pain STEMI ALERT WORKSHEET Supraventricular Tachycardia Suspected Child Abuse or Neglect Suspected CVA Syncope / Near Syncope TB – Pneumonia Tourniquet Application Trauma Definition – Level 1 Trauma Center Access Guidelines Trauma in Pregnancy Traumatic Arrest Unconscious - Unknown Etiology Use of Hemostatic Dressings Use of Mark I Auto Injectors Ventricular Fibrillation – Pulseless V-Tach Ventricular Tachycardia with a Palpable Pulse Withholding or Withdrawing of Resuscitative Efforts

M -17 C - 11 C-8 A - 18 R–2 R-3 P-4 A – 11 A-8 A-9 A - 13 A - 15 A - 17 A - 28 M-4 T-8 T - 15 A – 33 C-1 C – 14 C-3 P – 21 M-6 M-2 R–6 T – 10 T–6 T - 22 T - 12 M-3 T - 11 A - 31 C-6 C-5 A - 19