Embed Size (px)
Citation preview
General, Basic, Advanced & Paramedic Review
Methodology of Instruction
Stipulations
2015 Changes
The 2015 Protocol
Questions & Answers
2
= Emergency Medical Responder Skills & Procedures
= Emergency Medical Technician Skills & Procedures
= Advanced Emergency Medical Tech. Skills & Procedures
= Paramedic Skills & Procedures
Italics = Physician’s Orders
*** This is not a complete review of the protocol. Due to time limitations, the most important information will be covered.***
Pink Text or Boxes Refer to Pediatric Orders
4
A higher level of certification can perform all of the procedures that a lower lever of certification is allowed to perform.
The protocol has been written to promote “critical thinking”
5
Protocol is for use by individuals operating under the GMVEMSC Drug Box Exchange and properly certified by the State of Ohio
Nothing by be done without pre-approval of the Medical Director for the local agency
Recipe-style adherence to specific protocols may not be in the patient’s best interest.
No protocol can substitute for the EMS professional’s judgment.
Never should treatment options exceed those authorized without direct consultation with Medical Control
7
♦ Changed all references to Intermediate to AEMT
♦ Recommends manual B/P in patients with s/s of shock
♦ Removed most of the contraindications to drug administration within the protocol
♦ Drug Bags may only be exchanged within the same department
♦ Added Ambulance Restocking policy
♦ Added Protocol Testing Compliance
♦ Made slight changes to the Hospital Capabilities & Phone number lists
♦ Added additional requirements to the Drug Bag Program
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
9
♦ SMR applies to all age patients (if <3 y/o with a GCS <15, then immobilize)
♦ SMR for patients > 70 y/o should include a C-collar
♦ Deleted all references to remove or manage an insulin pump
♦ Recommends transporting all CVA patients flat
♦ Added additional APGAR at 10 minutes
♦ Mention cold water submersion for cooling heat stroke patients
♦ Added EMT & EMR administered Narcan, only EMT may repeat
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
10
♦ Added 1 mcg/kg IN admin. to Pediatric Fentanyl (max 100 mcg)
♦ Pediatric Midazolam changed to 0.2 mg (max. 4 mg) for IN/IM
♦ Under Chemical Restraint, removed MCP orders for initial dose for Midazolam
♦ Added 1 mcg/kg IN admin. to Pediatric Fentanyl (max 100 mcg)
♦ Added crush protocol
♦ Removed “last resort” verbage to IM Midazolam
♦ Asthmatic condition added to indication for CPAP
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
11
♦ Renal patients with wide complex bradycardia may need hyperkalemia therapy
♦ Pediatric Midazolam changed to 0.1 mg (max. 2 mg)
♦ Added pediatric dose of Hydroxocobalamine
♦ Replaced Dopamine with Norepinephrine throughout the protocol
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
12
Reasons to call hospital Prepare the receiving facility for the arrival To obtain orders To obtain advice
When calling: Paint a clear picture If trauma, include MIVT, ETA, GCS and findings If consultation is required, ask for Medical Control Call after transmission of any EKG, Paramedics do not have to
transmit (should only do so for advice) When calling for an alert, say “We recommend a __________
Alert”
14
Hospitals that request notification on every patient:
Children’s Medical Center (CMC) Maternity at Good Samaritan Maternity at Miami Valley Hospital Springfield Regional Medical Center Soin Medical Center VA Medical Center Wayne Hospital McCullough-Hyde Hospital WPAFB Medical Center
15
♦ Resuscitation won’t be initiated in the following circumstances:
Deep, penetrating, cranial injuries Massive truncal wounds DNR Order - present and valid Frozen body Rigor mortis, tissue decomposition, or dependent post-mortem lividity Triage demandsPediatric patients may meet criteria
If care began and it is readily apparent to EMS that the patient met non-initiation of care criteria, resuscitation efforts may cease.
16
Continued…
Resuscitation will not be initiated in the following circumstances:
Blunt trauma found in cardiac arrest unless one of the following conditions are present:
Patient can be delivered to an emergency department in 5 minutes
If the arrest is caused by a medical condition
Focused blunt trauma to the chest (Commotio Cordis)
17
Continued…
Resuscitation will not be initiated in the following circumstances:
Penetrating trauma found in cardiac arrest when the patient cannot be delivered to an emergency department within 15 minutes.
Resuscitation will be initiated on victims of penetrating trauma who arrest after they are in EMS care
Once en route, continue care even if the above time limits cannot be met.
18
19
Continued…
DNR-Comfort Care (CC)
Permits any medical treatment to diminish pain or discomfort that is not used to postpone the patient’s death
The following treatments are permitted: Suctioning Oxygen Splinting/Immobilization Control bleeding Pain control
20
Continued…
DNR-Comfort Care (CC)
Permits any medical treatment to diminish pain or discomfort that is not used to postpone the patient’s death
The following treatments are not permitted: Chest compressions Airway adjuncts (including CPAP) Resuscitative drugs Defibrillation/cardioversion/monitoring Respiratory assistance (oxygen, suctioning are
permitted)
21
Continued…
DNR-Comfort Care Arrest (CCA)
Permits any medical treatment until the patient goes into cardiac or respiratory arrest
Any appropriate standing orders treatment until cardiac or respiratory arrest/agonal breathing occurs.
22
Continued…
DNR-Comfort Care Arrest (CCA)
Note: When a Durable Power of Attorney for Healthcare (DPA-HC) is present and the “Living Will and Qualifying Condition” box is checked, the DPA-HC cannot override the patient’s DNR status.
A patient may change their DNR status at anytime verbally, in writing or action.
23
When a patient has failed to respond to ALS, it may be decided to terminate the effort
The following criteria must be met:
Patient 18 years or older Patient in asystole or PEA
If PEA rate above 40, then consider resuscitation Not be in arrest due to hypothermia Patient has an advanced airway Patient has vascular access
Contact medical control directly to receive consent for termination
Field Termination doesn’t apply to Pediatrics
24
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Field Termination with no ALS Equipment
If no ALS equipment is available at the scene, and transport time to a medical facility will exceed 20 minutes, consider field termination Must be 18 years or older Must not be in arrest due to hypothermia
Contact MCP directly to receive consent for termination
25
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
This section does not apply to Emergency MedicalResponders
The intent of this section is to avoid the risks of emergency transport of patients who are almost certainly non-viable.
Ensure that the EMS Coordinator of the hospital that authorized the Field Termination receives a copy of the run sheet for his/her records.
26
Follow basic life support algorithms as indicated based on current AHA guidelines
Obtain chief complaint (OPQRST), SAMPLE history, and vital signs per patient condition
Monitoring devices pulse oximeter, etc. as appropriate
Patient with IV pump experiencing an allergic reaction: discontinue only after receiving approval from MCP otherwise, maintain pump
Bring meds or list with dose and frequency
27
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Cardiac monitor
IV of Normal Saline (NS) or a Saline Lock (SL)
IVs: Shock:
Run wide-open. Decrease fluid rate if SBP >100. IV NS, 20 ml/kg
Medical Emergencies, Head Trauma, Cardiac Problems (with stable BP): Use TKO rate
Slow IV Meds means over 2 minutes Any IV Med can be given IO
Adult IO devices
28
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
IO Devices
Use when patient is hemodynamically unstable or unresponsive
When less invasive methods aren’t available. (IM or IN)
Lidocaine 1.5 mg/kg, IVP up to 100 mg via the IO 2% Lidocaine – 0.5 mg/kg IO
Utilize Central venous catheters, dialysis catheters, fistulas, or grafts if in cardiac arrest, profoundly unstable or rapidly deteriorating
29
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Blunt trauma
All patients with clinical indications of a spinal injury and/or with altered levels of consciousness must be immobilized with both a C-Collar and a spinal immobilization device
Other alert trauma patients can have a C-Collar placed and moved in-line as a unit to the cot. Including: Neck pain or spinal tenderness Pain on motion of the neck Age > 70 High risk mechanism (high speed MVC, fall > 10 ft, axial loading injury) Patients who are ambulatory may ambulate to the cot
30
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Penetrating trauma
Patients with penetrating trauma to the torso or neck with focal neurological signs or paralysis should be immobilized in a c-collar and with a spinal immobilization device.
Patients without focal neurological signs or paralysis need NOT be immobilized.
Delays in transport for immobilization are to be minimized
This protocol applies to all patients Those patients < 3 y/o with a GCS of < 15 should be fully immobilized
31
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Airway Management
Patients who are immobilized and require airway and / or ventilatory intervention (including intubation) may have the collar removed, with in-line stabilization performed during the intervention.
The collar should then be reapplied.
Patients who do not tolerate immobilization should have it adjusted to the point of removal if necessary
32
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Prehospital pain management is important. It reduces time to pain relief, avoids exacerbation of pain during movement and transport, is compassionate, and is good medical care
Use ice packs, position of comfort, and splinting to reduce pain as indicated
This protocol is for management of acute moderate to severe pain, it is NOT for treatment of exacerbations of chronic pain Call for orders for narcotics for pain from a chronic condition
Document pain at initial contact, during treatment and after intervention
MCP approval required before administration of Fentanyl in pediatric patients with abdominal pain
33
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
If patient is alert, Fentanyl 50 mcg slow IVP May repeat Fentanyl 50 mcg slow IVP after 5 min. Maintain SBP >100
If no IV, give Fentanyl 50 mcg IM or Fentanyl 100 mcg IN Repeat dose of Fentanyl 50 mcg IM (repeat after 30 min.) IN Fentanyl may be repeated (if a second drug box is available)
NO FENTANYL TO ANYONE < 2 YEARS OF AGE
Consider Fentanyl 1 mcg/kg, slow IV (max dose 50 mcg) May repeat Fentanyl 1 mcg/kg (max 50 mcg), slow IVP after 5 minutes Maintain appropriate normal SBP
If no IV, give Fentanyl 1 mcg/kg IM (max dose 50 mcg). Repeat dose of Fentanyl 1 mcg/kg IM (max dose 50 mcg, repeat after 30 min.)
Or if no IV, give Fentanyl 1/mcg/kg IN (max dose 100 mcg)
34
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
O2 PRN. Use the following rates as guidelines: 2 LPM by NC for patient with COPD 4 - 6 LPM by NC for other patients 12 - 15 LPM by NRB for severe trauma patients, distressed cardiac
patients, patients with respiratory distress, or patients who appear to need high flow O2
Ventilate patients who are symptomatic with an insufficient respiratory rate/depth
If indicated and approved, utilize a “Rescue Airway”
35
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Intubate for respiratory arrest with appropriate airway device
Decompress tension pneumothorax
If awake consider:
Lidocaine Jelly to the ET tube Lidocaine, 100 mg IN {half dose per nostril} or nebulized Lidocaine, 1.5 mg/kg IN or neb. with 8-10 LPM O2 ,max dose 100 mg
If resisting and SBP >100, consider Midazolam, 2 mg slow IVP Midazolam, 0.1 mg/kg slow IVP (max dose 2 mg)
36
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Sedate to Intubate
Lidocaine 100 mg, IVP in suspected CVA, intracranial hemorrhage, head injury, or signs of increased intracranial pressure
Etomidate 0.3 mg/kg, IVP (average initial dose is 15-25 mg). Repeat initial dose within 2 minutes.
Or Ketamine 100 mg IV. May repeat within 5 min. Or Ketamine 500 mg IM (2 doses of 250 mg), may repeat in 5 min.
After the jaw relaxes (30-60 seconds), intubate
After Intubation, if the patient is still resisting, and SBP is >100, administer Midazolam 2 mg IVP over 2 min
37
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
38
Limitations
The patient must have adequate perfusion.
May be useful for patients in cardiac arrest if color change is present.
Secretions, emesis, etc., can ruin the device.
Large amounts of carbonated beverage give a false positive.
Use the device for no more than two hours.
39
Continued…
Medication Issues:
If you administer medications via ETT, remove the EtCO2 detector for several ventilations, until no medication returns through the tube during exhalation.
Medications splashing up the tube can alter color change.
Intravenous sodium bicarbonate will produce more carbon dioxide resulting in enhanced color.
40
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Measures the amount of carbon dioxide in the exhaled ventilations of patients.
Can be used with patients who are not intubated.
In-line EtCO2 monitors can be used on patient with or without adequate perfusion.
Electronic monitors are more sensitive therefore changes can be seen in real time.
Is considered the “Gold Standard” and should be used every time if you have the equipment
41
Limitations:
A large amount of gastric air and late term pregnancy can give a false positive finding
A cold device may give a false negative result.
Can only be used on ETT
Cannot be used continuously.
May only be used on patients who are > 5 y/o and weigh at least 20 kg/44 pounds.
42
♦ Use of IO devices is limited to patients who are unresponsive or hemodynamically unstable; and then, only when less invasive means are ineffective or not available
♦ For an adult in cardiac arrest, the preferable order of vascular access:♦ External Jugular IV♦ Antecubital IV♦ Proximal Humeral IO♦ Last resort, Proximal Tibial IO
♦ Pediatrics, < 8 y/o use Tibial IO
43
Adults Pediatric
Arrest: Humerus Tibia
Non-arrest: Tibia Tibia
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
44
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
IO Insertion at Proximal Tibia Site
Identify the tibial tuberosity Prep the skin and insert needle according to manufacturer’s directions. Use 10-15O caudal angulation to further decrease risk of hitting growth
plate. Needle will stand up on its own with proper placement. Attach syringe and aspirate bone marrow (to further confirm
placement). Connect the IV line. If flow is good and extravasation is not evident
secure needle with gauze pads and tape. A pressure bag may facilitate infusion. Lidocaine 1.5 mg/kg up to 100 mg via IO for pain associated with IO Lidocaine 2% 0.5 mg/kg (max 100 mg) via IO for pain
45
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
46
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Acromion
Coracoid Process
Greater Tuberosity
IO Insertion at Humeral Head site
Position patient so shoulder is adducted (moved toward the middle of the body) and the greater tuberosity is most prominent by lying patient supine, arm at their side with palm on their navel.
Prep the skin and insert needle according to manufacturer’s directions. Insert the needle at 90-degree angle directly into the greater tuberosity. Needle will stand up on its own with proper placement. Attach syringe and aspirate bone marrow (to further confirm
placement). Connect the IV line. If flow is good and extravasation is not evident
secure needle with gauze pads and tape. A pressure bag may facilitate infusion.
47
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
48
Central Venous Catheter Internal Dialysis Fistula
Central catheter: Catheter placed through chest wall. Distal portion of catheter is external with access ports.
Subcutaneously Implanted Port: Device surgically placed under the skin on the chest. No external access. Do not use!
PICC Line: Catheter placed in arm. Distal portion of catheter is external with access port. Do not force fluids or drugs through the device
D10 by PICC is preferable to IM Glucagon.
Paramedics are only permitted to access central catheters and PICC lines, not subcutaneously implanted ports.
49
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Direct access can result in the following complications:
Air Embolism: Clamp before attaching the syringes Clamp before removing the syringes.
Heparin Bolus: Remove 5 cc of blood before using
Catheter Damage: Use a 10 cc syringe or bigger After draw, bolus 10 cc NaCl in pulsating manner Do not use catheter if no blood return.
50
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Artificial passage between an artery and a vein used to gain access to the bloodstream for hemodialysis.
Usually located in the inner aspect of the patient's forearm resulting in a bulge under the skin that should be visible or easily palpated.
In cardiac arrest or the profoundly unstable/rapidly deteriorating patient, a dialysis fistula, may be accessed to administer IV fluids or medication.
51
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Accessing the Fistula
Utilize an aseptic technique
Be careful not to puncture the back wall of the vessel.
Use pressure bag for infusion.
Blood may still backup in the IV tubing.
Increased risk of hemorrhage because of regular use of anticoagulants during hemodialysis.
Control bleeding with direct pressure.
52
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Treatable causes include:
53
Hypoxia Hypovolemia Hypo/Hyperkalemia Hypoglycemia Hydrogen Ion (acidosis)
Hypothermia
Trauma Thombosis Toxins Tamponade, (Cardiac)
Thrombosis, (Coronary & Pulmonary)
Tension Pneumothorax
Calcium Chloride 10% (1,000 mg) Calcium Chloride 10% 0.2 ml/kg (20 mg/kg) (max 500) slow
IVP
Flush IV line thoroughly between Calcium and Sodium Bicarb.
Sodium Bicarbonate, 100 mEq IVP Sodium Bicarbonate, 1 mEq/kg slow IVP
54
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
♦ For smoke inhalation or cyanide poisoning
♦ Administer Hydroxocobalamin, 5 gm slow IV, over 15 min. ♦ DO NOT ADMINISTER both Hydroxocobalamin and other cyanide antidotes to
the same patient. ♦ Pedi dose is 70 mg/kg IV, max dose 5000 mg♦ May repeat Pedi dose 35 mg/kg IV, max dose 2500 mg
♦ Sodium Thiosulfate 12.5 gm (50 ml) slow IVP♦ >25 kg - 12.5 gm (50 ml) slow IVP♦ <25 kg – 1.65 ml/kg (412.5 mg/kg) (50 ml) slow IVP
♦ Antidotes are no longer in Drug Bags. They are in multiple caches in the region.♦ Contact 937-333-USAR (8727)♦ Call if: Reported victim trapped, known cyanide event, or Mayday scenario
♦ No MCP orders needed if patient in Cardiac Arrest
55
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
If unwitnessed arrest, CPR for 2 minutes,then AED
If witnessed arrest, AED immediately
Continue CPR and AED
Consider treatable causes
First Defib @ 360 J (or biphasic equivalent) If witnessed, if not then 2 min CPR first Defibrillate 2 j/kg(or biphasic equivalent)
56
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
♦ Uninterrupted, Continuous CPR throughout the Code
♦ Second Defib @ 360 J (or biphasic equivalent)♦ Defibrillate 4 j/kg(or biphasic equivalent)
♦ Epinephrine 1 mg, IV/IO repeat every 3-5 minutes ♦ If no IV Epi 2mg ETT q 3-5 minutes (11 ml total)♦ Epi 0.01 mg/kg, IV/IO or Epi 0.1 mg/kg, ETT
♦ Third Defib @ 360 J (or biphasic equivalent)♦ Defibrillate 6 j/kg(or biphasic equivalent)
57
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Amiodarone 300 mg, IV/IO or Lidocaine, 1.5 mg/kg ETT Amiodarone 5 mg/kg (Max. 300 mg), IV/IO or Lidocaine, 1.5 mg/kg ETT
Fourth Defib @ 360 J (or biphasic equivalent) Defibrillate 8 j/kg(or biphasic equivalent)
Repeat Amiodarone 150 mg or Lidocaine 0.75 mg/kg ETT Repeat Amiodarone 5 mg/kg (Max. 150 mg), IV/IO or Lidocaine, 0.75
mg/kg ETT (Max. 100 mg)
Fifth Defib @ 360 J (or biphasic equivalent) Defibrillate 10 j/kg(or biphasic equivalent)
58
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
♦ Continue CPR and repeat treatment as indicated
♦ 12-lead EKG if return of spontaneous circulation♦ If AMI, transport to Interventional Cath Center
♦ If no anti-arrhythmic has been given:♦ Amiodarone, 150 mg IV over 10 minutes
59
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
♦ If unwitnessed arrest, CPR for 2 minutes, then AED
♦ If witnessed arrest, AED immediately
♦ Continue CPR and AED
♦ Uninterrupted, Continuous CPR throughout the Code
♦ Consider treatable causes
60
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Epinephrine 1 mg, IV/IO repeat every 3-5 minutes If no IV Epi 2mg ETT q 3-5 minutes (11 ml total) Epi 0.01 mg/kg, IV/IO or Epi 0.1 mg/kg, ETT
Consider Atropine 1mg, IV/IO for Asystole or slow PEA Repeat every 3-5 minutes up to 3 doses
12-lead EKG if return of spontaneous circulation If AMI, transport to Interventional Cath Center
Consider Field Termination
61
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Should be initiated during the CPR process
Trauma is a contraindication
Do not start if pt. is hypothermic (<34 C or 93.2 F)
Do not start if pt. is conscious
Place ice packs in axilla, groin (bilaterally) and neck Change ice packs every 15 min
Complete a neuro exam including GCS and Pupils
62
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Chilled IV bolus to a max. of 2 L rapidly
Administer medications in a normothermic IV
Notify Hospital so they are ready to continue cooling
If SBP remains < 100, Norepinephrine drip at 30 gtts/min titrate to BP 4 mg added to 250 ml bag, 60 gtt tubing
Max dose 44 gtt/min
Treat shivering Midazolam 5 mg slow IVP
Etomidate 0.3 mg/kg (20 mg max)
63
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
♦ CLINICAL PEARLS
♦ Protocol begins with a patient in Cardiac Arrest
♦ Inclusion Criteria
♦ Arrest not related to Trauma or hemorrhage
♦ Age 16 or older
♦ Advanced airway in place with EtCO2 > 20♦ Do not hyperventilate, patients may develop metabolic alkalosis♦ If no advanced airway, cooling only with MCP orders
♦ GSC less than 8 (no purposeful response to pain)
♦ For patients < 16 y/o, contact MCP
64
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
ASA, 324 mg to patient with symptoms of ACS, >25 y/o
Patient MUST CHEW the Aspirin Do not administer if pregnant patient is in 3rd Trimester Basics need MCP permission to access drug bag
Administer Nitro tabs 0.4 mg SL every 5 minutes x 3
If SBP >100, and the patient is > 25 years old Vital signs between doses EMTs need MCP permission to access drug bag or give more than one
dose of patient’s NTG Do not administer if Patient admits to the use of Viagra, Cialis, Levitra,
Revatio or similar drugs in the last 24 hrs. Establish IV access prior to admin if patient has never had Nitro
65
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
12 Lead EKG, (EMT & AEMT must transmit to MCP) Transmit with at least two patient identifiers For EMT & AEMT, MCP will make transport decision Include patient’s cardiologist by name in verbal assessment
Consider Fentanyl, 50 mcg slow IVP
Do not wait for 3 Nitro admin for pain management Repeat Fentanyl, 50 mcg slow IVP after 5 min. If no IV Fentanyl, 50 mcg IM Repeat Fentanyl, 50 mcg IM no sooner than 30 minutes if transport
time is > 30 minutes.
66
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
IV NS, up to 500 ml may be administered with SBP <100 without pulmonary edema.
With evidence of RVI, contact MCP for fluid bolus
If evidence of AMI, transport to interventional facility
Repeat 12 Lead EKGs throughout transport
67
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Inferior Wall MI (II, III, aVF)
Capture Lead V4R
Treat hypotension with a fluid challenge
Administer NTG or Fentanyl with caution.
If 2 type II or 3 block, prepare to pace immediately Consider Atropine, 0.5 mg IVP (max 3 mg) Set pacer @ 70 bpm, 20 mA increase till capture
Consider Midazolam 2 mg slow IVP
If SBP remains < 100, Norepinephrine drip at 30 gtts/min titrate to BP (max 44 gtts/min)
68
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Anterior Wall MI (V1-V4) ST elevation in 2 or more leads at high risk for death High risk for CHF or Cardiogenic shock May develop BBB, PVC or 3
o Block
If SBP remains < 100, Norepinephrine drip at 30 gtts/min titrate to BP (max 44 gtts/min)
Lateral Wall MI (I, aVL, V5, V6) May have some LV dysfunction, but not as severe as Anterior May also develop AV Nodal Block
69
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
♦ Atrium Medical Center♦ Kettering Medical Center♦ Good Samaritan Hospital♦ Miami Valley Hospital♦ Grandview Hospital ♦ Springfield Regional Medical Center♦ Southview♦ Reid Memorial Hospital
70
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Bradycardia
Wide-complex bradycardia in a renal patient may need 1 amp Calcium Chloride for hyperkalemia
For adequate perfusion, observe and monitor.
Consider 12 Lead EKG & Transmit
Transport unless ALS is < 5 min. away
For poor perfusion, Consider Atropine, 0.5 mg IVP up to 3 mg Set at 70 BPM, 20 mA and increase until mechanical capture
Consider Midazolam, 2 mg IVP
71
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Bradycardia
For adequate perfusion, observe, monitor vital signs, and apply oxygen if needed.
For poor perfusion:
Perform CPR if HR < 60/min
Epi (1:10,000) 0.01 mg/kg, IV/IO or
Epi (1:1,1000) 0.1 mg/kg, ETT every 5 minutes
72
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Bradycardia
If AV Block
Consider Atropine 0.02 mg/kg Minimum dose 0.1 mg Maximum dose 0.5 mg May repeat dose (total max. dose – 1.0 mg)
Consider pacing at 80 bpm Pedi pads for patients <15 kg Consider Midazolam, 0.15 mg/kg (Max. 4 mg) IVP over 1-2 minutes Start at 5 mA and increase to 200 mA
73
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Tachycardia
For adequate perfusion, observe and monitor.
Consider 12 Lead EKG & Transmit
Transport unless ALS is < 5 min. away
74
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Stable Tachycardia
Narrow Complex – Regular
Vagal maneuvers
Adenosine, 6 mg rapid IVP If patient advises it takes 12 mg of Adenosine, then administer Adenosine, 12 mg
rapid IVP
May repeat Adenosine, 12 mg rapid IVP x 2
75
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Stable Tachycardia
Wide Complex – Regular
Amiodarone, 150 mg IV over 10 minutes Infuse in a 250 Nacl bag 18 g Needle Use 60 gtt tubing wide open
Wide Complex – Irregular
Consider Amiodarone, 150 mg IV over 10 minutes
76
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Unstable Tachycardia
Cardioversion 100 J, 200 J, 300 J, 360J
Or biphasic equivalent
Consider Midazolam, 2 mg IVP
77
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Stable or Unstable Tachycardia
Vagal Maneuvers (blow through straw or O2 tubing)
Unstable Tachycardia
Adenosine, 0.1 mg/kg rapid IVP (Max. 6 mg)
Repeat Adenosine, 0.2 mg/kg rapid IVP (Max. 12 mg) x2
Cardioversion 1 j/kg followed by 2 j/kg
Consider Midazolam, 0.15 mg/kg (Max. 4 mg) slow IVP
78
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Without Pulmonary Edema
No JVD, edema, or rales noted
NS, 500 ml IV bolus, repeat if needed NS, 20 ml/kg IV bolus titrated to perfusion, repeat if needed
For persistent shock, additional vascular access.
If SBP remains < 100, Norepinephrine drip at 30 gtts/min titrate to BP (max 44 gtts/min)
79
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
With Pulmonary Edema
JVD, edema, or rales present
Consider NS, 250 ml IV bolus
Treat arrhythmias as indicated.
If SBP remains < 100, Norepinephrine drip at 30 gtts/min titrate to BP (max 44 gtts/min)
80
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Exsanguinating Hemorrhage
Vascular access(es) NS to maintain SBP ~100 en route to ED
Do not get SBP too high
NS, 20 ml/kg IV bolus titrated to perfusion, may repeat x2
81
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Complete GMVEMSC Prehospital Suspected CVA/TIA Checklist.
If signs of cerebral herniation Ventilate at a rate of 20 respirations per minute Ventilate at a rate of 10 faster than normal
If available, ventilate at EtCO2 readings of 30 mmHg
Complete Cincinnati Prehospital Stroke Scale. Facial Droop (patient shows teeth or smiles). Arm Drift (patient closes eyes and holds both arms straight out) Abnormal Speech (have patient say a phrase)
82
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If glucose <60, or there is strong suspicion of hypoglycemia despite glucometer readings
D10, IV 250 ml at wide open rate D10, 5 ml/kg IVP, maximum single dose of 250 ml D10 may be repeated in 10 min. if BSL <60
If unable to establish vascular access, Glucagon, 1 mg IM
Strongly consider transport to a Stroke Center If symptoms occurred >4 hours and <8 hours from last time they
were known to be free of stroke symptoms If patient wakes with symptoms
83
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Contact MCP with a Stroke Alert and for advice regarding destination if greater than 8 hrs since last seen normal
Transport the pt. with the bed flat to increase cerebral perfusion.
Transport historian with patient for pt. history and for permissions
Complete the “EMS CHECKLIST: SUSPECTED Stroke/CVA/TIA” for every stroke/TIA patient.
84
Interventionl Facilities: Miami Valley Hospital Kettering Medical Center
Symptoms mimicking stroke Seizures Subdural hematoma Brain tumor Syncope Toxic or metabolic disorders (i.e., hypoglycemia)
85
General Considerations
Scene size-up, with rapid assessment and recognition of major trauma/multiple system trauma and effective evaluation of the mechanism of injury are essential to the subsequent treatment.
Hypothermia is a significant and frequent problem in shock for major trauma patients. Maintain patient’s body temperature.
When patient is transported by helicopter, the EMS run sheet should be faxed to the receiving trauma center.
86
♦ General Considerations♦ The only procedures that should take precedence to
transport of major trauma patients are:♦ Airway management♦ Stabilization of neck/back or obvious femur and pelvic fractures
on a backboard♦ Exsanguinating hemorrhage control♦ Extrication
♦ Notification of the receiving facility is essential♦ Give Mechanism of Injury, Injuries, Vital signs, Treatment
(MIVT), GCS with components, and ETA.
87
♦ Evaluate patient condition:♦ Level of Consciousness♦ Pupillary size and reaction♦ Glasgow Coma Scale
♦ Ventilate at 20 BPM (10 BPM faster than normal) when the signs of cerebral herniation are present:♦ Blown or unequal pupil(s)♦ Bradycardia♦ Posturing♦ Decreased mental status
♦ Ventilate to maintain EtCO2 readings of 30 mmHg
88
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
89
< 2 Years Old Adult & Peds >2 y/o
Eyes
Spontaneously 4 Spontaneously 4
To Voice 3 To Voice 3
To Pain 2 To Pain 2
No Response 1 No Response 1
Verbal
Coos, Babbles 5 Oriented 5
Irritable Cry, Consolable 4 Confused 4
Cries to Pain 3 Inappropriate Words 3
Moans to Pain 2 Grunts, Garbled Speech 2
No Response 1 No Response 1
Motor
Normal Movements 6 Normal Movements 6
Withdraws to Touch 5 Localizes Pain 5
Withdraws to Pain 4 Withdraws to Pain 4
Flexion (Decorticate) 3 Flexion (Decorticate) 3
Extension (Decerebrate) 2 Extension (Decerebrate) 2
No Response 1 No Response 1
Assess pulse, motor and sensation before/after splinting and during transport.
For open fractures, control bleeding with direct pressure and cover with dry, sterile dressing.
Apply appropriate splinting device.
To reduce swelling, elevate extremity and apply ice
Consider Pain Control Protocol
90
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
History – Entrapped or under extreme load for >60 min
1 liter NaCl bolus IV. Then 500 ml/hour IV NaCl, 20 ml/kg IV
Follow pain management protocol
If hypotensive and the patient has been entrapped > 1 hr: Give additional NaCl, 1 Liter IV. Give additional NaCl, 20 ml/kg IV
12 lead EKG
91
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Normal ECG/hemodynamically stable, immediately prior to extrication: Sodium Bicarb 100 mEq IV Sodium Bicarb 1mEq/kg IV
Abnormal ECG/hemodynamically unstable: If after release, there are EKG changes consider Calcium
Chloride Peaked T waves with a QRS > 0.12 seconds. QT ≥0.46 seconds. Loss of P-wave. Sodium Bicarb 100 mEq IV Sodium Bicarb 1mEq/kg IV
92
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Consider Midazolam 2 mg IV 0.1 mg/kg IV, max dose of 2 mg
Special considerations: Potential for multiple system trauma Potential for hypo/hyperthermia. Hyperkalemia from crushed syndrome can produce ECG
changes, and may also cause a bizarre wide complex rhythm.
93
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Move patient to warm environment
Remove all wet clothing
Dry the patient
Cover with blankets.
Avoid any rough movement that may cause cardiac dysrhythmias.
It may be beneficial to immobilize the patient on the backboard.
Assess neurological status.
94
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
It may be necessary to assess pulse and respirations for up to 30-45 seconds to confirm arrest.
Consider possibility of other medical conditions (i.e. overdose, hypoglycemia, CVA)
Transport to a trauma center.
Use the least invasive means possible to secure airway. Intubate if necessary, as gently as possible.
Complete the following steps during transport: Establish vascular access and consider warmed fluids Treat bradycardia only if it is profound Do not initiate CPR if there is a pulse, no matter how slow
95
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If patient arrests:
CPR continuously
If severe hypothermia (<86F (30C)) is strongly suspected, limit defibrillation attempts to 1 and withhold medications/defibrillations except on orders from Medical Control
If body temperature is >86F (30C), follow normal arrest protocols
Intubate and oxygenate the patient with warmed and humidified 100% O2
Continue resuscitative efforts while in transit, even if there is no response
96
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Protect injured area(s)
Remove clothing and jewelry from injured parts.
Do not attempt to thaw injured part with local heat.
Maintain core temperature.
Severe frostbite injuries should be transported to a burn center.
Consider vascular access with {warmed} fluids
Consider Pain Control Protocol
97
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Keep patient warm.
Superficial and partial thickness burns <10% may have wet dressings applied.
Cover burn areas with clean, dry sheets or dressings after cooling burns <10% first
Remove clothing and jewelry from injured parts
CO Oximeter (if available) 5-12 PaCO in a non-smoker needs monitoring Over 12 PaCO is significant
98
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Do not remove items which have adhered to the skin
Radiation burns:
Treat as thermal burns Except when burn is contaminated with radioactive source Then treat as Hazmat situation
Consider contacting Haz-Mat team for assistance in contamination cases
99
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Inhalation Burns: Provide O2 {humidified with Saline} If no humidifier is available, administer a Saline Nebulizer, 3 ml. Repeat PRN
Provide early endotracheal intubation as indicated
Sodium Thiosulfate, 12.5 gm (50 ml) if Cyanide is possible >25 kg - 12.5 gm (50 ml) slow IVP <25 kg – 1.65 ml/kg (412.5 mg/kg) (50 ml) slow IVP
Or Hydroxocobalamin (Cyanokit), 5grams, via slow IV infusion Pedi dose is 70 mg/kg IV, max dose 5000 mg May repeat Pedi dose 35 mg/kg IV, max dose 2500 mg
100
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Antidotes are no longer in Drug Bags. They are in multiple caches in the region. Contact 937-333-USAR (8727) Call if: Reported victim trapped, known cyanide event, or Mayday scenario
No MCP orders needed if patient in Cardiac Arrest
Hydroxocabalamin considerations Do not administer both Cyanokit and other antidotes Administer in separate IV line when possible
Control seizure activity with Diazepam or Midazolam
101
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Consider Hyperbaric Treatment for the following:
Underlying cardiovascular problems
Symptoms such as chest pain or shortness of breath
> 60 years of age
Obvious neurological symptoms, such as any interval of unconsciousness, loss of time, inability to perform simple motor tasks, or loss of memory
Smoke inhalation victims
Pregnancy
102
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Provide high flow O2 to all suspected CO poisonings
SpO2 readings will be falsely high
CO Oximeter (if available) 5-12 PaCO in a non-smoker needs monitoring Over 12 PaCO is significant
103
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Consider Hyperbaric Treatment for the following:
Underlying cardiovascular problems
Symptoms such as chest pain or shortness of breath
> 60 years of age
Obvious neurological symptoms, such as any interval of unconsciousness, loss of time, inability to perform simple motor tasks, or loss of memory
Smoke inhalation victims
Pregnancy
104
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Move patient to a cool environment.
Strip the patient of clothing, cool the patient, and apply water to the skin.
Apply cold packs to underarms and groin area.
If neither vomiting nor extremely nauseous provide oral fluids.
Hyperthermia patients should be transported to a trauma center.
If hypotensive or mental status changes are present administer NS, 500 ml bolus. May repeat x1 NS 20 ml/kg IV
105
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Geriatric, pediatric, diabetic and spinal injury patients are most likely to suffer heat-related illnesses.
The following medications increase risks; cardiac, diuretics, cold medications and psychiatric.
Be prepared for seizures.
Consider other medical conditions (i.e. overdose, hypoglycemia, CVA).
Transport to a Trauma Center
106
If possible, contact lenses should be removed.
Chemical Burns:
Irrigate immediately with NS or water for a minimum of 20 minutes
Determine chemical involved. Bring MSDS, if available
107
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Major Eye Trauma:
Cover injured eye.
Do not use a pressure or absorbent dressing on or near any eye that may have ruptured, or have any penetrating trauma
Cover both eyes to limit movement
Transport with head elevated at least 30%
108
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Prior to irrigation with NS or for significant eye pain:
Tetracaine - 2 drops in affected eye(s).
Do not irrigate or use Tetracaine if penetrating trauma
Morgan Lens or nasal cannula and IV tubing for irrigation
Irrigate for at least 30 mins or until Med Control is contacted
109
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
CPAP or Bi-PAP (should be primary therapy)
Consider need for possible early ET Tube
If patient has SBP >100: Nitroglycerin 0.4 mg SL up to X 3 every 5 minutes. Maintain SBP >100.
110
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Assist with Albuterol MDI
Consider Albuterol 2.5 mg and Ipratropium 0.5 mg, nebulized with O2 @ 8-12 LPM.
May repeat Albuterol 2.5 mg nebulized X 2.
After intubation, avoid Auto-PEEP by ventilating at: 8-10 bpm 10-15 bpm
If patient arrests, strongly consider bilateral needle decompression for relief of tension pneumothorax.
111
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
For asthmatics in severe distress: If >30 kg:
Adult EpiPen and EpiPen Jr. or Epinephrine (1:1,000) 0.5 mg IM May repeat Epinephrine (1:1,000) 0.5 mg/kg IM
If <30 kg: EpiPen Jr. or Epinephrine (1:1,000) 0.01 mg/kg IM (max 0.5 mg) May repeat Epinephrine (1:1,000) 0.01 mg/kg IM (max 0.5 mg)
COPD: CPAP or Bi-PAP
112
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If severe allergic reaction, assist patient in with Epi-Pen if patient has his/her medication.
If patient doesn’t have their Epi-pen, access drug bag after MCP If >30 kg: Adult EpiPen and EpiPen Jr.
or Epinephrine (1:1,000) 0.5 mg IM May repeat Epinephrine (1:1,000) 0.5 mg IM
If <30 kg: EpiPen Jr. or Epinephrine (1:1,000) 0.01 mg/kg IM (max 0.5 mg) May repeat Epinephrine (1:1,000) 0.01 mg/kg IM (max 0.5 mg)
If patient develops wheezing, assist them with taking their prescribed Albuterol metered dose inhaler The EMT may NOT administer Albuterol to a patient that is not currently
prescribed Albuterol
113
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If patient deteriorating or unresponsive, consider early intubation, possibly with smaller than normal ET tube. If patient is apneic, intubate
In conscious patient requiring ETT, consider: Lidocaine Jelly to the ET tube Lidocaine, 100 mg IN (1/2 dose per nostril) or via Nebulizer Lidocaine 1.5 mg/kg IN or Nebulizer (max. dose 100 mg)
If patient is wheezing: Albuterol, 2.5 mg and Ipratropium, 0.5 mg in nebulizer with O2 flowing at 8-12 LPM, may repeat Albuterol x2
114
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If patient is intubated, Albuterol, 2.5 mg by nebulizer into the endotracheal tube. If Ipratropium not given before intubation, add to first Albuterol.
If hypotensive, NS, bolus to maintain SBP >100 If hypotensive, NS IV 20 ml/kg to maintain adequate perfusion
Diphenhydramine 50 mg, IM/IV Diphenhydramine 1 mg/kg IM/IV (max dose 50 mg)
If patient remains hypotensive after a fluid bolus, Epinephrine (1:10,000) 0.5 mg, slow IV.
For patients unresponsive to Epinephrine, Glucagon 1 mg, IV/IM.
115
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
If glucose <60, or suspicion of hypoglycemia Oral Glucose
D10, 250 ml IV at a wide open rate D10, 5 ml/kg IVP maximum single dose of 250 ml
Repeat D10 250 ml. if blood sugar remains under 60
Document amount of D10 in milliliters
If no vascular access, Glucagon, 1 mg IM.
Maintain normothermia
116
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Naloxone, 2 mg IN or slow IVP or or up to 4 mg IM (Titrate to effect)
<20 kg - 0.1 mg/kg slow IN/IV/IM/IO/ETT (Max. 2 mg) 1 mg IN (may repeat once)
>20 kg - 2 mg slow IN/IV/IM/IO/ETT (may repeat once)
Slow IV is the preferred method, but may be given IN first
If IN, if resp. don’t improve after 3 min., administer IV dose
Titrate to effect or adequate respirations
After Naloxone administration, transport is encouraged
117
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
CLINICAL PEARLS
Patients 18 y/o may be permitted to refuse if: Repeat physical exam and V/S, patient must be A&O X 3 Warn the patient that there is a significant risk of going back
into hypoglycemia, especially if on oral hypoglycemics Advise the patient to eat something substantial immediately Advise the patient to contact their family physician as soon as
possible to minimize future episodes Advise the patient to stay with someone Follow normal patient refusal procedures Continue D10 infusion (minimum of 250 ml) during the refusal
process Ensure that the EMS Coordinator of the hospital that replaces
your Drug Bag and Supplies receives a copy of the run sheet for his/her records.
118
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
BVM and nasopharyngeal airway during seizure as needed.
Maintain normothermia.
If glucose <60, or there is strong suspicion of hypoglycemia despite glucometer readings: Administer Oral Glucose (if able to swallow)
D10, 250 ml IV wide open D10, 5 ml/kg IVP maximum single dose of 250 ml
D10 may be repeated in 10 minutes with BGL <60
If no vascular access, Glucagon, 1 mg IM In a diabetic patient with an insulin pump and a glucose <60, disconnect
patient from the pump or “suspend” the device if you are familiar with its operation.
119
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If seizing, Diazepam, 5 mg slow IV/IO or Midazolam, 10 mg, IN (5 mg in each nostril) Midazolam may also be given 2 mg slow IV/IO or Midazolam may also be given 4 mg IM IM Midazolam is a no longer last resort
Repeat Diazepam, 5 mg slow IV/IO or Midazolam, 5 mg, IN, or Midazolam 2 mg IV/IO , or Midazolam 4 mg IM
If no vascular access or MAD, Diazepam, 10 mg PR
120
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If seizing, Diazepam, 0.2 mg/kg slow IV (Max dose 5 mg) or Midazolam, 0.2 mg/kg, IN (Max dose 4 mg) Midazolam, 0.1 mg/kg slow IVP (Max dose 2 mg) Midazolam, 0.2 mg/kg IM (Max dose 4 mg)
Repeat Diazepam, 0.2 mg/kg slow IV or Repeat with half dose of administered Midazolam Do NOT repeat if Midazolam was administered IM
If no vascular access or MAD, Diazepam, 0.5 mg/kg PR. (Max. dose 10 mg)
121
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
When obtaining history be sure to include the following:
Description of seizures, areas of body involved, and duration
Other known medical history; i.e. head injury, diabetes, drugs, alcohol, stroke, heart disease.
122
Patient will be on a drug therapy of a Phenothiazine (Phenergan, Thorazine, etc.) Butyrophenone (Haldol, Droperidol, etc.)
Signs/Symptoms Acute muscular spasms Motor restlessness Mental status unaffected Vitals normal
Initiate IV of Normal Saline
123
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If glucose is <60, or suspicion of hypoglycemia D10, 250 ml IV wide open D10, 5 ml/kg IVP maximum single dose of 250 ml
D10 may be repeated in 10 minutes with BGL <60
If no vascular access, Glucagon, 1 mg IM
Consider Diphenhydramine 50 mg IV or IM Diphenhydramine 1 mg/kg IV or IM (Max dose 50 mg)
124
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Contact MCP for suspected poisonings, Poison Control is for Public
Manage Airway
Gather appropriate history
Thorough search for source substance
Glucometer
Ingested Poison Transport container and / or remaining medication to the hospital
with the patient.
125
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Consider patient restraint before Naloxone
If patient has a pulse, Naloxone before ETT
Naloxone, 2 mg IN or slow IVP or or up to 4 mg IM (Titrate to effect)
<20 kg - 0.1 mg/kg slow IN/IV/IM/IO/ETT (Max. 2 mg), 1 mg IN (may repeat once)
>20 kg - 2 mg slow IN/IV/IM/IO/ETT (may repeat once)
Slow IV is the preferred method, but may be given IN first
If IN, if resp. don’t improve after 3 min., administer IV dose
All levels except EMR may repeat Narcan dosing
126
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Nitroglycerine 0.4 mg SL, if SBP >100
Diazepam, 5 mg slow IV/IO, if SBP >100 or Midazolam, 10 mg, IN (5 mg in each nostril) Midazolam may also be given 2 mg slow IV or Midazolam may also be given 4 mg IM IM Midazolam is a last resort
Repeat Diazepam, 5 mg slow IV/IO or Midazolam, 5 mg, IN, or Midazolam 2 mg IV/IO , or Midazolam 4 mg IM
127
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Sodium Bicarbonate, 1 mEq/kg, IV.
Repeat Sodium Bicarbonate 0.5 mEq/kg, IV for persistent QRS prolongation.
Note: Overdose with tricyclic antidepressant medications may be evidenced by bradycardia, tachycardia, hypotension and prolongation of the QRS complex. Risk of rapid deterioration or sudden onset V. Fib is high.
128
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Calcium Channel Blocker Overdose
Calcium Chloride, 1 gm IV Calcium Chloride, 0.2 ml/kg (20mg/kg) slow IVP
Max. dose 500 mg Glucagon, 1 mg IM or IV
Beta Blocker Overdose
Glucagon 1 mg, IM or IV.
129
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Ondansetron (Zofran), 4 mg IV for nausea or vomiting
If no IV, 4 mg dissolving tablet PO may be administered Or administer the IV dose PO AEMT will administer 4 mg Zofran PO
Ondansetron (Zofran), 0.1 mg IV (Max dose 4 mg) AEMT will administer 4 mg PO if patient is > 12 y/o and > 40 kg
For pain relief, consider Pain Control Protocol AEMT requires MCP for pediatric pain relief
130
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
General Considerations
Directly after delivery, dry, warm, maintain airway. Place in the sniffing position (1” towel under shoulders). Suction infant until all secretions are clear of airway.
If meconium-stained and vigorous, with strong respirations, good muscle tone, and heart rate greater than 100 BPM, suction the mouth and nose in the same way as for infants with clear fluid.
If meconium-stained and depressed, with poor respiratory effort, decreased muscle tone, or heart rate less than 100 BPM, Suction the trachea before taking other resuscitative steps.
Lower airway suction is achieved by intubating the infant and suctioning directly through the ET Tube, re-intubated with a new tube each time
131
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
General Considerations
Mechanical suction may be used on infants, but only if the suction pressure does not exceed 100 mmHg or 136 cm H2O. Bulb suctioning is preferred.
If drying and suctioning has not provided enough tactile stimulation, try flicking the infant’s feet and/or rubbing the infant’s back. If this stimulation does not improve the infant’s breathing, then BVM may be necessary.
Avoid direct application of cool oxygen to infant’s facial area as may cause respiratory depression
Use length/weight based resuscitation tape
132
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Assess the airway/breathing while drying and position head down.
If HR <100, ventilation is necessary to increase HR Ventilate at 40-60/min Ventilation is also indicated for apnea and persistent central
cyanosis.
Despite adequate ventilation, if HR <60 begin CPR Compress at 120/bpm. (ratio of 3:1) Epinephrine 1:10,000, 0.01 mg/kg IV/IO or 1:1,000 0.1 mg/kg ETT. If no response, repeat Epinephrine 1:10,000 every 3-5 min.
133
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
If hypovolemic, NS, 10 ml/kg over 5-10 minutes.
Consider Naloxone, 0.1 mg/kg, IV/IO/IM every 3 minutes until respirations improve.
Dextrose 2 ml/kg D10 if BS <40 mg/dl.
134
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Consider staging until police have assured scene safety
Have patient searched for weapons
Obtain previous mental health history: Suicidal or violent history Previous psychiatric hospitalization, when and where Location that patient receives mental health care Medications Recreational drugs/alcohol – amount, names
135
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Do not judge, just treat.
Transport all patients who are not making rational decisions and who are a threat to themselves or others for medical evaluation
Threat of suicide, overdose of medication, drugs or alcohol and/or threats to the health and well being of others are not considered rational.
136
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Determine patient incompetence
Consider medical causes for patient’s condition
Explain the need for restraint to the patient
Recheck a restrained patient’s ability to breathe often
Have the ability to remove/cut restraints if the patient vomits or develops respiratory distress
137
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Document the restraints used and justification for the restraints thoroughly
Do not transport restrained patients in a prone position with the hands and feet behind the back or sandwiched between backboards or other items.
Consider Ketamine 500 mg IM (repeat in 10 min.) 2 separate doses of 250 mg in large muscles (anterolateral thigh) Or 100 mg slow IVP (repeat in 5 min.)
Consider Midazolam, 10 mg IN (5 mg in each nostril) (repeat in 5 min.) or Midazolam 2 mg IV (repeat in 5 min.) or Midazolam 4 mg IM (repeat in 10 min.)
All sedatives may be repeated for combative patients
138
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Continued…
Pediatric Sedation
Consider Ketamine 1 mg/kg slow IV (Max dose 100 mg) Ketamine 5 mg/kg IM (Max dose 500 mg) Patient must be 8 y/o or greater
Consider Midazolam, 0.2 mg/kg IN/IM (Max dose 4 mg) or Midazolam 0.1 mg/kg slow IV (Max dose 2 mg)
Call MCP for all repeat sedative doses
139
= EMR
= EMT
= AEMT
= Paramedic
Italics = MCP
Methodology of Instruction
Stipulations
2015 Changes
The 2015 Protocol
Questions & Answers
140
