Rapid City (Pennington Co) (SD) Protocols (2008)

8/7/2019 Rapid City (Pennington Co) (SD) Protocols (2008)

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RAPID CIT Y

PENNI NGTON COUNTY

ADVA NCED LIFE SUPPORTPROTOCOLS

These protocols are effective as of January 2007


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Pre-hospital Emergency Medical Services in the Rapid City metro andPennington County area have evolved dramatically in the past decade.

Since the first major revision of these Advanced Life Support (Paramedic)Protocols, what were once a few pages in a notebook have mushroomed into aformidable volume. The current revision of these protocols is a compilation ofinput from multiple sources local, national and international.

Our practice of pre-hospital emergency medicine is second-to-none. In anincreasingly sophisticated and technologybased environment, a special thanksgoes to those dedicated individuals who take the knowledge condensed herein andprovide a critical service for our community. It should always be remembered thatprotocols define process, people provide care.

As always, these protocols are an evolving project. We invite yourcomments and suggestions.

Sincerely,John M. Rud, M.D., F.A.C.E.P


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Rapid City and Pennington CountyPre-hospital Advanced Life Support Protocols

Rapid City Department of Fire and Emergency Services Paramedics

RECEIPT OF PROTOCOL ACKNOWLEDGEMENT

This is to certify that the undersigned has received the Rapid City and PenningtonCounty Pre-hospital Advanced Life Support Protocols, and accepts the responsibility forknowing and practicing in accordance with these protocols.

Name (please print) Date

Signature


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Rapid City and Pennington CountyPre-hospital Advanced Life Support Protocols

Rapid City Department of Fire and Emergency Services Paramedics

INTRODUCTION

This protocol manual represents the foundation for the clinical standards of the

Pre-hospital Emergency Medical Services system in Rapid City and Pennington County.The process which resulted in the construction of this set of protocols will remain inplace and these protocols will continue to be edited and revised to reflect the dynamicrole of Pre-hospital Emergency Medical Services within the medical care community.

Section 1. contains the Patient Assessment Protocols.

Section 2. contains the Medical Treatment Protocols.

Section 3. contains the Trauma Treatment Protocols.

Section 4.contains the Environmental Injury Treatment Protocols.

The Treatment Protocols are divided into adult and pediatric sections, each with twoparts:

I. Level I. treatment is an intervention that can performed without contactingmedical control. (Designated by Roman numeral I.)

II. Level II. treatment is an intervention that requires contact with MedicalControl prior to performing. (Designated by red Roman numeral II.)

Section 5.

contains the Procedure Protocols. The Procedure protocols whereapplicable, include a description of Indications, Precautions, Techniques, andComplications for procedures approved for use in the Rapid City/Pennington CountyEMS System. Procedure Protocols will in some instances include Level I.and Level II.interventions.

Section 6. contains the Operational Protocols required for effective clinical and tacticalEMS operations in the Rapid City/Pennington County EMS system.

Section 7. contains Drug Summaries. The Drug Summaries include a description ofActions, Indications, Contraindications, Side Effects, Dosages (adult and pediatric ifapplicable) and available forms of those drugs approved for use in the RapidCity/Pennington County EMS System.

Section 8. contains a full list of tables and illustrations.


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INDEXADVANCED LIFE SUPPORT PROTOCOLS

Page

Definitions .................................................................................................................... 1-1

1.

Patient AssessmentAssessment-Trauma Patient, Primary Survey................................................... 1-3Assessment-Trauma Patient, Secondary Survey.............................................. 1-5Assessment-Medical Patient............................................................................. 1-8Assessment-Pediatric Patient ........................................................................... 1-9Assessment-Neurologic .................................................................................. 1-11Patient History................................................................................................. 1-14

2. Treatment Protocols - MedicalProtocol 2.1: General Supportive Care............................................................ 2-1Protocol 2.2: Abdominal Pain .......................................................................... 2-6

ACLS core pro toc o lsProtocol 2.3: Asystole.................................................................................... 2-7Protocol 2.4: Bradycardia ............................................................................ 2-10Protocol 2.5: Narrow-Complex Tachycardia ................................................ 2-12Protocol 2.6: Neonatal Resuscitation .......................................................... 2-15Protocol 2.7: Premature Ventricular Ectopy................................................. 2-17Protocol 2.8: Pulseless Electrical Activity, (PEA) ........................................ 2-19Protocol 2.9: Ventricular Fibrillation / Pulseless Ventricular Tachycardia .... 2-22Protocol 2.10: Wide-Complex Tachycardia with Pulse .................................. 2-25

Protocol 2.11: Airway Obstruction ................................................................... 2-28

Protocol 2.12: Allergic Reaction / Anaphylaxis ................................................ 2-30Protocol 2.13: Asthma..................................................................................... 2-32Protocol 2.14: Behavioral / Psychiatric ............................................................ 2-33Protocol 2.15: Cardiogenic Shock ................................................................... 2-35Protocol 2.16: Chest Pain................................................................................ 2-36Protocol 2.17: Coma / Altered Mental Status .................................................. 2-38Protocol 2.18: COPD....................................................................................... 2-40Protocol 2.19: Diabetic Emergencies .............................................................. 2-42Protocol 2.20: Drug Overdose / Ingestion / Poisoning..................................... 2-44Protocol 2.21: Hypertensive Emergencies ...................................................... 2-49Protocol 2.22: OB / GYN ................................................................................. 2-51

Protocol 2.23: Pulmonary Edema.................................................................... 2-55Protocol 2.24: Seizures and Status Epilepticus............................................... 2-56Protocol 2.25: Sudden Infant Death Syndrome (SIDS) ................................... 2-58Protocol 2.26: Syncopal Episode..................................................................... 2-59


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INDEX (CONT.)ADVANCED LIFE SUPPORT PROTOCOLS

Page3. Treatment Protocols - Trauma

Protocol 3.1: Trauma and Hypovolemic Supportive Care................................. 3-1Protocol 3.2: Abdominal / Pelvic Trauma ......................................................... 3-6Protocol 3.3: Amputation .................................................................................. 3-8Protocol 3.4: Burns......................................................................................... 3-10Protocol 3.5: Chest Trauma ........................................................................... 3-17Protocol 3.6: Extremity Injuries....................................................................... 3-20Protocol 3.7: Eye Injuries ............................................................................... 3-22Protocol 3.8: Head Trauma ............................................................................ 3-24Protocol 3.9: Spinal Trauma........................................................................... 3-27Protocol 3.10:Trauma Cardiac Arrest.............................................................. 3-29

4. Treatment Protocols Environmental InjuryProtocol 4.1: Bites and Stings .......................................................................... 4-1Protocol 4.2: Drowning / Near Drowning .......................................................... 4-3Protocol 4.3: Hyperthermia............................................................................... 4-6Protocol 4.4: Hypothermia and Frostbite .......................................................... 4-8

5. Procedure ProtocolsProtocol 5.1: Airway Management: General Principles ................................... 5-1Protocol 5.2: Airway Management: Assisting Ventilation................................. 5-4Protocol 5.3: Airway Management: Clearing and Suctioning the Airway ......... 5-6Protocol 5.4: Airway Management: Obstructed Airway ................................... 5-9Protocol 5.5: Airway Management: Opening the Airway ............................... 5-12Protocol 5.6: Advanced Airway Management: Combitube ............................ 5-15Protocol 5.7: Advanced Airway Management: Orotracheal Intubation .......... 5-19Protocol 5.8: Advanced Airway Management: Nasotracheal Intubation ........ 5-24Protocol 5.9: Advanced Airway Management: Rapid-Sequence Induction.... 5-28Protocol 5.10: Advanced Airway Management: Needle Cricothyrotomy ......... 5-33Protocol 5.11: Advanced Airway Management: Surgical Cricothyrotomy........ 5-37Protocol 5.12: CPAP ....................................................................................... 5-41Protocol 5.13: Defibrillation ............................................................................. 5-44Protocol 5.14: Endotracheal Drug Administration............................................ 5-47Protocol 5.15: External (Transcutaneous) Cardiac Pacing.............................. 5-49Protocol 5.16: Glucose Level Determination ................................................... 5-53Protocol 5.17: Intraosseous Infusion (Jamshidi & EZ-IO)................................ 5-56Protocol 5.18: Medication Administration ........................................................ 5-64Protocol 5.19: Nebulized Bronchodilators ....................................................... 5-68Protocol 5.20: Pain Management .................................................................... 5-70Protocol 5.21: Peripheral IV Line Insertion...................................................... 5-72Protocol 5.22: Restraint (Physical and Chemical) ........................................... 5-75Protocol 5.23: Saline Lock Insertion................................................................ 5-79


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Page5. Procedure Protocols (Cont.)

Protocol 5.24: Spinal Immobilization ............................................................... 5-80Protocol 5.25: Splinting, Extremity................................................................... 5-84Protocol 5.26: Stroke (CVA) Stroke Alert ...................................................... 5-87Protocol 5.27: Tension Pneumothorax Decompression .................................. 5-89Protocol 5.28: Trauma Alert ............................................................................ 5-93Protocol 5.29: 12 Lead ECG ........................................................................... 5-95

6. Operational ProtocolsProtocol 6.1: Advanced Directives / DNR Orders............................................ 6-1Protocol 6.2: Confidentiality............................................................................. 6-4Protocol 6.3: Controlled Substance Documentation........................................ 6-6Protocol 6.4: Crime Scene Operations.......................................................... 6-13Protocol 6.5: Field Determination of Death.................................................... 6-17Protocol 6.6: Hazardous Materials / WMD Incidents ..................................... 6-21Protocol 6.7: Helicopter Utilization................................................................. 6-67Protocol 6.8: Infectious / Communicable Disease......................................... 6-76Protocol 6.9: Inter-facility Transport (Critical Care) ....................................... 6-83Protocol 6.10: Multiple Casualty Incidents (MCI)............................................. 6-85Protocol 6.11: No-Transport (Refusal, Cancel) ............................................... 6-99Protocol 6.12: Patient Care Report (PCR) Requirements ............................. 6-106Protocol 6.13: Public Inebriate Disposition .................................................... 6-109Protocol 6.14: Radio Reports ........................................................................ 6-112Protocol 6.15: Rules of Engagement............................................................. 6-115

7. Drug SummariesApproved Drug List ...................................................................................................... 7-1Adenocard (Adenosine) ............................................................................................... 7-3Albuterol (Proventil) ..................................................................................................... 7-5Amiodarone (Cordarone) ............................................................................................. 7-7Aspirin (Acetylsalicylic Acid)......................................................................................... 7-9Ativan (Lorazepam).................................................................................................... 7-10Atropine Sulfate (as a cardiac agent)......................................................................... 7-11Atropine Sulfate (as an antidote for poisoning) .......................................................... 7-13Benadryl (Diphenhydramine) ..................................................................................... 7-15Calcium Gluconate..................................................................................................... 7-17Cyanokit ..................................................................................................................... 7-19Dextrose 50% (D50) .................................................................................................. 7-21Dextrose 25% (D25) .................................................................................................. 7-22Dopamine Infusion (Intropin)...................................................................................... 7-23Epinephrine (1:10,000) .............................................................................................. 7-25Epinephrine (1:1000) ................................................................................................. 7-27Etomidate (Amidate) .................................................................................................. 7-29


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8. Tables and Illustrations (Cont.) Page

Illustration 5.A. Combitube Placement...................................................................... 5-16Illustration 5.B. Combitube Anatomy......................................................................... 5-17Illustration 5.C. Combitube Anatomy......................................................................... 5-18Illustration 5.D. Mallampati Classification.................................................................. 5-31Illustration 5.E. Thyromental Distance ...................................................................... 5-32Illustration 5.F. PTLV O2 Delivery Device................................................................ 5-36Illustration 5.G. Laryngeal Anatomy.......................................................................... 5-40Illustration 5.H. Intraosseous Needle Placement ...................................................... 5-59Illustration 5.I. Cook Emergency Pneumothorax Kit................................................ 5-92Illustration 5.J. 12-Lead Precordial Lead Placement................................................ 5-98Table 5.A. ETT Size By Age ..................................................................................... 5-23

Illustration 6.A. RCRH Controlled Drug Administration Record................................. 6-10Illustration 6.B. Ambulance Controlled Substance Log ............................................. 6-11Illustration 6.C. Controlled Substance Usage Log..................................................... 6-12Illustration 6.D. HazMat Zones.................................................................................. 6-66Illustration 6.E. 20-Minute Ground Travel Zone ........................................................ 6-75Illustration 6.F. MCI IC Flowchart.............................................................................. 6-96Illustration 6.G. START Triage.................................................................................. 6-97Illustration 6.H. METTAG Triage Tag........................................................................ 6-98

Table 7.A. Dopamine Drip......................................................................................... 7-70Table 7.B. Epinephrine Drip...................................................................................... 7-70Table 7.C. Lidocaine Drip.......................................................................................... 7-70Table 7.D. Procainamide Drip................................................................................... 7-71Table 7.E. Pediatric Infusions ................................................................................... 7-71Table 7.F. Heparin Drip............................................................................................. 7-72Table 7.G. Nitroglycerin Drip..................................................................................... 7-72


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Rapid City and Pennington County Section 1Pre-hospital Advanced Life Support Protocols Patient Assessment

Rapid City Department of Fire and Emergency Services Paramedics, PAGE 1-1

Definitions

Level I Treatment:

Level I treatment is denoted by a Roman numeralI.

It is defined as anintervention that can be performed under standing orders and does notrequire contact with medical control to perform (within protocol parameters).

Level II Treatment:

Level II treatment is denoted by a red Roman numeral II. It is defined as anintervention that requires contact with medical control to perform.

Clinical Definitions:

It is necessary to make a differentiation between neonatal, infant and adultpatients to select appropriate protocols.A. Neonate:

The difference between neonates and infants, for the purposes of theseprotocols, is based on age. A neonate is in a physiological transition frommechanisms used in utero to those that are used after delivery andseverance of the umbilical cord. Thus, a patient less than six weeks old willbe considered as a neonate.

B. Infant:

Infants have functional differences from older children, which relate to theirdeveloping physiology and their poorly developed intellect. Ability tocommunicate and understand are limited. This is a distinction based on age,not size. A patient less than one (1) year of age will be considered as aninfant.

C. Pediatric and Adult:

The term pediatric is used in these protocols as a collective term, includingneonates, infants, children and adolescents. Any patient less than 18 yearsold is considered pediatric, from a legal standpoint (except emancipated ormarried minor). The legal standpoint must be considered in decisions aboutpatient rights in regard to treatment refusals, choice of hospitals, etc.


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Definitions (cont.)

For medical purposes, differences between neonates, infants and childrenmay appear in protocols such as dysrhythmia and arrest protocols. Without

specific notations, all these groups are treated similarly. Age in these youngpatients may still be an important factor in the history, influencing theprobability for accidental ingestion of poisons or the occurrence of certaintypes of accidents.

A more subtle distinction, from a medical perspective, is made betweenadolescents and adults. Adolescents are nearly equal physiologically toadults, aside from age and size. Most significantly, drug dosages foradults assume a body size between 50 and 200 kg (100 - 400lbs.). Froma medication dosage standpoint, pediatric patients weigh less than 50 kg(100 lbs.).

Reference:

Thomas, CL (Ed.): Tabers Cyclopedic Medical Dictionary, F.A. DavisCo., Philadelphia, 1985. pgs. 43, 839, 1105, 1244


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ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY

Environmental Assessment:

A. Recognize environmental hazards to rescuers, and secure area fortreatment.

B. Recognize hazard to patient, and protect from further injury.

C. Identify number of patients. Initiate a triage system if appropriate.

D. Observe position of patient, mechanism of injury, surroundings.

E. Initiate communications if hospital resources require mobilization; call forbackup if needed.

F. Identify self. ConsiderTRAUMA ALERT.

Primary Survey:

Note initial level of responsiveness (awake, verbal, pain, unresponsive).

A. Airway:

1. Observe the mouth and upper airway for air movement.2. Protect cervical spine from movement in trauma victims. Use

assistant to provide continuous in-line cervical immobilization.3. Look for evidence of upper airway problems such as vomitus,

bleeding, and facial trauma.

B. Breathing:

1. Look for jugular venous distention and tracheal deviation.2. Expose chest and observe chest wall movement.3. Note respiratory rate (qualitative), noise, and effort.4. Look for life-threatening respiratory problems and briefly stabilize:

a. Open or sucking chest wound - Seal.b. Large flail segment - Stabilize.c. Tension pneumothorax: transport rapidly and consider

decompression.

5. Auscultate for crackles (wet sounds), wheezes, or decreasedbreath sounds.

6. Palpate for tenderness, wounds, fractures, crepitus, or unequal riseof chest.


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ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY (cont.)

C. Circulation:

1. Palpate for radial and carotid pulses. Note pulse quality (strong,weak), and general rate (slow, fast, moderate). Where a pulse isable to be palpated can be indicative of an approximate systolic BP.The following are general guidelines, they should not be consideredabsolutes:

a. Radial pulse - systolic BP > 90b. Femoral pulse - systolic BP > 80c. Carotid pulse - systolic BP > 70

2. Check capillary refill time in fingertips: 2 sec is typically normal.3. Check skin color and condition.4. Control hemorrhage by direct pressure with clean dressing to

wound.

D. Responsiveness:

1. Reassess level (awake, responsive to voice or pain, no response).2. Briefly note body position and extremity movement.3. Check movement and sensation in all four extremities prior to

moving patient.


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ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY

Secondary survey is the systematic assessment of the entire patient. Thepurpose of the secondary survey is to uncover problems which are not life-

threatening but which could be injurious or could become life-threatening tothe patient. It should be performed after:

1. Primary survey.2. Stabilization and initial treatment of life-threatening airway,

breathing, or circulatory difficulties.

A. Initial Vital signs.

B. Additional History.

C. Head and Face:

1. Observe for deformities, asymmetry, bleeding.2. Palpate for deformities, tenderness, or crepitus.3. Re-check airway for potential obstruction: dentures, bleeding, loose

or avulsed teeth, vomitus, abnormal tooth position from mandibularfracture, and absent gag reflex.

4. Eyes: pupils (equal or unequal, responsiveness to light), foreignbodies, contact lenses, periorbital ecchymosis (raccoon eyes).

5. Nose: deformity, bleeding, discharge.6. Ears: bleeding, discharge, bruising behind ears. (Battles sign)

D. Neck:

1. Re-check for deformity or tenderness if not already immobilized.2. Observe for penetrating wounds, neck vein distention and use of

neck muscles for respiratory effort. Also note altered voice, andmedical alert tags.

3. Palpate for crepitus, tracheal shift, sub-q air.E. Chest:

1. Observe for wounds, symmetry of chest wall movement2 Have patient take deep breath: observe for pain, symmetry, air

leak from wounds.


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ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont).

3. Re-auscultate for crackles (wet sounds), wheezes, and decreasedor absent breath sounds.

4. Palpate for tenderness, wounds, fractures, crepitus, or un-equalrise of chest.

F. Abdomen:

1. Observe for wounds, bruising, distention.2. Palpate all 4 quadrants for tenderness, rigidity.

G. Pelvis:

1. Palpate and compress lateral pelvic rims and symphysis pubis for

tenderness or instability.

H. Shoulders/Upper Extremities:

1. Observe for angulation, protruding bone ends, symmetry.2. Palpate for tenderness, crepitus.3. Note distal pulses, color, medical alert tags.4. Check sensation.5. Test for weakness if no obvious fracture present (have patient

squeeze your hands).6. If no obvious fracture, gently move arms to check overall function.

I. Lower Extremities:

1. Observe for angulation, protruding bone ends, symmetry.2. Palpate for tenderness, crepitus.3. Note distal pulses, color.4. Check sensation.5. Test for weakness if no obvious fracture present (have patient push

feet against your hands).6. If no obvious fracture, gently move legs to check overall function.

J. *Back:

1. If patient is stable, logroll, observe and palpate for wounds,fractures, tenderness, bruising.

2. Recheck motor and sensory function as appropriate.


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ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont).

* Examination of the back may take place after the primary survey andprior to placing patient on backboard if rapid transport is indicated (see

Trauma and Hypovolemic Supportive Care Protocol).

Special Notes:

A. Be systematic. If you jump from one obvious injury to another, thesubtle injury that is most dangerous to the patient is easily missed.

B. Obtain and record two or more sets of vital signs and neurologicobservations on every patient. A patient cannot be called Stablewithout sets of vital signs giving similar normal readings. Serial vitalsigns are an important parameter of the patients physiologic status.Vital signs should be repeated as necessary to document changes inabnormal findings.

C. Use your judgment. Weigh benefits vs risks to patient in considering aprolonged field evaluation vs rapid transport to medical facility.


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ASSESSMENT - MEDICAL PATIENT

A primary survey is done on all medical and trauma patients. In the awakemedical patient, this may consist only of identifying yourself and noting the

patients responsiveness and general appearance. The formal secondarysurvey may not need to be done on patients with a specific complaint, suchas chest pain. Assessment must be no less thorough, but it may be limitedto the body systems that are pertinent to the presenting problem.

A. Vital signs: quantitative vital signs (including oxygen saturation) usuallyprecede the rest of the exam.

B. Head/Face:

1. Note airway patency, oral swelling, and hydration.2. Eyes: note pupil symmetry, reaction to light, movement.3. Note symmetry of facial movements.

C. Neck:1. Observe for neck vein distention in the upright position and use of

accessory muscles for breathing.

D. Chest:

1. Observe chest wall for symmetry of air movement.2. Auscultate:

a. Breath sounds for symmetry, crackles (wet sounds),wheezing, or evidence of obstruction.

b. Heart for regularity (if irregular, is it intermittently orconsistently irregular?).

E. Abdomen:

1. Observe for distention, bruising2. Palpate for tenderness, rigidity, masses.

F. Extremities:

1. Observe: presence of edema, color of skin.2 Palpate for warmth, tenderness, presence of pulses.

G. See Neurologic Assessment


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ASSESSMENT - PEDIATRIC PATIENT

Children can be examined easily from head to toe, but lack of understandingby the patient, poor cooperation, and fright often limit the ability to assess

completely in the field. Children often cannot verbalize what is botheringthem, so it is important in trauma victims to do a systematic primary andsecondary survey, which covers areas that the patient may not be able to tellyou about. Any observations about spontaneous movements of the patientand areas that the child protects are very important. In the patient with amedical problem, the more limited set of observations listed below shouldpick up potentially serious problems.

A. General:

1. Level of alertness, eye contact, attention to surroundings.

2. Muscle tone: Normal, increased or weak and flaccid.3. Responsiveness to parents, caregivers; is the patient playful orinconsolable?

B. Head:

1. Signs of trauma.2. Fontanelle, if open: abnormal depression or bulging.

C. Face:

1. Pupils: size, symmetry, reaction to light.2. Hydration: brightness of eyes, is child making tears, are the mouth

and lips moist or dry?

D. Neck: note stiffness.

E. Chest:

1. Note presence of stridor, retractions (depressions between ribs oninspiration), grunting, increased respiratory effort, or rapid/overlyslow respiratory rate.

2. Breath sounds: symmetrical, wet, wheezing.3. Heart rate, obvious murmur?

F. Abdomen: distention, rigidity, bruising, tenderness.


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ASSESSMENT - PEDIATRIC PATIENT (cont.)

G. Extremities:

1. Brachial pulse.2. Signs of trauma.3. Muscle tone, symmetry of movement.4. Areas of tenderness, guarding or limited movement.

H. Skin:

1. Skin temperature and color, capillary refill.2. Unusual rashes, i.e., petechia, urticaria.3. Skin turgor.

I. See Neurologic Assessment

TABLE 1.A.

NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP

AGE PULSEbeats/min.(mean)

RESPIRATIONSrate/min.

BLOOD PRESSURESystolic + or - 20

Premature 144 20-38 N/A

Newborn 140 20-38 N/A6 months 130 20-30 80 palp

1 year 130 20-24 90 palp

3 years 100 20-24 95 palp5 years 100 20-24 95 palp8 years 90 12-20 100 palp


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ASSESSMENT - NEUROLOGIC

Management of patients with head injury or neurologic illness depends oncareful assessment of neurologic function. Changes are particularly

important. The first observations of neurologic status in the field provide thebasis for monitoring sequential changes. It is therefore important that thefirst responder accurately observe and record neurologic assessment usingmeasures which will be followed throughout the patients hospital course.

A. Vital Signs: Observe particularly for adequacy of ventilation, also depth,frequency, and regularity of respirations.

B. Level of consciousness: Use Glasgow Come scale.

TABLE 1.B.

GLASGOW COMA SCALE ADULT / CHILD

EYE OPENING:None 1To pain 2To speech 3Spontaneously 4

BEST VERBAL RESPONSE:None 1Garbled sounds 2Inappropriate words 3Disoriented sentences 4Oriented 5

BEST MOTOR RESPONSES:None 1Abnormal extension 2Abnormal flexion 3Withdrawal to pain 4Localizes pain 5Obeys commands 6

Score = Sum of scores in 3 categories: (15 points possible)


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ASSESSMENT - NEUROLOGIC (cont.)

C. Eyes:

1. Direction of gaze.2. Size and reactivity of pupils.

D. Movement: Observe whether all four extremities move equally well.

E. Sensation (if patient awake): Observe for absent, abnormal, or normalsensation at different levels if cord injury is suspected.

Special Notes:

A. The Glasgow Coma Scale (GCS) used above has gained acceptance as

one method of scoring and monitoring patients with head injury. It isreadily learned, has little observer-to-observer variability, and accuratelyreflects cerebral function. Always record specific responses rather than

just the score (sum of observations). Remember that a patient who istotally without response will have score of 3, not 0.

B. Use a flow sheet to follow and identify changes rapidly.

C. Sensory and motor exam must be documented before moving patientwith suspected spinal injury.

D. Note what stimulus is being used when recording responses. Appliednoxious stimuli must be adequate to the task but not excessive. Initialmild stimuli can include light pinch, dull pinprick - if these areunsuccessful at eliciting a pain response, pressure with a dull object tobase of nailbed, stronger pinch (particularly in axilla) may be necessaryto demonstrate the patients best motor response.Note: The sternal rub shall not be used to test pain response.

E. When responses are not symmetrical, use motor response of the bestside for scoring GCS and note asymmetry as part of neurologicevaluation.

F. Use of restraints or intubation of patient will obviously make someobservations less accurate. Be sure to note on chart ifcircumstances do not permit full verbal or motor evaluation.


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ASSESSMENT - NEUROLOGIC (cont.)

Special Notes (cont.):

G. Glasgow Coma Scale of 13 or less-observe closely for deterioration.Glasgow Coma Scale of 8 or less will probably require airwayintervention at some point.

H. In infants and small children, the GCS may be difficult to evaluate.Children who are alert and appropriate should focus their eyes andfollow your actions, respond to parents or caregivers, and use languageand behavior appropriate to their age level. In addition, they shouldhave normal muscle tone and a normal cry. Several observers shouldattempt to elicit a best verbal response, to avoid over orunderestimation of level of consciousness.

TABLE 1.C.

GLASGOW COMA SCALE INFANT / SMALL CHILD

EYE OPENING:None 1To pain 2To speech 3Spontaneously 4

BEST VERBAL RESPONSE:None 1Moans, grunts 2Cries to pain 3Irritable cries 4Coos, babbles 5

BEST MOTOR RESPONSES:None 1Abnormal extension 2

Abnormal flexion 3Withdrawal to pain 4Localizes pain 5Spontaneous movement 6

Score = Sum of scores in 3 categories: (15 points possible)


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PATIENT HISTORY

Medical:

A. Chief complaint:

1. When did it start? How long has it been going on? Is it changing?2. How intense is the problem? Very severe, mild?3. What caused or brought on the condition?4. Does anything make it better or worse?5. For pain: describe the location, type of pain, severity, radiation.6. What caused the patient or family to seek help at this time?7. Has the patient experienced or been treated before for this

problem? When?

B. Associated complaints: Are there any other symptom bothering thepatient at this time?

C. Pertinent past medical history.

D. Allergies.

E. Medications and drugs.

F. Survey of surroundings for evidence of drug abuse, mental function,family, problems.

Trauma:

A. Chief complaints: areas of tenderness, pain.

B. Associated complaints.

C. Mechanism of injury:

1. What were the implements involved-weapons, autos, etc?2. How did the injury happen: cause, precipitating factors?3. What trajectories were involved. Bullets, cars, people?

4. How forceful was the mechanism: speed of vehicles, force of theblow, etc.?


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PATIENT HISTORY (cont.)

Trauma (cont.):

4. With a vehicle: What is the condition of windshield, steering wheel,and vehicle body? Was there significant intrusion into thepassenger compartment? Were the passengers wearingseatbelts? Was the patient ejected from the vehicle? Type:rollover, head-on, rear-end, T-bone?

D. Mental status and pertinent findings since accident according towitnesses or bystanders. Patient getting worse? Better?

E. Treatment since accident: movement of patient by bystanders, etc.Patient ambulatory at scene?

Special Notes:

A. Do not let the gathering of information distract from management of life-threatening problems.

B. Appropriate questioning can provide valuable information whileestablishing authority, competence, and rapport with patient.

C. In medical situations, history is commonly obtained before or duringphysical assessment. In trauma cases it may be simultaneous or

following the primary survey. An assistant is often used for gatheringinformation from family or bystanders.

D. USE BYSTANDERS to confirm information obtained from the patientand to provide facts when the patient cannot. History from the scene isinvaluable.

E. Over-the counter medications (including aspirin and birth control pills)are frequently overlooked by patient and EMS, but may be important toemergency problems.


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Rapid City and Pennington County Section 2Pre-hospital Advanced Life Support Protocols Treatment Protocols - Medical


PROTOCOL 2.1: GENERAL SUPPORTIVE CARE

Note: This protocol provides guidelines for the initial care and packaging ofmedical patients. Because patients with hypovolemia and/or traumatic

complaints may require different treatment and transport priorities, aseparate Trauma and Hypovolemia Supportive Care Protocol has beencreated.

The General Supportive Care Protocol is meant to be the foundation ofcare for all medical patients, and may be the only protocol invoked forany particular patient. If there is a question as to whether a patientrequires a particular intervention, contact with Medical Control is advised.Medical Control contact is not required if only this protocol isimplemented. Contact may be required if other protocols need to beimplemented.

ADULT CARE

I.1. Patient assessment and history-taking. Include charting ofat least twosets of vital signs.

I.2. Airway management:

A. Initial management includes patient positioning and manualmaneuvers to assure a patent airway.

B. Patients with obvious signs and symptoms of hypoxia (e.g.tachypnea, cyanosis, tachycardia, altered mental status,) shouldinitially be treated with 10-15 L/min via non-rebreather mask(Exception: Patients with COPD may initially be started on 2-4L/minvia nasal cannula See 2.18: COPD Protocol) Respiratorysuppression from oxygen administration should be closely monitoredand managed by assisted ventilation.

C. If the patient has continued difficulty with oxygenation and ventilationafter simple airway maneuvers, airway adjuncts and/or advancedairway procedures may be used.

D. Endotracheal tube placement must be verified by three (3)different methods immediately following intubation (see 5.7-9:Advanced Airway Management Protocols). Tube placement mustalso be re-verified after securing tube, after moving the patient, andat any other time of concern or change in the patients condition(including the movement of the patient from the ambulance cot to thehospital bed).


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PROTOCOL 2.1: GENERAL SUPPORTIVE CARE- (cont.)

ADULT CARE-(cont.)

If there is any question regarding the position of the endotrachealtube, the endotracheal tube should be withdrawn and the patient re-intubated.

E. When in the ambulance, the patient on O2 should be connected tothe on-board oxygen supply and the portable O2 tank securelystowed. This is to avoid the possibility of the O2 tank becoming apotentially lethal missile during sudden stops or accidents. Allpatients receiving O2 during transport must continue to receive O2from the vehicle to the ED.

I.3 ECG monitoring should be done in all patients with previous cardiachistory, potential for, or signs of instability. All patients monitored duringtransport shall continue to be monitored during transfer from the vehicleto the receiving ED.

I.4 Venous access:

A. Paramedic discretion should be used in determining which route ofaccess, if any should be established. General guidelines follow.

B. Establish intravenous access with NS or saline lock, and preferably,an 18 gauge, or larger catheter in any patient with abnormal vitalsigns or in whom the possibility of development of instability exists.Examples include patients with hypertension, SOB, or chest pain.

C. Medical patients with systolic BP < 90 mm/Hg associated with signsand symptoms of shock should have an IV of NS established.

D. Cardiac arrests, all significant trauma patients, and diabetics with lowor elevated glucose levels should have a large-bore IV of NSestablished unless contraindicated.

I.5 Follow additional protocols as needed, establishing Medical Control

contact as dictated by protocol. If Medical Control is not needed, contactthe destination facility to give patient report, following the 6.14: RadioReport Protocol.


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PROTOCOL 2.1: GENERAL SUPPORTIVE CARE- (cont.)ADULT CARE- (cont)

I.6 Transport red lights and sirens (Code 3, HOT) if patients condition iscritical. Critical is defined by a medical or traumatic condition requiringimmediate medical intervention by physician and nursing personnelupon arrival at the Emergency Department. Critical may further bedefined as any patient whose deteriorating medical condition cannot becontrolled by the Paramedic. NOTE: The exception to this is the chestpain patient; the alert chest pain patients condition may be worsened bya red lights and siren transport due to the elevated anxiety factor. Theattending Paramedic should weigh risk vs benefit when deciding how totransport these patients. All other patients will be transported non-redlights and sirens (Code 2, COLD).

PEDIATRIC CAREI.1. Patient assessment and history-taking. Will include charting ofat least

two sets of vital signs, including blood pressure.

I.2. Airway Management:

A. Initial management includes patient positioning and manualmaneuvers to assure a patent airway.

B. Patients with signs and symptoms of hypoxia (e.g. tachypnea,cyanosis, tachycardia, altered mental status,) should initially betreated with O2 by non-rebreather mask. Respiratory suppressionfrom oxygen administration should be closely monitored andmanaged by assisted ventilation.

C. If the patient has continued difficulty with oxygenation and ventilationafter simple airway maneuvers, airway adjuncts and advancedairway procedures may be used. Authorized airway access methodsinclude oral and nasal airways and endotracheal intubation.Nasotracheal intubation is not recommended in children of less than

8 years of age because anatomical relationships make it especiallydifficult.

D. Endotracheal tube placement must be verified by three differentmethods immediately following intubation (see 5.7-9: AdvancedAirway Management Protocols). Tube placement must also be


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PROTOCOL 2.1: GENERAL SUPPORTIVE CARE - (cont.)

PEDIATRIC CARE-(cont.)

re-verified after securing tube, after moving the patient, and at anyother time of concern or change in the patients condition (includingthe movement of the patient from the ambulance cot to the hospitalbed). If there is any question regarding the position of theendotracheal tube, the endotracheal tube should be withdrawn andthe patient re-intubated.

E. When in the ambulance, the patient on O2 should be connected tothe on-board oxygen supply and the portable O2 tank securelystowed. This is to avoid the possibility of the O2 tank becoming apotentially lethal missile during sudden stops or accidents. Allpatients receiving O2 during transport must continue to receive O2from the vehicle to the ED.

I.3 ECG monitoring should be done in all patients with previous cardiachistory, potential for, or signs of instability. All patients monitored duringtransport must continue to be monitored during transfer from the vehicleto the receiving ED.

I.4 Venous access:

A. Paramedic discretion should be used in determining whether venousaccess is needed and which route of access is most appropriate.(NOTE: intraosseous infusion is typically (not EZ-IO) a Level IIintervention and requires Medical Control authorization except incases of cardiac arrest.) The need for a prophylactic IV is rare inthe pediatric patient. If there is a question as to the necessity ofestablishing an IV, contact Medical Control.

B. When needed, establish intravenous access with NS TKO or salinelock. In children less than 50 kg, use a 250 ml or 500 ml bag with aBuretrol micro drip and the largest size catheter possible. Average-sized teenage children (weighing more than 50kg) may be treatedthe same as adults in determining type of IV access. If a pediatric

patient requires a significant fluid bolus administration for anyreason, contact with Medical Control is strongly encouraged, thoughnot necessarily before the volume infusion.

I.5. Follow additional protocols as needed, establishing Medical Controlcontact as dictated by protocol. If Medical Control contact is not needed,contact the destination facility to give patient report, following the 6.14:Radio Report Protocol.


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PROTOCOL 2.1: GENERAL SUPPORTIVE CARE - (cont.)


I.6 Transport red lights and sirens (Code 3, HOT) if patients condition iscritical. Critical is defined by a medical or traumatic condition requiringimmediate medical intervention by physician and nursing personnelupon arrival at the Emergency Department. Critical may further bedefined as any patient whose deteriorating medical condition cannot becontrolled by the Paramedic. All other patients will be transported non-red lights and sirens (Code 2, COLD).

Note:Infants of less than six months of age can be obligate nose-breathers,

therefore nasal congestion can present with apparently severerespiratory distress. This may be easily remedied by suctioning ofmucous from the nose with a bulb syringe or suction catheter.

Children often naturally assume a position which maintains their airwayadequately. Attempts to force the patient out of this position, away fromcomforting family members, or to administer O2 may result in agitationwhich may produce further airway compromise. Oxygen may be bettertolerated if administered via blow-by from a mask held by the patient orparent.

Transport of small children without need of cervical/spinal immobilizationmay best be accomplished with the child restrained in a car seat, apediatric restraint device made expressly for the ambulance cot, or lessoptimally, held by the caretaker and both securely restrained to thestretcher or seat in the ambulance. No pediatric patient will betransported without being restrained in some manner. A parent orcaretaker can be allowed to travel with the child unless that personspresence may be detrimental to the childs treatment.

Cardiac dysfunction in children is more likely to respond to effectiveoxygenation and ventilation than fluid administration and medications.Defibrillation alone is rarely successful.


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PROTOCOL 2.2: ABDOMINAL PAINADULT CARE

I.1. General Supportive Care.

I.2. Position of comfort.

I.3. Nothing by mouth.

I.4. If systolic BP < 90 (check for orthostatic changes in vital signs) andsigns of shock:

a) O2, 10-15 L/min, non-rebreather mask.

b) IV NS, 500 cc fluid challenge, consider contact with Medical Controlprior to further fluids being infused. Upper abdomen and lowerchest pain may reflect thoracic pathology such as myocardialinfarction, etc. and massive fluid resuscitation may becontraindicated.

c) Consider second line if fluid resuscitation not contraindicated.

II.1. None.

PEDIATRIC CARE


I.2. Position of Comfort.

I.3. Nothing by mouth.

I.4. If hypotensive (based on age) and signs of shock are present:

a) O2 via non-rebreather mask.

b) IV NS 20 cc/kg initial fluid challenge.

II.1. Contact Medical Control prior to further fluids being infused.


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PROTOCOL 2.3: ASYSTOLE

ADULT CARE

I.1 Identify asystole in two leads.

I.2 If asystole is due to blunt trauma and criteria from 6.5: FieldDetermination of Death Protocol are met, contact Medical Control fortermination of efforts.

I.3 If asystole is due to penetrating trauma, resuscitation will not terminatedin the field unless signs of irreversible death are present (decapitation,significant dependent lividity, rigor mortis, etc.). See 6.5: FieldDetermination of Death Protocol.

I.4 CPR.

I.5. Intubate and large-bore IV, IO NS, TKO

I.6. Epinephrine, 1 mg 1:10,000 solution IV/IO every 3-5 minutes forduration of pulselessness (ET dose 2-2.5 mg if IV/IO access delayed orunavailable).

I.7. Atropine, 1 mg IV/IO every 3-5 minutes to maximum dose of 3 mg. ETdose 2-2.5 mg if IV/IO access delayed or unavailable. Maximum dosealso doubled if ET).

I.8. Glucagon, 1-2 mg IV/IO if patient known to be taking or has beta-blockermedications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.)

I.9. Search for and treat possible reversible cause:

a) HypoxiaSecure airway and ventilate

b) Hyperkalemia (renal failure, dialysis patient, potassium ingestion)Consider Sodium Bicarbonate / Calcium Gluconate

c) HypothermiaLimit ALS, handle gently

d) HyperthermiaMove from heat, resuscitate in cool environment

e) HypovolemiaHistory any suspicions give fluid boluses


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PROTOCOL 2.3: ASYSTOLE- (cont.)

f) AcidosisSecure airway, ventilate, consider Sodium Bicarbonate

g) Tension pneumothoraxChest decompression (needle thoracostomy)

h) Drug overdoseObtain history treat accordingly

I.10. Consider fine V-Fib

II.1. ConsiderSodium Bicarbonate, 1.0 mEq/kg, IV, (hyperkalemia,metabolic acidosis).

II.2. ConsiderCalcium Gluconate 2.3 - 3.7 mEq IV injected over 10-20seconds, repeated at 10 minute intervals if necessary (hyperkalemia).

II.3. Contact Medical Control for possible termination of efforts if steps I.1 toI.9 are completed and patient remains asystolic. (See 6.5: FieldDetermination of Death Protocol).

PEDIATRIC CARE

I.1. Use Broselow Tape!

I.2. Identify asystole in two leads.

I.3. CPR.

I.4. Intubate and IV NS, TKO.

I.5. If peripheral IV access not possible, establish intraosseous line NS, TKO.

I.6. Epinephrine, 0.01 mg/kg, IV/IO 1:10,000 solution every 3-5 minutes forduration of pulselessness. (If IV/IO access delayed or not available, 0.1mg/kg ET 1:1000 solution.

I.7. Check glucose level. If blood glucose < 60 in child or < 40 in newborn

a) > 2 years: D50 at 1 ml/kgb) < 2 years: D25 at 2 ml/kgc) < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS)d) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20

kg, 0.5 mg IM.


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PROTOCOL 2.3: ASYSTOLE- (cont.)

PEDIATRIC CARE- (cont.)



b) Hyperkalemia (renal failure, potassium ingestion)Consider Sodium Bicarbonate



e) HypovolemiaHistory any suspicions give fluid boluses(20 ml/kg NS over30 minutes)




II.1 Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (hyperkalemia,metabolic acidosis)


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PROTOCOL 2.4: BRADYCARDIA

ADULT CARE


I.2 The asymptomatic patient that presents with a bradycardia (< 60 BPM)should have an IV started, but drug therapy should be withheld if thepatient seems to tolerate the rate well. Contact Medical Control if indoubt.

I.3. If systolic BP < 90, PVCs, altered mental status, signs or symptoms ofischemia: Atropine, 0.5 mg IV or ET, repeated every 3-5 min up to 3 mgtotal. (Note: Atropine may not be effective on high degree block / wideQRS Bradycardia. One 0.5 dose may be attempted, but if completely

ineffective or patient in extremis, pacing should become primarytreatment).

1.4. Obtain 12-lead ECG (when it can be done without delaying neededtreatment).

1.5. Strongly consider pacing (see 5.15: External Cardiac Pacing Protocol)if:

a) Patient does not respond to Atropine.b) IV access unsuccessful.c) Symptoms so severe that waiting for a maximal response to

Atropine would be detrimental.

II.1. ConsiderDopamine infusion 2-10 mcg/kg/min. (See Drug Summaries -Infusion Charts, Page 7-71).

II.2. ConsiderEpinephrine infusion containing 1 mg in 250 ml D5W given at arate of 2-10 mcg, / min. IV (30-150 micro drops/min), titrate to pulse 60.(See Drug Summaries - Infusion Charts, Page 7-71).

PEDIATRIC CARE




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PROTOCOL 2.4: BRADYCARDIA

PEDIATRIC CARE- (cont.)

I.3. Establish airway and assure ventilation - cardiac arrest or significantrhythm disturbance in children is almost always due to respiratoryinsufficiency first.

I.4. Establish IV access and consider a bolus with 20 ml/kg of NS over 30minutes.


a) > 2 years: D50 at 1 ml/kgb) < 2 years: D25 at 2 ml/kg

c) < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS)d) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20kg, 0.5 mg IM.

I.6. If hypotension (age dependent) present, PVCS, altered mental status, orsigns and symptoms of ischemia and poor perfusion:

a) Epinephrine, 0.01 mg/kg IV/IO 1: 10,000 repeated every 3-5minutes at same dose. If no IV or IV delayed and patient intubated:ET 0.1 mg/kg (0.1ml/kg) 1:1000.

b) ConsiderAtropine, 0.02 mg/kg IV/IO; may repeat once. Atropinemay be used first if suspected increased vagal tone or AVblock.

1. 0.1 mg minimum dose2. Maximum single dose 0.5 mg in child; I mg in adolescent3. Maximum total dose 1 mg in child; 2mg in adolescent

II.1 Consider pacing see 5.15: External Cardiac Pacing Protocol.

II.2 ConsiderEpinephrine orDopamine infusions, (See Drug Summaries -Pediatric Infusion Charts, Page 7-72)


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PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA

Note: A narrow QRS is less than .12 milliseconds in duration.

Rate must be > 150; tachycardia is most likely a secondary problemwhen the heart rate is less than 150. Treat hypoxia, hypovolemia, painand other problems first.

The field treatment of this rhythm will depend on what the rhythm is, andwhether the patient is stable or unstable. Unstable is defined as:

A. Systolic BP < 90 mm/Hg ORB. Decreased level of consciousness ORC. Signs and symptoms of pulmonary edema ORD. Severe chest pain and shortness of breath.

ADULT CARE

I.1. General Supportive Care. Record rhythm strip before, during, and afterintervention.

I.2. Obtain 12-lead ECG (when it can be done without delaying neededtreatment).

CONSCIOUS, STABLE:

I.1. Vagal maneuvers.

I.2. If rhythm is Atrial fibrillation (irregular) or Atrial flutter, Adenosine isineffective. Contact Medical Control to discuss treatment options.

I.3. Adenosine, 6 mg rapidIV push followed by 20 ml NS IV flush.

I.4. If rhythm persists 1-2 min after initial dose, repeat Adenosine, 12 mgrapidIV push. Follow all doses immediately with 20 ml NS IV flush.

II.1. Repeat Adenosine,12 mg dose may be considered in 1-2 min. if rhythmpersists.


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PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA (cont.)

ADULT CARE (cont.)

UNSTABLE: (all rhythms)

II.1. Consider sedation with Etomidate, .1 mg/kg orValium, 5 mg IV prior tocardioversion.

Note: Patients with drastically decreased mentation should not receivesedation.

II.2. Synchronized biphasic cardioversion, 30J**




* If rhythm is not Atrial Fibrillation or Atrial flutter, prior to cardioversion,pharmacologic conversion with Adenosine may be attempted at thediscretion of Medical Control.

* In the presence of severe hypotension, pulmonary edema orunconsciousness, administer immediate unsynchronized shocks toavoid delays.

PEDIATRIC CARE

Note: Pediatric SVT rate is generally greater than 230 bpm.

Unstable in the pediatric patient is defined as:

A. Age dependent hypotension (despite oxygenation and ventilation)OR

B. Decreased level of responsiveness ORC. Abnormal skin color ORD. Capillary refill > 2 seconds.

STABLE:

I.1. General Supportive Care if patient is stable.


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PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA (cont.)

PEDIATRIC CARE (cont.)

UNSTABLE:


I.1. Establish IV NS, TKO.

II.1. If peripheral IV access not possible and patient severely obtunded,establish intraosseous line NS, TKO.

II.2. Consider vagal maneuvers if child is old enough, but do not delaypharmacologic therapy or cardioversion if patient is obtunded. Vagal

maneuvers should not be attempted without discussion with MedicalControl.

II.3. If IV access is immediately available, considerAdenosine,0.1 mg/kg IVor IO rapid IV push followed by 10 ml NS IV flush. Second dose ifnecessary and possible may be doubled (0.2 mg/kg). Maximum first dose:6 mg; maximum second dose: 12 mg.

II.5. Consider sedation with Valium, 0.2 mg/kg IV, (not to exceed 10 mg/dose)in preparation for cardioversion, but do not delay cardioversion.

II.3. Synchronized biphasic cardioversion at 0.5 - 1.0 joules/kg.

II.4. Synchronized biphasic cardioversion at 2.0 joules/kg if initial energyineffective.


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PROTOCOL 2.6: NEONATAL RESUSCITATION

Note: The level of resuscitation the neonate will require will be dependent onthe infants clinical presentation. The APGAR score can be used as a

tool to help determine this, but resuscitation of a newborn child shouldnot be delayed to obtain an APGAR score if the infant is in obviousdistress. See APGAR Score Chart, Table 2.A, at the end of this protocoland 2.22: OB / GYN Protocol.

APGAR scoring guidelines:

0 to 3 indicates severe distress

4 to 6 indicates moderate distress

7 to 10 indicates mild or no distress

If the APGAR score at 5 minutes is less than 7, obtain additional scores(if possible) every 5 minutes until the score reaches 7 or more.

The primary enemy of newborns is hypothermia, which can occur withinminutes due to increased evaporative heat loss due to the infants largebody surface area and the presence of amniotic fluid.

I.1. Dry immediately and warm!

I.2. Tactile stimulation, rub with towel.

I.3. Position airway and suction mouth, oropharynx and then nose.

I.4. If normal respiratory rate, HR > 100 and core color pink, providesupportive care only.

I.5. If apnea/gasping respirations, HR < 100 or central cyanosis, administer100% oxygen and assist ventilations with BVM at a rate of 40-60.

I.6. If HR < 60 and no improvement after 30 seconds of BVM assistedventilation, intubate.

I.7. If HR < 60 and no improvement after 30 seconds of BVM assistedventilation, begin chest compressions at a rate of 120/min.

A. Compression/ventilation ratio 3:1.B. One third to one half chest depth.


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PROTOCOL 2.6: NEONATAL RESUSCITATION (cont.)

C. Perform compressions with both thumbs (with hands encircling theback) at mid-sternum.

I.8. If meconium present, perform deep tracheal suctioning through ETT withproper suction adapter.

I.9. Check glucose level, if < 40, administerD10, 5 ml/kg.

II.1. Consider intraosseous IV if infant severely obtunded, but do not delaytransport for IV access; utilize ETT for Epinephrine administration ifneeded and vascular access is difficult.

II.2. ConsiderEpinephrine, 0.01 mg/kg IV/IO/ET (0.1 ml/kg) 1: 10,000

repeated every 3-5 minutes. Use Broselow Tape!

TABLE 2.A.

APGAR Score

APGAR Score

0 Points 1 Point 2 Points1

Minute5

Minutes

Heart Rate Absent 100

Respiratory Effort Absent Slow, irregular Strong cry

Muscle Tone Flaccid Some flexion Active motion

Irritability No response Some Vigorous

Color Blue, pale Blue & pink Fully pink

TOTAL:

* Infants with scores of 7-10 usually require supportive care only.

* A score of 4-6 indicates moderate depression.

* Infants with scores of 3 or less will require aggressive resuscitation.


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PROTOCOL 2.7: PREMATURE VENTRICULAR ECTOPY

Indications:

Treatment of PVCs should be limited to those patients with probablecardiac complaints, e.g. chest pain, syncope, SOB, etc. Patients whohave PVCs and are asymptomatic generally do not require intervention.Use this protocol if the ventricular complexes meet any of these criteriaand the underlying heart rate is greater than 60:

1. With frequency 6/min and symptomatic.

2. Multifocal at any frequency.

3. R on T pattern at any frequency.

4. Coupling (bigeminy or trigeminy) at any frequency (This protocol isfor isolated coupling and bursts (see 2.10: Wide-ComplexTachycardia With Pulse Protocol for rapid sustained patterns ofventricular complexes).

Note: Underlying heart rate shouldbe closely monitored, if PVCs are perfusingand underlying heart rate is very low, suppressing the PVCs may leavethe patient unable to perfuse at all. Ventricular escape beats can sustaina patient temporarily.

Medication dosage should be reduced by 50% if patient age > 70,presence of CHF, shock or liver disease.

If patient is borderline as to whether and how to treat, contact MedicalControl to discuss treatment options.

Cardiac monitor strip recordings must document premature complexesprior to pharmacologic intervention.

ADULT CARE


I.2. Lidocaine, 1mg - 1.5mg/kg IV or ET.

I.3. If PVCs not suppressed with first bolus, Lidocaine, 0.5 - 0.75 mg/kg IV orET, repeated as necessary at 10 minute intervals to suppress ventricularectopy. Total bolus dose not to exceed 3 mg/kg.


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PROTOCOL 2.7: PREMATURE VENTRICULAR ECTOPY (cont.)

ADULT CARE(cont.)

I.4. If PVCs suppressed, Lidocaine infusion at a rate of 2-4 mg/min. (30-60microdrops/min. (See Drug Summaries - Infusion Charts, Page 7-71).

II.1. ConsiderAmiodarone 150 mg over 10 minutes. If Lidocaine ineffective.

PEDIATRIC CARE

I.1. General Supportive Care. Treat ectopy with pharmacologic interventiononly if child is symptomatic.

II.1. Lidocaine, 1 mg/kg IV or ET bolus.

II.2. If PVCs not suppressed with first bolus, Lidocaine, 0.5 mg/kg IV or ET,repeated as necessary at 10 minute intervals to suppress ventricularectopy. Total bolus dose not to exceed 3 mg/kg.

II.3. If PVCs suppressed, Lidocaine infusion containing 300 mg Lidocaine in250 mg D5W given at a rate of 20-50 mcg/kg/min. (1- 2.5microdrops/kg/min. (See Drug Summaries - Pediatric Infusion Charts,Page 7-72).


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PROTOCOL 2.8: PULSELESS ELECTRICAL ACTIVITY, (PEA)

ADULT CARE

I.1. CPR.

I.2. Intubate and large-bore IV or IO NS, TKO (Consider fluid bolus ifhypovolemia suspected).

I.3. Epinephrine, 1 mg 1:10,000 solution IV every 3-5 minutes for duration ofpulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable.

I.4. Atropine, 1 mg IV every 3-5 minutes to maximum dose of 2.5 mg (0.04mg/kg) IFheart rate < 60/min. (ET dose 2-2.5 mg if IV access delayed orunavailable. Maximum dose also doubled if ET).

I.5. Glucagon, 1-2 mg IV/IO if patient known to be taking or has beta-blockermedications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.)



b) Hyperkalemia (renal failure, dialysis patient, potassium ingestion)Consider Sodium Bicarbonate / Calcium Gluconate



e) HypovolemiaHistory any suspicions give fluid boluses





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PROTOCOL 2.8: PULSESLESS ELECTRICAL ACTIVITY, (PEA) (cont.)

ADULT CARE (cont.)

II.1. ConsiderSodium Bicarbonate 1.0 meq/kg, IV. (Hyperkalemia, metabolicacidosis)

II.2. ConsiderCalcium Gluconate 2.3 - 3.7 mEq IV injected over 10-20seconds, repeated at 10 minute intervals if necessary (hyperkalemia).

PEDIATRIC CARE


I.2. CPR.

I.3. Intubate and IV NS, TKO.

I.4. If peripheral IV access not possible, establish intraosseous line NS, TKO.


a) > 2 years: D50 at 1 ml/kgb) < 2 years: D25 at 2 ml/kgc) < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS)d) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20

kg, 0.5 mg IM.

I.6. Epinephrine, 0.01 mg/kg, IV or IO 1:10,000 solution every 3-5 minutes forduration of pulselessness. (If IV access delayed or not available, 0.1mg/kg ET 1:1000 solution.

I.7. Search for and treat possible reversible cause






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PROTOCOL 2.8: PULSESLESS ELECTRICAL ACTIVITY, (PEA) (cont.)





h) Drug overdose

Obtain history treat accordingly

II.1 Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (Hyperkalemia,metabolic acidosis).


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PROTOCOL 2.9: VENTRICULAR FIBRILLATION AND PULSELESSVENTRICULAR TACHYCARDIA:

Note: This protocol assumes refractory V-Fib/pulseless V-Tach, or a

successful conversion to a perfusing rhythm from those rhythms. If atany time, rhythm converts to another pulseless rhythm (PEA, Asystole),continue treatment from that protocol.

If interfacing with 1st responder AED, it is always wise to let 1stresponders continue with AED defibrillation sequences if the situation isprogressing correctly, this allows ALS personnel time to set up for airwayand other procedures. If 1st responder defibrillation is not progressingcorrectly, disconnect AED, hook up manual cardiac monitor-defibrillatorand continue or begin defibrillation sequence.

Chest compressions are very important and interruptions to chestcompressions should be minimized wherever possible. Compressionsshould continue while drugs are being administered and defibrillator ischarging. It is not important whether a drug is administered before orafter a shock. Countershocks should be administered and drugsequences continued as long as VF/VT persists.

ADULT CARE

I.1. Biphasic countershock, 150 J*.

I.2. CPR (5 cycles or minimum of 2 minutes).

I.3. Intubate and large-bore IV, IO NS, TKO whenever possible.

I.4. Epinephrine, 1 mg 1:10,000 solution IV/IO every 3-5 minutes for durationof pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable.

I.5. Continue CPR (5 cycles or minimum of 2 minutes), rhythm check.

I.6. Biphasic countershock 150-200 J*.

I.7. Amiodarone, 300 mg IV/IO, consider repeat dose of 150 mg IV/IO in 3-5minutes.

I.8. Continue CPR (5 cycles or minimum of 2 minutes), rhythm check.

I.9. Biphasic countershock 150-200 J*.

I.10. Glucagon, 1-2 mg IV/IO ifpatient known to be taking or has beta-blockermedications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.)


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PROTOCOL 2.9: VENTRICULAR FIBRILLATION AND PULSELESSVENTRICULAR TACHYCARDIA-(cont.)

PEDIATRIC CARE (cont.):

I.12. ConsiderLidocaine, 1 mg/kg IV or IO (can repeat twice).

I.13. Contact Medical Control at earliest opportunity to discuss treatmentoptions and transport as soon as possible.

I.14. Search for and treat possible reversible cause









I.15. If rhythm converts and then patient re-fibrillates, countershock immediatelyusing the same energy as the last successful shock.

II.1. ConsiderSodium Bicarbonate, 1.0 meq/kg, IV, (Hyperkalemia, metabolicacidosis)

* If countershock restores a perfusing rhythm, treat heart rate, bloodpressure and cardiac rhythm as required by pertinent protocol.


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PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE

Note: A wide QRS is more than .11 milliseconds in duration.

The field treatment of this rhythm will depend on whether the patient isstable or unstable. Unstable is defined as:

A. Systolic BP < 90 mm/Hg ORB. Decreased level of consciousness ORC. Signs and symptoms of pulmonary edema ORD. Severe chest pain and shortness of breath.

ADULT CARE

I.1. General Supportive Care. Record rhythm strip before, during, and afterintervention.

I.2. Obtain 12-lead ECG to verify rhythm (when it can be done withoutdelaying needed treatment).

CONSCIOUS, STABLE

I.1. Amiodarone,150 mg IV over 10 minutes. May repeat once in 10 minutesif needed.

I.2. Consider trial of Adenosine (see Protocol 2.5. Narrow ComplexTachycardia) if rhythm is possibly SVT with aberrancy. If unsure ofrhythm, contact Medical Control and send 12-lead to hospital forinterpretation (do not delay transport).

II.1. ConsiderProcainamide,100 mg IV over 5 min. (20mg/min.). Maximumtotal dose 17 mg/kg. If chemical conversion successful, maintenanceinfusion at 1 to 4 mg/min. (See Drug Summaries - Infusion Charts,Page 7-72).

II.2. If pharmacologic intervention is unsuccessful, contact Medical Control to

discuss treatment options. The conscious, stable patient in V-Tachseldom needs cardioversion in the field, but if transport times will beprolonged, synchronized cardioversion may be attempted at the discretionof Medical Control (see UNSTABLE treatment).

II.3. If at any point the conscious, stable patient begins to deteriorate, preparefor synchronized cardioversion (see UNSTABLE treatment).


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PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE (cont.):

ADULT CARE (cont.):

UNSTABLE:

Note: If patient in extremis and deteriorating rapidly, and contactingMedical Control will be time consuming, do not delay cardioversion!proceed and contact Medical Control at earliest opportunity.

II.1. Consider sedation with Etomidate, .1 mg/kg or Valium 5 mg IV prior tocardioversion.

Note: Patients with drastically decreased mentation should not receivesedation.

II.2. Synchronized biphasic cardioversion, 75 joules*.




II.6. If wide-complex rhythm re-curs, synchronized cardioversion, at levelpreviously successful.

* In the presence of severe hypotension, pulmonary edema orunconsciousness, administer immediate unsynchronized shocks toavoid delays.

PEDIATRIC CARE

Note: A wide QRS in the pediatric patient is generally considered to beanything .08 milliseconds or more in duration.

Unstable in the pediatric patient is defined as:

A. Age dependent hypotension (despite oxygenation and ventilation)OR

B. Decreased level of responsiveness ORC. Abnormal skin color ORD. Capillary refill > 2 seconds.


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PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE (cont.)


STABLE:

I.1. General Supportive Care if patient is stable.


I.3. Establish IV NS, TKO.

I.4. Consider trial of Adenosine (see Protocol 2.5. Narrow ComplexTachycardia) if rhythm is possibly SVT with aberrancy. If unsure ofrhythm, contact Medical Control for consult.

UNSTABLE:

Note: If patient in extremis and deteriorating rapidly, and contactingMedical Control will be time consuming, do not delay cardioversion!proceed and contact Medical Control at earliest opportunity.

II.1. If peripheral IV access not possible and patient severely obtunded,establish intraosseous line NS, TKO.

II.2. Consider sedation with Valium, 0.2 mg/kg IV, (not to exceed 10 mg/dose)in preparation for cardioversion, but do not delay cardioversion ifpatient in extremis.

II.3. Synchronized Cardioversion at 0.5 - 1.0 joules/kg.*

II.4. Synchronized Cardioversion at 2.0 joules/kg* if initial energy ineffective.

II.5. If a second shock (2.0 joules/kg) is unsuccessful or if the tachycardia

recurs quickly, consider Amiodarone 5 mg/kg over 20 minutes before athird shock at 2.0 joules/kg.*

* If delays in synchronization occur and patient is severely obtunded,administer immediate unsynchronized shocks.


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PROTOCOL 2.11: AIRWAY OBSTRUCTION

Indications:

1. All patients who cannot phonate and are suspected of foreign bodyairway obstruction.

2. Suspect patients in cardiac arrest that occurred in a restaurant or duringa meal.

ADULT CARE


I.2. If air exchange is adequate, do not provide specific treatment.

I.3. If air exchange is inadequate and there is a reasonable suspicion offoreign body obstruction, perform Heimlich maneuver to try and relieveobstruction.

I.4. If unable to relieve obstruction with Heimlich maneuver, visualize withlaryngoscope and extract foreign body with McGill forceps.

II.1. If obstruction cannot be relieved by direct laryngoscopy and patientremains unable to ventilate and continues to deteriorate, contact MedicalControl for possible Surgical Cricothyrotomy intervention (see 5.11:

Advanced Airway Management: Surgical Cricothyrotomy Protocol).

PEDIATRIC CARE


I.2. If air exchange is adequate, do not provide specific treatment.

I.3. If air exchange is inadequate and there is a reasonable suspicion offoreign body obstruction, perform age-correct Heimlich maneuver to try

and relieve obstruction.

I.4. If unable to relieve obstruction with Heimlich maneuver, visualize withlaryngoscope and extract foreign body with McGill forceps.


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PROTOCOL 2.11: AIRWAY OBSTRUCTION (cont.)


II.1. If obstruction cannot be relieved by direct laryngoscopy and patientremains unable to ventilate and continues to deteriorate, contact MedicalControl for possible Needle Cricothyrotomy intervention (see 5.10:Advanced Airway Management: Needle Cricothyrotomy Protocol).


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Rapid City (Pennington Co) (SD) Protocols (2008)