VALLE AMBULANCE DISTRICTdrfpd.org/training/videos/Valle SOG 2014.pdfMED20 Glucagon 137 MED21 . Glucose (Instant Oral) 138 . MED22 ; Haldol . 139 ; MED23 . Ibuprofen ; 140 . MED24 Lidocaine

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VALLE AMBULANCE DISTRICT

“We’re Here For Life”

CLINICAL PRACTICE GUIDELINES

VERSION 14.3

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CLINICAL PRACTICE GUIDELINES INTRODUCTORY STATEMENT

These pages represent the hard work and dedication to quality patient care, of all clinicians at Valle Ambulance District. This document will be maintained by the Clinical Practice Department, led by the Chief Medical Officer, at Valle Ambulance District. This document is living and breathing. It will be edited and updated frequently to stay on the cutting edge of pre-hospital medicine. These changes will be driven by our robust Continuous Quality Improvement (CQI) program. These Clinical Practice Guidelines are just that, guidelines. We have moved away from traditional “protocols” in an effort to provide well-rounded patient care. We understand that most patients do not fit into an individual protocol. Therefore, it is our responsibility as professional clinicians, to understand physiology of the human body, understand physiology of disease processes, understand physiology of our treatment options, and then create a plan of care for each individual patient. It is highly likely and expected that most patients will require reference to multiple guidelines. It is because of these high standards that our education and training program has such strict standards. Each clinician should understand his or her licensure level and should use these guidelines only within his or her skill set and licensed scope of practice. If at any time there is a question regarding patient care, a medical control physician should be contacted immediately for consultation.

____________________________ ____________________________ Jesse Barton, EMT-P Justin Duncan, NRP, CCEMT-P

Chief of EMS Chief Medical Officer Valle Ambulance District Valle Ambulance District

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CLINICAL PRACTICE GUIDELINES PHYSICIAN AUTHORIZATION STATEMENT

These operational policies, clinical guidelines, authorized skills and drug formulary have been created by the Clinical Practice Department at Valle Ambulance District, with the authorization of the medical director, as allowed by the State of Missouri.

These operational policies, clinical guidelines, authorized skills and drug formulary will be continuously reviewed and revised based on the Continuous Quality Improvement Process at Valle Ambulance District.

Based on significant recommended changes in drug therapies and / or procedures the medical director may authorize interim protocol changes as deemed appropriate at any time.

All clinicians operating under these guidelines must adhere to education and training standards outlined in this document, in order to practice under the license of the medical director. This is a requirement and not an option.

It should be noted that these Clinical Practice Guidelines (CPG’s) are to be utilized for both on-scene response and inter-facility transports and that each provider should only use CPG’s to the skill level at which they are trained.

I, Shayne, Keddy, DO authorize the use of these clinical practice guidelines, authorized skills and drug formulary within the statutes and laws of the State of Missouri and the scope of practice of each member for use by the Valle Ambulance District along with the following fire departments or districts functioning at Emergency Medical Response Agencies:

DeSoto City Fire Department DeSoto Rural Fire Protection District Hillsboro Fire Protection District

____________________________ Shayne Keddy, DO

Medical Director Valle Ambulance District

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Clinical Practice Guideline Index SECTION ONE – OPERATIONAL POLICIES

CPG NUMBER CPG TITLE PAGE NUMBER

OPS1 Destination Decision 10 OPS2 Medical Director Authority 13 OPS3 Education & Training 14 OPS4 Continuous Quality Improvement 16 OPS5 New Hire Orientation Process 19 OPS6 Controlled Substance 20 OPS7 Vaccine Administration 22 OPS8 Tuberculin Skin Testing 24 OPS9 Infection Control 26 OPS10 Triage 28 OPS11 Incident Rehab 29 OPS12 Air Ambulance Utilization 30 OPS13 Transfer of Care 31 OPS14 Refusal of Care 32 OPS15 Determination of Death 34 OPS16 Discontinuation of Resuscitation 35 OPS17 DNR Orders 36 OPS18 Incident Command System 37 OPS19 Inter-facility Transfers 38 OPS20 Specialty Care Transports 39 OPS21 Clinical Documentation 41 OPS22 RN Functioning as ALS Provider 43 OPS23 Emergency Medical Response Agencies 44

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Clinical Practice Guideline Index SECTION TWO – ADULT TREATMENT GUIDELINES


ATG1 Routine Patient Care 46 ATG2 Airway Management 47 ATG3 Airway Obstruction 48 ATG4 Failed Airway 49 ATG5 Rapid Sequence Intubation 50 ATG6 Post Intubation Management 52 ATG7 Pulmonary Edema 53 ATG8 Bronchospasms 54 ATG9 Chest Pain 55 ATG10 STEMI 56 ATG11 Tachycardic Arrhythmias 57 ATG12 Bradycardic Arrhythmias 58 ATG13 Cardiac Arrest – BLS 59 ATG14 Cardiac Arrest – ACLS 60 ATG15 Post Resuscitative Care 61 ATG16 Shock (Non-Trauma) 62 ATG17 Overdose/Toxic Abnormalities 64 ATG18 General Pain Management 65 ATG19 Procedural Sedation 66 ATG20 Nausea & Vomiting 67 ATG21 Altered Mental Status 68 ATG22 Stroke 69 ATG23 Seizures 70 ATG24 Allergic Reaction/Anaphylaxis 71 ATG25 Abdominal Pain 72 ATG26 Behavioral Emergencies 73 ATG27 Hypertensive Emergencies 74 ATG28 Cold Related Emergencies 75 ATG29 Heat Related Emergencies 76 ATG30 Trauma Criteria 77 ATG31 General Trauma Care 79 ATG32 Traumatic Arrest 80 ATG33 Crush Injuries 81 ATG34 Amputations 82 ATG35 Burns 83 ATG36 Envenomation 85 ATG37 Child Birth 86 ATG38 Pregnancy Complications 87

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Clinical Practice Guideline Index SECTION THREE – PEDIATRIC TREATMENT GUIDELINES


PED1 Routine Patient Care 89 PED2 Airway Management 90 PED3 Airway Obstruction 91 PED4 Failed Airway 92 PED5 Rapid Sequence Intubation 93 PED6 Post Intubation Management 95 PED7 Bronchospasms 96 PED8 Tachycardic Arrhythmias 97 PED9 Bradycardic Arrhythmias 98 PED10 Cardiac Arrest – BLS 99 PED11 Cardiac Arrest – ACLS 100 PED12 Shock (Non-Trauma) 101 PED13 Overdose/Toxic Abnormalities 103 PED14 General Pain Management 104 PED15 Procedural Sedation 105 PED16 Nausea & Vomiting 106 PED17 Seizures 107 PED18 Allergic Reaction/Anaphylaxis 108 PED19 Fever 109 PED20 Altered Mental Status 110 PED21 Abdominal Pain 111 PED22 Behavioral Emergencies 112 PED23 Trauma Criteria 113 PED24 General Trauma Care 114 PED25 Burns 115

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Clinical Practice Guideline Index SECTION FOUR – MEDICATION FORMULARY


MED1 Adenosine 118 MED2 Albuterol 119 MED3 Amiodarone 120 MED4 Aspirin 121 MED5 Atropine 122 MED6 Calcium Chloride 123 MED7 Decadron 124 MED8 Dextrose 125 MED9 D5W 126 MED10 Diazepam (Valium) 127 MED11 Dilaudid 128 MED12 Diltiazem (Cardizem) 129 MED13 Diphenhydramine (Benadryl) 130 MED14 Dopamine 131 MED15 Duo-Neb 132 MED16 Epinephrine 133 MED17 Etomidate 134 MED18 Fentanyl 135 MED19 Furosemide (Lasix) 136 MED20 Glucagon 137 MED21 Glucose (Instant Oral) 138 MED22 Haldol 139 MED23 Ibuprofen 140 MED24 Lidocaine 141 MED25 Lorazipam (Ativan) 142 MED26 Magnesium Sulfate 143 MED27 Methylprednisolone (Solu-Medrol) 144 MED28 Metoprolol (Lopressor) 145 MED29 Midazolam (Versed) 146 MED30 Morphine Sulfate 147 MED31 Naloxone (Narcan) 148 MED32 Nitroglycerine (NTG) 149 MED33 Norepinephrine (Levophed) 150 MED34 Normal Saline 151 MED35 Oxygen 152 MED36 Oxytocin (Pitocin) 153 MED37 Phenergan (Promethazine) 154 MED38 Rocuronium 155 MED39 Sodium Bicarbonate 156 MED40 Sterile Water 157 MED41 Succinylcholine (Anectine) 158 MED42 Thiamine 159 MED43 Tylenol 160 MED44 Vecuronium (Norcuron) 161 MED45 Xopenex 162 MED46 Zofran 163

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Clinical Practice Guideline Index SECTION FIVE – SKILLS FORMULARY


SKL1 Airway: Oxygen Administration 165 SKL2 Airway: Suction 166 SKL3 Airway: CPAP 167 SKL4 Airway: PEEP Valve 168 SKL5 Airway: Nasal Pharyngeal Airway 169 SKL6 Airway: Oral Pharyngeal Airway 170 SKL7 Airway: Nasal Tracheal Intubation 171 SKL8 Airway: Oral Tracheal Intubation 172 SKL9 Airway: King Airway 173 SKL10 Airway: Per-Trach 174 SKL11 Airway: Surgical Cricothyrotomy 175 SKL12 Airway: Gastric Tube 176 SKL13 Diagnostics: Vital Signs 177 SKL14 Diagnostics: Pulse Oximiter (SPO2) 178 SKL15 Diagnostics: Waveform ETCO2 179 SKL16 Diagnostics: Multi-Lead EKG (12, 15, 18) 180 SKL17 Diagnostics: Blood Glucose Assessment 182 SKL18 Diagnostics: Doppler 183 SKL19 Procedure: Mechanical Ventilator Operations 184 SKL20 Procedure: Medication Infusion Pump Operations 185 SKL21 Procedure: IO Access 186 SKL22 Procedure: IV Access 187 SKL23 Procedure: Pre-Existing Catheter Access 188 SKL24 Procedure: Venous Blood Draw 189 SKL25 Procedure: Maintenance of Vascular Access 190 SKL26 Procedure: Cardioversion/Defibrillation 191 SKL27 Procedure: Transcutaneous Pacing 192 SKL28 Procedure: Medication Administration 193 SKL29 Procedure: Needle Thoracentesis 194 SKL30 Procedure: Restraints 195 SKL31 Trauma: Commercial Tourniquet 196 SKL32 Trauma: Spinal Immobilization 197 SKL33 Trauma: Spinal Clearance 198 SKL34 Trauma: Sager Traction Splint 199 SKL35 Trauma: General Splinting 200 SKL36 Trauma: Pelvic Binder 201

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SECTION ONE OPERATIONAL POLICIES

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Valle Ambulance District Clinical Practice Guidelines

Destination Decision Operational Policy

CPG Number OPS1

Date Created 1/1/2010

Date Revised 2/25/2014

Clinicians at Valle Ambulance District should use the following guidelines when deciding on a destination for their patient(s).

1. Patients should be transported to the CLOSEST & MOST APPROPRIATE facility, if at all possible and practical. Serious considerations should be made for patients requiring a SPECIALTY RESOURCE CENTER (IE: trauma center, stroke center, STEMI center). It should be noted that the closest hospital MAY NOT be the most appropriate hospital for the patient.

2. Patients in extremis (in full arrest, impeding arrest, unmanageable airway) WILL BE TRANSPORTED to the closest Emergency Department.

3. Patients who are district residents MAY BE transported to the Emergency Department of their choice, within a 50 mile radius from the district boundary when possible and practical. The need for a SPECIALTY RESOURCE CENTER should be considered.

4. Patients who are non-district residents will be transported to the closest Emergency Department, unless a SPECIALTY RESOURCE CENTER is required.

5. An ABN should be obtained for any transport other than closest facility, unless a SPECIALTY RESOURCE CENTER is required.

TRAUMA PATIENTS • Trauma patients meeting level I or level II trauma criteria, should be transported to a

level I or level II trauma center, when possible and practical. • See Trauma Triage Guideline for further information.

STROKE PATIENTS • Patients meeting stroke criteria should be transported to a designated stroke center. • Preference should be given to level I or II stroke centers when possible and practical. • See Stroke Guideline for further information

STEMI PATIENTS • STEMI patients should be transported to a STEMI receiving center. • Preference should be given to level I or II STEMI centers when possible and practical. • See STEMI Guideline for further information.

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Specialty Resource Centers for Reference

Level One Trauma Centers – ADULT

Mercy Hospital St. Louis

St. Louis University Hospital

Barnes-Jewish Hospital

Level One Trauma Centers – PEDIATRIC

St. Louis Children’s Hospital

Cardinal Glennon Children’s Hospital

Level TWO Trauma Centers – ADULT

St. Anthony’s Medical Center

DePaul Health Center

Burn Center – ADULT

Mercy Hospital St. Louis

Burn Center – PEDIATRIC

St. Louis Children’s Hospital

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Specialty Resource Centers for Reference Continued

Stroke Center Designations

Mercy Hospital Jefferson – Level 3

St. Anthony’s Medical Center – Level 1

St. Claire Hospital – Level 1

Mercy Hospital St. Louis – Level 1

Barnes-Jewish Hospital – Level 1

STEMI Center Designations

Mercy Hospital Jefferson – Level 1

St. Anthony’s Medical Center – Level 1

St. Claire Hospital – Level 1

Mercy Hospital St. Louis – Level 1

Barnes-Jewish Hospital – Level 1

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Medical Director Authority Operational Policy

CPG Number OPS2



• The EMS Medical Director is designated as the final medical authority at Valle Ambulance District. In the absence of the EMS Medical Director, the on-line Emergency Department Physician assumes this authority.

• Any orders provided from the on-line medical control Physician, must come DIRECTLY FROM THE PHYSICIAN. It is not acceptable for the Physician to relay orders through an RN. The lead Paramedic MUST consult directly with a Physician. Any issues should be IMMEDIATELY reported to Chief Medical Officer for corrective action.

• Physicians appearing at the scene of an emergency may, after appropriate identification and with the consent of Medical Direction via radio or telephone communication, assume full medical responsibility for patient care provided that this Physician will accompany the patient to the hospital with the transporting Valle Ambulance.

• If the Physician at the scene will not assume full responsibility for patient care as defined above, Valle Ambulance District clinicians will continue to function and provide care solely under the auspices of the EMS Medical Director or receiving Physician. EMS personnel should diplomatically decline Physician offers to provide services at the scene to avoid compromising patient care.

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Education & Training Operational Policy

CPG Number OPS3



The Clinical Practice Department, led by the Chief Medical Officer at Valle Ambulance District will maintain a training center in accordance to state regulatory standards. In addition to the state mandated requirements, the following are mandatory courses required to function as a clinician on independent status at Valle Ambulance District.

EMT-Basic:

• Basic Cardiac Life Support • International Trauma Life Support OR Pre-Hospital Trauma Life Support • NIMS 100, 200 & 700 • HAZ-Mat at the Awareness Level (within first year of hire) • Monthly In-House Education • In-House Rapid Sequence Intubation Course • Annual In-House Education & Training Symposium (Skills Fair)

Paramedic:

• Basic Cardiac Life Support • International Trauma Life Support OR Pre-Hospital Trauma Life Support • NIMS 100, 200 & 700 • HAZ-Mat at the Awareness Level (within first year of hire) • Advanced Cardiac Life Support • Pediatric Advanced Life Support • Advanced Medical Life Support • Monthly In-House Education • In-House Rapid Sequence Intubation Course • Annual In-House Education & Training Symposium (Skills Fair)

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MONTHLY EDUCATION REQUIREMENTS

The Clinical Practice Department at Valle Ambulance District will provide monthly education to be announced annual in the form of an “education plan.” All education is considered mandatory. Failure to comply will result in loss of ability to function as a clinician on independent status until education has been satisfied.

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Continuous Quality Improvement Operational Policy

CPG Number OPS4



The Clinical Practice Department, led by the Chief Medical Officer at Valle Ambulance District will maintain a comprehensive Continuous Quality Improvement (CQI) program to ensure quality care is provided to every patient we encounter and to promote change in an effort to stay on the cutting edge of pre-hospital medicine. Goals

• To provide a consistent, program wide approach to clinical quality management that focuses on process improvement

• To establish a framework designed to systematically measure and assess the performance of clinicians providing direct patient care.

• To evaluate outcomes of the service we provide and identify opportunities for improvement.

• To promote collaborative and cross-functional team activities to improve services and patient care.

• To establish the plan and processes for communicating the results of performance measurement and improvement activities to all personnel.

Our Approach Find a process to improve Organize to improve the process Clarify current knowledge of the process Understand the sources of process variation Select the process changes to test Plan the experiment and the data collection Do the experiment and the data collection Check the results of the experiment Act to hold the gain and continue to improve the process Repeat the cycle

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Aspects for Review The Clinical Practice Department at Valle Ambulance District will identify clinical aspects for review considered most important to the health and safety of patients we transport. We will focus our chart review on high acuity/low frequency patients as well as review of new processes and or procedures. CQI activities include monitoring and evaluating the following:

• Assessment of patients • Care of patients • Invasive and non-invasive procedures • Processes related to medication use • Appropriate receiving facility • Diversion by facilities • Response times, scene times, transport times and reason for delays • Clinical outcomes • Education & Training • Safety

Chart Review Process

The Clinical Practice Department at Valle Ambulance District will provide 100% chart review and provide documentation for the following multi-level processes: LEVEL ONE CHART REVIEW This level of review will be completed by an on-duty Captain with the following goals:

• Will verify all charts being 100% complete. • Will verify all signatures are present. • Will verify all forms are present and complete; making the case ready for billing. • Will notify the Chief Medical Officer immediately of any potential clinical issues.

LEVEL TWO CHART REVIEW This level of review will be completed by the Chief Medical Officer with the following goals:

• Will determine status (red, yellow or green). • Will flag the chart with appropriate comments based on clinical practice guidelines. • Will follow up with primary clinician on all GREEN & YELLOW charts via email to provide

feedback on an AS NEEDED basis. • Will follow up with both clinicians on all RED charts either in-person or via phone as

appropriate to provide feedback.

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LEVEL THREE CHART REVIEW All RED charts will be forwarded to the Medical Director for this level of review.

• Will request further information regarding follow up with clinicians as needed. • Will require in-person meetings with clinicians on an as needed basis. • Will require education, training and/or remediation on an as needed basis. • Will follow up with both clinicians on all RED charts either in-person or via phone as

appropriate to provide feedback. The Clinical Practice Department at Valle Ambulance District will use the following guidelines to appropriately “code” charts:

• RED o All specialty care transport patients o All intubated patients; or where intubation was attempted o All RSI patients o All full arrest patients o All STEMI Alert patients o All Stroke Alert patients o All Trauma Alert patients o All patients being flown from the scene o Any patients in which an advanced procedure is performed

1. I.O. access 2. Chest decompression

• YELLOW

o Any chart that needs corrective action as determined by the Chief Medical Officer

o All patient refusals o Any patients requiring restraints (physical or chemical) o Any inter-facility transfer patient (hospital to hospital)

• GREEN

• All other charts not identified above. The Clinical Practice Department at Valle Ambulance District will use the CQI process to improve clinical care as a whole as outlined below:

• Establish opportunities for district wide education & training • Establish opportunities for process improvement • Establish individual remediation type training as needed

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New Hire Orientation Process Operational Policy

CPG Number OPS5



The Clinical Practice Department, led by the Chief Medical Officer at Valle Ambulance District will maintain a robust new hire orientation process to ensure that new clinicians are able to provide quality patient care when released to function independently. A clinicians’ final release to function independently will only be approved by the Chief Medical Officer.

Orientation Step Major Objectives Duration Advancement Requirement Step 1: Classroom • Completion of all required

courses and exams as presented by the education team

• Prove initial competency regarding equipment, CPG’s, policies & procedures

2 full 8 hour days Competency Assessment: • Policies/Procedures • Clinical Guidelines • Written Exam’s

Step 2: Drivers Training • Complete CEVO II course • Demonstrate ability to

safely operate emergency vehicle

24 hours Competency Assessment: • Driving Instructors Approval

Step 3: Field Training • Function as 3rd person on ambulance with a FTO

• Complete all objectives as outlined in the orientation manual

10- 12 hour shifts

Competency Assessment: • Equipment • Clinical Guidelines • Policies/Procedures *All Written Evaluations Reviewed & Complete

Step 4 : Final Testing • Prove competency to function as primary clinician, independently by working a shift with the Chief Medical Officer

• Provide complete and accurate records of individual orientation process

1 full 8 hour day Competency Assessment: • Equipment • Clinical Guidelines • Policies/Procedures • Final Scenarios • Final Exam

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Controlled Substances Operational Policy

CPG Number OPS6



Employees will follow the policy set forth in the Valle Ambulance District Policy and Procedure Manual, regarding controlled substances. The following outlines the storage and use of narcotics, from a clinical practice stand-point. Power of Attorney for Controlled Substances

• The authority to purchase and store controlled substances lies with the Chief of EMS • The Chief of EMS may provide his power of attorney for the purchasing and storage of

controlled substances to the Chief Medical Officer and Asst. Chief • Documentation of such is to be housed with the controlled substances in stock

Storage of Controlled Substances

• All controlled substances shall remain double locked at all times, unless in use • This is applicable for on trucks and storage of stock medicines

Chain of Custody

• Chain of custody must be documented for all controlled substances • Chain of custody will be signed to/from crews at the time of shift change • Counts must remain accurate at all times including receiving and transferring medicines

to/from stock and expired stock Lost/Broken/Stolen/Damaged Controlled Substances

• In the event that a controlled substance is damaged or the containers seal is damaged, the on-duty Captain and Chief Medical Officer and/or Asst. Chief shall be notified immediately

o A controlled substance incident report shall be completed immediately o Copies of controlled substance sheets and broken seals shall be attached to the

controlled substance incident report with the vial of wasted medicine (when applicable)

• In the event that a controlled substance is lost or stolen, the unit will be taken out of service, the on-duty Captain, Chief Medical Officer and/or Asst. Chief and Chief of EMS shall be notified immediately

o The on-duty Captain shall notify the proper authorities if a controlled substance is reported as lost or stolen

o A controlled substance incident report shall be completed immediately

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o Copies of controlled substance sheets and broken seals shall be attached to the controlled substance incident report with the vial of wasted medicine (when applicable)

Field Use of Controlled Substances – Documentation

• The use of controlled substances must be clearly documented in the patient care record • The use of controlled substances must be clearly documented on the controlled

substances log • The waste of unused controlled substances must be witnessed and signed for on the

controlled substances log • These all must correlate 100% • A copy of the patient care record, along with a copy of the controlled substance log, the

empty vial of medicine and broken seal must be submitted to the Chief Medical Officer and/or Asst. Chief for review after the use of a controlled substance

• The Chief Medical Officer is responsible for ensuring accuracy and quality with the use and documentation of controlled substances

• Any errors will be reported to the Chief of EMS and documented in the employees personnel file

Documentation of Stock Controlled Substances

• Controlled substances in stock will remain accounted for at all times under double lock unless in use (re-stocking, discarding expired, etc.)

• Controlled substances will be logged on individual forms for each medicine and their status

o Non-Expired (useable) o Expired

• Re-stocking of trucks controlled substances will take place with the Chief Medical Officer, Asst. Chief or Chief of EMS and a witness to confirm accuracy

• Controlled substances purchased from supplier will be added directly to stock medications by the Chief Medical Officer, Asst. Chief or Chief of EMS with a witness to confirm accuracy

• Removal of medicines from stock (expired going to reverse distributor) will take place with the Chief Medical Officer and/or Asst. Chief and Chief of EMS to confirm accuracy

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Vaccine Administration Operational Policy

CPG Number OPS7



This operational policy will address the administration of Influenza Vaccine to children and adults at least 5 years of age. Valle Ambulance District Paramedics in partnership with the Jefferson County Health Department can provide flu vaccine to area residents and employees.

About 2 weeks after the vaccination, antibodies that provide protection against influenza virus infection develop in the body. October and November are usually the best time to get vaccinated, but vaccination can still be given in December or later.

Recommendation from the CDC (Centers for Disease Control) and Jefferson county Health Department should be followed each season.

People who should not be vaccinated without first consulting a physician include:

1. People who have severe allergy to chicken eggs. 2. People who have had a severe reaction to an influenza vaccination in the past. 3. People who developed Guillain-Barre syndrome (GBS) within 6 weeks of getting the

vaccine (1-2 cases per million people vaccinated) 4. Influenza vaccine is not approved for children less than 6 months of age. 5. Children who are under 5 or have never had the vaccine. 6. Pregnant women should be referred to their OB>

Different side effects can be associated with the flu shot. Minor side effects that occur are:

1. Soreness, redness, or swelling to the injection site 2. Low grade fever 3. Aches

If these problems occur, they begin soon after the shot and usually last 1-2 days. Ice or Tylenol may be used to control the soreness. Almost all people who receive influenza vaccine have no serious problems from it.

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INFLUENZA VACCINE ADMINISTRATION

Procedure:

1. Obtain influenza Vaccine Consent as provided by Jefferson County Health Department. 2. Advice regarding possible side effects. 3. Assure that no contraindication exist before proceeding. 4. Using standard precautions obtain a disposable syringe and needle; draw up 0.5ml of

Influenza Vaccine. (22-25g, 5/8 to 1” needles should be used if possible to assure that the injection in intramuscular).

5. Prepare the site for injection in either the right or left deltoid muscle by preparing with alcohol. Identify the acromial process and the point on the arm in line with the axilla. Place the needle 2.5 cm below the acromial process at 90 degrees. Asking patients to put their hand on their hip relaxes the muscle and makes it easier to access. Bunching up the muscle in older patients with reduced muscle mass also makes the injection easier.

6. Discard disposable needles and syringes in an appropriate sharps container. 7. Provide Jefferson County Health Department with vaccination report.

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Tuberculin Skin Testing Operational Policy

CPG Number OPS8



This operational policy will address the administration and reading of Terbuclin Skin Testing for employees and students of the Valle Ambulance District. Valle Ambulance District Paramedics are authorized to administer the Tuberculin Skin Test as well as read for a “positive” or “negative” result. EXCLUSION CRITERIA Persons who have had a previously “positive” Tuberculin Skin Test and/or are confirmed as allergic to tuberculin should not receive the skin test. These persons should receive a chest x-ray as per district policy. SUPPLIES A vial of tuberculin, a single-dose disposable tuberculin syringe, a ruler with millimeter (mm) measurements, 2x2 gauze pads or cotton balls, alcohol swabs, a puncture resistant sharps disposal container, record-keeping forms for the patient and provider, and a pen. ADMINISTRATION

• Choose a site free of lesions, excess hair, and veins. The usual site for injection is the anterior aspect of the forearm.

• Clean injection site with an alcohol swab. Allow area to air dry completely before the injection.

• Intradermally inject all of the tuberculin using a ¼ to ½ inch 27-gauge needle with a short bevel. This will produce a 6-10 mm wheal. If a wheal of 6-10 mm is not produced, another test should be done immediately at a site at least 2 inches from the original site.

• Use a cotton ball to dab the area lightly and to wipe off any drops of blood. Do not apply pressure or use a bandage on the test site. Instruct patient to avoid scratching the test site.

DOCUMENTATION OF ADMINISTRTAION

• Use the Valle Ambulance District Tuberculin Skin Test Form • Name and signature of person administering test • Date and time test administered • Location of test (e.g., right forearm, left forearm) • Tuberculin manufacturer, lot number and expiration date

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READING

• Confirm that TST was applied within 48 to 72 hours prior to reading. • If < 48 hours, patient must return after 48 hours and before 72 hours. • Use a millimeter ruler to measure the diameter of induration perpendicular to the long

axis of the arm. • A reading of LESS THAN 5mm across is considered negative

DOCUMENTATION OF READING

• Use the Valle Ambulance District Tuberculin Skin Test Form • Name and signature of person reading test • Date and time test read • Interpretation of reading (i.e., positive or negative, based on individual's risk factors)

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Infection Control Operational Policy

CPG Number OPS9



This operational policy was designed to prevent the occupational exposure to communicable diseases. All personnel will follow Valle Ambulance District’s Infection Control plan.

General Guidelines

A. Gloves are to be worn with all patients contact. B. Protection of the eyes and mouth can be accomplished with face shield or masks

and protective eyewear in those circumstances that may find you exposed to blood or body fluids being sprayed, e.g. vomit or blood.

C. Your uniform in most instances will afford you adequate protection. After suspected or confirmed exposure, changing your uniform is suggested. Washing and drying you uniforms in the usual manner is adequate.

D. Administration of the Hepatitis Vaccine is required by OSHA, for all personnel involved in pre hospital care. Each individual has the right to refuse said vaccine, signing a form he/she refused.

E. Wash your hands after each patient contact. 1. Hospital anti-germicidal and water 2. Waterless hand cleaner is carried on ambulances

Discarding of Sharps and Containment Items

A. A sharps container is provided in the ambulance and in the drug bag. Anytime an I.V. catheter is used, it should not be recapped, but placed in one of the sharps containers

B. The sharps container shall be replaced anytime the needles or catheters will not fall into the container. Do not force any sharps into the container; this may result in a needle stick.

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C. Full sharps containers shall have the lid locked into place and the container deposited in the ED soiled room for proper disposal

D. Contaminated dressings, bandages, and paper towels used to wipe up contaminates shall be placed in a red contaminated bag for disposal. This shall be left be left in the E.D. soiled room for proper disposal.

Disinfecting of Ambulance After each call the ambulance interior shall be wiped down and disinfected.

1. Gloves shall be worn during this process 2. All blood, vomit, urine and feces shall be wiped up with paper towel. This

should then be discarded in a red contaminated bag. 3. A 10% bleach solution should be used to wipe down all surface areas and left

to air dry.

Disinfecting of Equipment After each call equipment shall be cleaned and disinfectant

1. Gloves shall be worn during this process 2. Intermediate level: may be accomplished by use of a 10% bleach solution

after wiping any surface dirt off with light soap and water a. Blood pressure cuff b. Stethoscope c. Monitor cables d. Splints that came into contact with intact skin

Needle Sticks Should you receive a needle stick, follow the protocol listed in the Policy Manual

1. Cleansing of the wound shall be immediately accomplished with an antibacterial solution All communicable Disease Exposures should be reported by receiving medical facilities to Emergency Responder Personnel under state regulations.

Personal Protective Equipment The appropriate PPE should be worn as required for the nature of the call

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SMART Triage Operational Policy

CPG Number OPS10



Clinicians at Valle Ambulance District will follow the SMART Triage guidelines for multi-patient incidents.

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Incident Rehab Operational Policy

CPG Number OPS11



This operational policy will apply to all responders on the scene of an emergency or training event with prolonged exposure to the elements, exertion and/or scene hazards. If a responder has a medical emergency, refer to the appropriate guideline. This guideline is for the purpose of evaluation and clearing a responder to return to duty. If treatment is rendered, a treat and release form DOES NOT need to be completed however a refusal form needs to be completed as well as an ePCR. Disposition of the responder will be communicated with the incident commander. The incident commander on the scene has the final authority with allowing a responder to return to duty. For this evaluation, we will encourage the responder to remove all PPE to include bunker pants being pushed down on top of his or her boots. We will encourage rest, passive cooling and oral rehydration prior to the evaluation as outlined below.

YES

NO YES

NO

Return to Full Duty

Perform orthostatic vitals

Does pulse increase >20 or Systolic drop >20?

Mandatory rest, rehydration and re-evaluate in 10 min. Transport to ED if no improvement

IV rehydration up to 2 liters until pulse is at least 100 and systolic is >100. If pulse remains elevated or BP low, transport to ED. If pulse/BP is WNL, do not return to scene activities.

Heart Rate >140? OR

Blood Pressure SBP >200

Or DBP >110? OR

Respirations <8 per min Or >30 per min?

OR Temperature >101

Tympanic/oral? OR

Pulse Oximetery <90%?

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Air Ambulance Utilization Operational Policy

CPG Number OPS12



Clinicians at Valle Ambulance District should utilize the following guidelines when utilizing an air ambulance for rapid transport to a specialty resource center, for service not available in the local area.

1. A standby (air or ground) should be requested when en route to a scene when a helicopter is potentially needed. An ETA should be given at that time.

2. Once on scene communication regarding GO or NO GO of the helicopter should be relayed through command.

3. The closest appropriate helicopter and LZ should be chosen. No preference should be given as to what service is used.

4. Helicopter times should be included in you EPCR including: Dispatch time, on scene time, departure time, and ETA that was originally given.

5. A helicopter should be considered when one or more of the following criteria exist: A significant reduction in transport time exists compared to ground transport for

seriously ill or injured patient requiring a SPECIALTY RESOURCE CENTER. Severely injured or acutely ill patients are located in remote or off road areas not

readily accessible to ground ambulance. Ground resources exhausted (i.e. disaster). Prolonged vehicle extrication time is anticipated over 20 minutes. Special environmental conditions (i.e. extreme cold) are present which affect

potential patient outcome Delayed ground access to hospital (i.e. road, bridge damage, flood, traffic

conditions).

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Transfer of Care Operational Policy

CPG Number OPS13



The intent of this operational policy is to insure continuity of patient care through communication and transmission of patient care information to subsequent providers.

1. Upon transfer of patient care to the Emergency Department RN or Physician, air

ambulance RN or Paramedic, nursing home staff, or to another ambulance crew; the receiving individual shall be advised of the patient’s condition, treatment provided, patient history, medications, allergies, and any applicable further care instructions.

2. After patient transfer, the crew shall have the receiving person sign the ePCR to accept the responsibility of patient treatment, with the exclusion of air ambulance. The ePCR shall be completed, including all times and a copy left with the receiving facility or individual, excluding air ambulance and residential transfers. If it is not feasible to leave a report at that time, one may be faxed to a secure fax line.

3. The ePCR shall include the time care was transferred and the condition of the patient at the time of transfer.

32


Refusal of Care Operational Policy

CPG Number OPS14



This operation policy refers to those situations in which a patient refuses evaluation, treatment, and/or transportation by clinicians at Valle Ambulance District.

• The patient or guardian must understand the risks and consequences associated with their decision, up to and including death or serious disability.

• The patient or guardian must verbally refuse and agree to the risks and consequences outlined to them.

• The patient or guardian must sign refusal and it must be witnessed.

Persons presumed competent to make decisions affecting their medical care shall be allowed to make such decisions.

Evaluating Competency

A patient may not be considered competent to refuse medical care and/or transportation if the severity of their medical condition prevents them from making rational decisions regarding their medical care. A patient MAY NOT refuse medical care and/or transport if any of the following criteria are met:

1. Alter level of consciousness, including those with a head injury or under the influence of drugs and/or alcohol.

2. Attempted suicide or verbalized suicidal intent. 3. Are mentally retarded or have a mental deficiency. 4. Are clearly not acting as a reasonably person would, given the same circumstances. 5. Medical Control may be contacted if there is any question about the patient’s ability to

refuse evaluation, treatment, and/or transport. 6. Are under eighteen (18) years of age and do not qualify as an adult.

Under 18 Exceptions:

1. An emancipated minor 2. A minor who is married 3. A minor who is in the military

A parent, guardian, or immediate family member over 18 may refuse medical care for the patient. A signature or verbal confirmation via phone is needed. If unavailable the patient must be transported.

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DOCUMENTATION OF REFUSAL

The following items should be included in your patient refusal documentation:

• A clear description of the patient’s mental status. • All pertinent negatives regarding the patient’s chief complaint. • A statement that you advised the patient of the risk and consequences of refusing

treatment and/or transport, up to and including death or serious disability. • The reason the patient is refusing. • The patient’s person plan of care and/or follow-up regarding the event. • If Medical Control contacted, document who you talked to and their recommendation. • Name of parent, legal guardian, or immediate family member refusing for a minor. • If a Treat and Release is obtained, an improvement of symptoms must be documented. • A full set of appropriate vital signs given the patients complaint.

TREAT AND RELEASE SITUATION

A Treat and Release may be obtained with a refusal of transport. A patient may have a transient condition that is quickly remedied at the scene and has the right to refuse transport. The patient should be made aware of the charges of a Treat and Release prior to receiving a medication, if a refusal is suspected. The following drugs may be given, following the appropriate protocol:

1. IV Fluids 2. Oxygen 3. Zofran 4. Dextrose 50% 5. Epinepherine 1:1,000 6. Benadryl 7. Duoneb 8. Albuterol 9. Solu-Medrol 10. Oral Glucose 11. Aspirin 12. Nitroglycerin PO 13. Narcan

If patient symptoms are alleviated and transport is no longer needed or wanted, follow the Refusal Protocol and also have patient sign the Treat and Release form. The form shall be completed with prices totaled prior to the patient signing.

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Determination of Death Operational Policy

CPG Number OPS15



The following operational policy will provide guidance when the resuscitation of a patient should not be attempted. If, upon examination, it is evident that resuscitation is impossible or the patient has been dead for an extended period of time, the Paramedic may determine that death has occurred and not begin resuscitation measures. The Paramedic must use clinical judgment and discretion.

Some findings consistent with determination of death:

1. Extended down time >20 minutes 2. Rigor mortis (i.e. stiff, cold) 3. Venous pooling/lividity 4. Body in state of decomposition 5. Major traumatic injury (i.e. severe chest trauma, brain injury, etc. that is incompatible

with life) 6. Pupils fixed and dilated 7. Absence of carotid pulse 8. Absence of respirations 9. Absence of heart tones 10. Asystole per EKG monitor, verified in 3 leads

If the Paramedic determines death has occurred, Law Enforcement must be contacted. The scene must be turned over to Law Enforcement prior to returning to service.

In the event of a crime scene death in which a Paramedic has determined death has occurred, the clinician must make every attempt to preserve evidence by not moving the body or manipulating the scene.

Thorough documentation including physical signs of death, mechanism, and historical factors must be completed. An EKG strip is not necessary if death is obvious and easily documented.

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Discontinuation of Resuscitation Operational Policy

CPG Number OPS16



The following operational policy will provide guidance when the resuscitation of a patient has proven futile and should be discontinued in the field. The following items must be completed prior to a patient being pronounced dead in the field:

1. Airway secured (ET tube, Rescue Airway or Surgical Cricothyrotomy) and confirmed patent with waveform ETCO2.

2. Vascular access obtained and patent. 3. Continuous quality CPR has been performed. 4. At least 2 rounds of ACLS medications have been administered. 5. A minimum of 20 minutes of ACLS resuscitation has been attempted. 6. Noted Asystole or PEA with a rate less than 60 documented in 3 or more leads.

If all of the above criteria have been met, the lead Paramedic WILL MAKE ON-LINE CONTACT WITH A MEDICAL CONTROL PHYSICIAN. It will be the responsibility of the on-line medical control physician to make the final decision if the patient is to be pronounced dead in the field or not. Should on-line medical control authorize the patient being pronounced dead in the field, the scene will be turned over to Law Enforcement. It is the responsibility of the lead Paramedic to discuss the situation with family members on scene. If at any time there are questions regarding the appropriate disposition of the patient, transport should be initiated.

36


DNR Orders Operational Policy

CPG Number OPS17



The following operational policy will provide guidance when clinicians at Valle Ambulance District encounter a patient with a valid Do Not Resuscitate order.

• It is the responsibility of the lead Paramedic to confirm that the DNR order is in fact, valid. If the DNR order is not valid, the is questions regarding its validity, the patient verbally requests treatment and/or the family on scene requests treatment; treatment will be initiated as if the DNR order did not exist. When in doubt, resuscitate!

• The lead Paramedic on scene should thoroughly read the DNR order to confirm exactly

what or what not the patient would like done as far as treatment aggressiveness.

• Please remember, a DNR order IS NOT a Do Not TREAT order. Patient should be treated aggressively up until the point resuscitation efforts are necessary.

CONTACT WITH ON-LINE MEDICAL CONTROL PHYSICIAN SHOULD BE MADE IF THERE ARE ANY QUESTIONS AND/OR FOR CONSULTATION PURPOSES.

37


Incident Command System Operational Policy

CPG Number OPS18



It is the purpose of this operational policy to establish responsibilities and determine actions required to manage and coordinate our agency response to incidents of any size within the Valle Ambulance District. DEFINITION OF THE INCIDENT COMMAND SYSTEM ICS is a combination of equipment, personnel, and procedures for communications operating within a common organizational structure with responsibilities for the management of assigned resources to effectively accomplish objectives pertaining to an emergency incident. ICS is a sub-system of the National Inter-Agency Incident Management System (NIIMS). OUR POLICY All incidents in which the Valle Ambulance District responds to will employ some type of incident command. The size and requirements of the incident command system will expand and contract along with the size and complexity of the incident. All Valle Ambulance District personnel will utilize the NIMS type command system and will make every effort to ensure that a unified command is utilized on each and every incident. Valle Ambulance District employees will make sure that patient care is priority, but in all situations the employee must function at some level in the ICS. Valle Ambulance clinicians will function as the EMS BRANCH or DIVISION of the ICS. The first arriving unit on any scene should give a brief “size up” of the incident if one is warranted and if no other unit has given one and then move onto the following:

• Conduct a scene safety assessment. • Perform an initial size up of the incident to determine the number of patients and the

level of resources needed. • Call for or cancel additional resources if needed though the ICS. • All requests for information or additional equipment should go through the FIRE

DEPARTMENT’S ICS unless this is not feasible, practical, or the fire department does not have an ICS in place.

• Provide appropriate patient care. • After the incident has been mediated and all patient care is finished the remaining EMS

personnel at the scene should disband through the ICS also.

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Inter-Facility Transfers Operational Policy

CPG Number OPS19



The purpose of this operational policy is to outline the procedure for conducting emergency, infer-facility transfers. DEFINITION: The definition of an inter-facility transfer is the moving of a patient from one hospital to another, for the purpose of a higher level of care or services not available at the sending facility. POLICY: All inter-facility transfers must be handled on a case-by-case basis. The on-duty captain will make the decision if an inter-facility transfer request is to be accepted. If there is any question, the Chief or Chief Medical Officer will be contacted for guidance. The closest, readily available resource will be dispatched to the inter-facility transfer, unless specialty crew assignments are deemed necessary by the sending facility and Valle Ambulance District leadership team member approving the transfer. The assigned crew will follow Valle Ambulance District CPG’s with regards to patient care. Should a required treatment or medication therapy be required for the transfer, a Specialty Care Transport should be initiated. At any time, the transferring lead paramedic may contact the sending physician or any member of the Valle Ambulance District leadership team for guidance.

39


Specialty Care Transport Operational Policy

CPG Number OPS20



The purpose of this operational policy is to outline the procedure for conducting emergency, Specialty Care Transports. DEFINITION: The definition of a Specialty Care Transport (SCT) is the moving of a CRITICALLY ILL patient from one hospital to another, for the purpose of a higher level of care or services not available at the sending facility that requires treatment by a clinician with training beyond that of a Paramedic. POLICY: All SCT requests must be handled on a case-by-case basis. The on-duty captain will make the decision if an SCT request is to be accepted. If there is any question, the Chief of EMS, Chief Medical Officer or Medical Director will be contacted for guidance, as needed. When an SCT request has been accepted, the closest, readily available Valle Ambulance will be dispatched as long as there is one available Valle Ambulance left in the district in service. Simultaneously, the on-call SCT provider will respond and rendezvous with the Valle Ambulance at the sending facility. The SCT provider will assume the role of “lead” for the SCT run, and will complete all documentation. There will be, at a minimum, 1 other standard paramedic in the patient compartment at all times during the SCT run. The SCT provider will follow Valle Ambulance District CPG’s with regards to patient care. Should a required treatment or medication therapy that falls outside of the CPG’s be required for the transfer, written orders must be obtained by the sending physician and agreed upon by the transferring SCT provider. At any time, the transferring SCT provider may contact the sending physician, receiving physician, medical director or any member of the Valle Ambulance District leadership team for guidance.

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SCT PROVIDER QUALIFICATIONS: To be qualified as a SCT provider at Valle Ambulance District, the clinician must have CURRENT certification or licensure as a critical care transport provider. Below are examples of acceptable licenses or certifications:

• CCEMT-P • CCP-C • FP-C • RN with CEN • RN with CCRN • RN with CFRN • RN with CTRN

EXAMPLES OF SCT RUNS: SCT runs must originate at a sending facility, usually a hospital ER and must end at a receiving facility with services necessary to treat the critically ill patient. Below are examples of SCT runs:

• Any patient requiring advanced airway management or the potential for advanced airway management

• Ventilator dependant patients • Patients requiring vaso-active medications • Patients receiving blood or blood product transfusions • Patients receiving thrombolytic therapy • Patient with potential for circulatory collapse

LIMITATIONS: Valle Ambulance does not have the capabilities to transport patients requiring the following therapies:

• Intra-Aortic Balloon Pump • Swan-Ganz Catheter • Monitoring of Arterial Blood Pressure • Ventilator dependant patients less than 25kg • Neonatal patients of any kind

41


Clinical Documentation Operational Policy

CPG Number OPS21



The purpose of this operational policy is to outline documentation expectations for every patient encounter. All members of the clinical team who render care during patient contact are responsible for completing and ensuring that all aspects of the patient care record generated are accurate and complete. A. Dispatch Information

a. Incident number as provided by Jefferson County 911 b. Referring type i.e. 911 call c. Category: classification of patient d. Outcome i.e. treated and transported, transport refused, call cancelled, etc. e. Signatures of all crew members involved in the patient care required f. The chart must identify the crew members and credentials who completed the

patient care record g. Referring Location h. Receiving Location; with justification i. Times as provided by Jefferson County 911 j. Loaded miles

B. Patient Information

a. Patient’s full name b. Home address c. Date of birth d. Age, if unknown due to injuries- approximate age e. Social security number (if available) f. Sex g. Weight in kilograms h. Barriers to care i. Race j. Current PMHX k. Current medications l. Current allergies

C. Billing information

a. Consent form signed and complete b. Receiving facilities signatures obtained c. All available insurance information should be obtained; copies of cards appreciated

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D. Chief complaint or history of present Illness

a. Patient presentation, how the patient was found b. Primary and secondary impressions c. Chief complaint and duration d. History of Present Illness e. Scene description/vehicle description if applicable f. Factors affecting care g. Additional injury details, Cardiac arrest, Drugs/Alcohol options when applicable

E. Primary and secondary assessment information

a. Airway Status b. Breathing Status c. Circulation status d. Neurological assessment e. GCS (Glasgow coma scale) f. Secondary systems and findings as appropriate g. Extremities: presence of pulses, sensation, motor function h. Appearance of skin i. Pain level

F. General documentation guidelines

a. All “procedures” must be documented in the flow chart and filled out completely b. Vital signs shall be assessed every 5 minutes on “unstable” patients or when

titration of vasoactive medications is taking place. c. Vital signs shall be assessed every 15 minutes on “stable” patients d. EKG strips will be attached to the record when EKG monitoring has been

documented e. 12 lead EKG’s will be attached to the record when 12 lead monitoring has been

documented f. ETCO2 strips will be attached to the record on any intubated patient g. For intubated patients document a general statement that airway placement was

reassessed with each patient move and at the receiving facility h. For intubated patients document the physician that confirmed airway placement

and have them sign for such i. For trauma patients immobilized on a long spine board, document movement of all

extremities before and after each patient move j. There should be detailed documentation as to how the patient was moved to the

stretcher and secured

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RN Functioning as ALS Provider Operational Policy

CPG Number OPS22



The purpose of this operational policy is to outline the necessary training for a Registered Nurse to function as an Advanced Life Support provider at Valle Ambulance District. Allowing a RN to function as an ALS provider will be on a case-by-case basis, as approved by the medical director. Items Required

• Current and valid license as a Registered Nurse in the state of Missouri • Current certifications required for Paramedics • Documented airway management experience, specifically endotracheal intubations

o Operating room clinical time highly encouraged • Current licensure as an EMT is highly encouraged

Should the RN be approved by the medical director and meets the above criteria, he/she may replace a paramedic at Valle Ambulance District. The RN will be held to the same education and training standards as any paramedic would be.

44


Emergency Medical Response Agencies Operational Policy

CPG Number OPS23



The purpose of this operational policy is to outline the relationship between Valle Ambulance District and the emergency medical response agencies that follow our clinical practice guidelines. Authorization Clinicians at each department or district functioning under the Valle Ambulance District Clinical Practice Guidelines are authorized to practice at the EMT-B level as long as they are licensed as such. Clinicians are NOT authorized to administer any medications, other than Oxygen. EMRA clinicians are NOT authorized to complete patient refusals. EMRA clinicians are authorized to perform any “skill” that is noted to be “BLS” in nature as per these guidelines. Should a Valle Ambulance District paramedic be on-duty with the EMRA and are requested to perform ALS procedures by the on-scene ambulance, that paramedic will immediately be “on-duty” with Valle Ambulance District and will then be authorized to function in an ALS capacity. They will be required to log the time they are functioning as an ALS provider on their time card at Valle Ambulance District. This situation is addressed in the Valle Ambulance District policy manual which has the final authority on the situation. Verification of Licensure & Certification The Chief of each department or district is responsible for maintaining licensure and certification of their clinicians that meet state of Missouri BEMS requirements. Records will be maintained by each department or district and will be available for audit by Valle Ambulance District as requested. Education & Training The Chief of each department or district is responsible for creating their own education plan that ensures clinicians meet state of Missouri BEMS requirements. Records will be maintained by each department or district and will be available for audit by Valle Ambulance District as requested. Continuous Quality Improvement The Chief of each department or district is responsible for submitting required charts for review as per the CQI policy. Charts meeting red criteria as well as 10% of other charts by random draw will be submitted to the Valle Ambulance District Chief Medical Officer on a quarterly basis for review. The medical director will review the cases and provided feedback.

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SECTION TWO ADULT TREATMENT GUIDELINES

FOR THE PURPOSE OF THESE GUIDELINES, AN ADULT PATIENT WILL BE CONSIDERED ANY HUMAN AT OR ABOVE THE AGE OF 18 YEARS OLD.

46


Routine Care Adult Treatment Guidelines

CPG Number ATG1



It is the policy of Valle Ambulance District to provide quality clinical care in the safest manner possible. Through that vision, we have developed the following routine care procedures that shall be used on every adult patient encounter.

Ensure scene safety Bring all necessary equipment to the patient’s side

Demonstrate professionalism and courtesy

Don personal protective equipment Airborne or droplet precautions if indicated

Assess CABs, and intervene if indicated

Control any major bleeding Provide oxygen and assist ventilations if indicated

Spinal immobilization if indicated Obtain chief complaint, associated signs/symptoms

Obtain complete set of vital signs Obtain past medical history and SAMPLE-type history

Where appropriate, provide routine ALS care:

• Establish vascular access, draw blood • Monitor cardiac rhythm • Perform multi-lead EKG as appropriate • Measure and monitor waveform ETCO2 • Measure and monitor SPO2 • Measure blood glucose

CONTACT MEDICAL CONTROL PHYSICIAN AT ANY TIME DURING PATIENT

ENCOUNTER WHEN GUIDANCE IS NEEDED TRANSPORT PATIENTS ACCORDING TO DESTINATION DECISION OPERATIONAL POLICY

47


General Airway Management Adult Treatment Guidelines

CPG Number ATG2



mO

Assess ABC’s Assess Respiratory Rate, Rhythm Quality

Assess Airway Patency ADEQUATE

INADEQUATE

Provide Appropriate Monitoring • Consider monitoring SPO2 • Consider monitoring ETCO2

Provide BLS Airway Management • Position/Adjunct/Suction • Ventilatory Support w/ O2

Provide Basic Treatment • Provide Oxygen as appropriate • Transport in position of comfort

Provide Appropriate Monitoring • SPO2 & ETCO2 • EKG & NIBP

Provide ALS Airway Management • Intubation (Oral/Nasal) • RSI as needed

Package & Transport • Follow Post Intubation Management

Guideline as appropriate

IF UNABLE TO MAINTAIN AIRWAY, UNABLE TO VENTILATE, AND/OR

UNABLE TO OXYGENATE AT ANY TIME:

GO DIRECTLY TO: FAILED AIRWAY GUIDELINE

IF AIRWAY OBSTRUCTION ENCOUNTERED AT ANY TIME:

GO DIRECTLY TO: AIRWAY OBSTRUCTION GUIDELINE

48


Airway Obstruction Adult Treatment Guidelines

CPG Number ATG3



CONFIRM AIRWAY OBSTRUCTION IS PRESENT • Assess Mental Status

CONSCIOUS PATIENT

• Perform Heimlich maneuver until: A. Obstruction is removed or B. Patient becomes unconscious

UNCONSCIOUS PATIENT • Check for foreign body visible in mouth; remove if found • Begin CPR with compressions first

IF ABOVE IS UNSUCCESSFUL: INITIATE ALS PROCEDURES • Perform direct laryngoscopy and attempt to remove obstruction

o Suction o Forceps

• If able to remove obstruction, go to Airway Management Guideline • If unable to remove obstruction, go to Failed Airway Guideline

IF SUCCESSFUL: GO TO AIRWAY MANAGEMENT GUIDELINE

IF UNSUCCESSFUL: GO TO FAILED AIRWAY GUIDELINE

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Failed Airway Adult Treatment Guidelines

CPG Number ATG4



The encountered failed airway is something that each clinician at Valle Ambulance District must be prepared for. Proper reaction to the failed airway is paramount in the survivability of the critically ill patient. Should a failed airway be encountered, use the following algorithm.

FALL BACK TO BASICS – BLS AIRWAY MANAGEMENT

• Good positioning of patient • BLS airway adjuncts • Good suction • 2 person BVM technique

CONSIDER RESCUE AIWAY

(if unable to ventilate/oxygenate with BVM)

• King Tube

EMERGENCY CRICOTHYROTOMY (if unable to ventilate/oxygenate with BVM and unable to place rescue airway)

• Per-Trach • Needle Cricothyrotomy • Surgical Cricothyrotomy

GO TO POST INTUBATION MANAGEMENT GUIDELINE AS APPROPRIATE

50


Rapid Sequence Intubation Adult Treatment Guidelines

CPG Number ATG5



CONFIRM RSI IS INDICATED (one of the items below)

• Inadequate ventilation and/or oxygenation is present • Patient is unable to maintain airway • Predicted clinical course indicates need for airway management

PREPERATION

• Gather and assemble all tools, 2 IV’s in place • Ready all medications (RSI and post intubation)

PREOXYGENATION • Provide 100% FiO2 by LEAST INVASIVE means possible • Avoid BVM if at all possible

PREMEDICATION • Consider Fentanyl for pain: 0.5-2.0mcg/kg SIVP • Fluid bolus if patient is hypotensive or borderline hypotensive

PARALYSIS WITH INDUCTION (simultaneous administration of sedative & paralytic is required)

• SEDATION (pick one) o Etomidate: 0.3mg/kg IV or IO o Versed: 0.1mg/kg IV or IO

• PARALYTIC (pick one) o Succinylcholine: 1.0-1.5mg/kg IV or IO (max single dose 200mg) o Rocuronium: 1.0mg/kg IV or IO (if Succinylcholine is contraindicated)

PLACEMENT WITH PROOF • Oral Intubation, use bougie • Confirm placement, use ETCO2


IF SUCCESSFUL GO TO POST INTUBATION MANAGEMENT GUIDELINE

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INFORMATION ON RAPID SEQUENCE INTUBATION

The process of Rapid Sequence Intubation is designed to take an airway from a patient that has one of the following at the time of exam:

A. Inadequate ventilation and/or oxygenation present and not responding to conventional treatments (Oxygen by mask, CPAP, other treatments, etc.).

B. Inability to maintain airway (altered mental status, unconsciousness, etc.). C. Predicted clinical course that indicates a need for airway management (severe

combative nature, obvious head injury, major trauma, etc.). Rapid Sequence Intubation should not be taken lightly. This is a skill that by definition, is taking away something the patient has. The clinician performing the RSI should be completely confident in his or her ability to manage the patient’s airway. Prior to performing the RSI, the clinician should perform a thorough risk vs. benefit analysis on the patient to confirm that RSI is in fact the indicated and appropriate treatment. The clinician should perform a complete assessment of the airway and predict any difficulties that may arise. The clinician should go into the RSI situation with the “worst case scenario” in mind, and be prepared to manage that scenario. Please Note: After any attempt at RSI, the Chief Medical Officer will be contacted by the on-duty crew immediately after transferring care to discuss the case.

52


Post Intubation Management Adult Treatment Guidelines

CPG Number ATG6



The post intubation management guideline was developed for the treatment of any patient who has an artificial airway in place (ET tube, rescue airway, emergency cricothyrotomy).

CONFIRM AIRWAY IS PATENT AND SECURED • Lung sounds remain present, epigastric sounds remain absent • Continuous monitoring of waveform ETCO2 is REQUIRED (ideal range is 35-45) • Secure the airway with a commercial device, when available

CONSIDER PLACEMENT A GASTRIC TUBE • Oral route is preferred; with 18f.

CONSIDER SEDATION • Versed: 2.5-5.0mg IV or IO, every 10-20 minutes (used for normotensive patients) • Ativan: 1-2mg IV or IO every 10-20 minutes (used for hypotensive patients)

CONSIDER ANALGESIA

• Fentanyl : 0.5-2.0mcg/kg IV or IO every 10-20 minutes o Consider half dose or withholding if patient is hypotensive

CONSIDER CONTINED PARALYSIS

• Vecuronium: 0.1mg/kg IV or IO (will last 60 minutes)

PROVIDE CONTINUOUS REASSESSMENT • Maintain constant ETCO2 monitoring • Vital signs every 5 minutes • Assume intubated patients are under sedated and in pain; treat accordingly

ENSURE ADEQUATE VENTILATION & OXYGENATION • Provide 100% FIO2 • Either with bag valve device or mechanical ventilator • Ensure adequate tidal volume (6-8cc/kg) • Ensure adequate respiratory rate (usually 8-12/min) – normal ETCO2 35-45 • Consider adding mechanical PEEP, unless contraindicated (usually 5-10cm/H2O)

53


Pulmonary Edema Adult Treatment Guidelines

CPG Number ATG7



PERFORM ROUTINE CARE

• Assess and monitor vital signs and EKG • Assess and support ABC’s as needed • Provide Oxygen, as appropriate, titrate SPO2 >94% • Provide routine monitoring: EKG, NIBP & SPO2, as appropriate • Perform multi-lead EKG as appropriate • Establish vascular access, draw blood

ASSESS FOR RESPIRATORY FAILURE

• Consider early CPAP therapy (5-10 cm/H2O is ideal) • Consider RSI at any time in this guideline

Consider NTG: 400mcg SL, repeat PRN (5 minute intervals between doses)

Consider NTG Infusion: 5-100mcg/min IVPB, titrate to effect

(hypertension, obvious pulmonary edema)

Consider Lasix: 40mg IVP or double patients current dose (obvious pulmonary edema)

• Have high suspicion for Acute MI with obvious pulmonary edema; EKG is imperative. • Primary treatment should focus on CPAP and Nitrates (aggressive) • NTG contraindicated with hypotension or use of E.D. medications. • Remember, patients must be able to maintain airway and be alert to use CPAP. • Consider RSI if patient does not improve with treatments provided and/or unable to tolerate CPAP.

54


Bronchospasm Adult Treatment Guidelines

CPG Number ATG8






• Consider early CPAP therapy • Consider RSI at any time in this guideline

Consider Duo-Neb: x 1 (Albuterol 2.5mg and Atrovent 0.5mg) via UDN (respiratory distress – wheezing and/or rhonchi)

Consider Solu-Medrol: 125mg IVP, IM or UDN (presumed lung injury)

Consider Continuous Albuterol: 5.0mg via UDN, repeat PRN

(severe distress)

Consider Magnesium Sulfate: Infusion 2gm in 100cc IVPB over 10 minutes (severe distress)

• Have high suspicion for Acute MI caused by hypoxia; EKG is imperative. • Remember, patients must be able to maintain airway and be alert to use CPAP. • Consider RSI if patient does not improve with treatments provided and/or unable to tolerate CPAP. • ETCO2 with “shark fin” waveform indicative of bronchospasm.

Consider Xopenex: 1.25mg via UDN, repeat x 2 PRN (if patient is tachycardic)

55


Chest Pain Adult Treatment Guidelines

CPG Number ATG9



.

ASA 324 mg PO (Baby ASA 81 mg x4)

Consider NTG: 400mcg SL, repeat PRN

(5 minute intervals between doses)

Consider Morphine: 2-10mg IVP OR Fentanyl 0.5-2mcg/kg IVP (continued pain)



Consider Lopressor: 5mg SIVP, repeat x 2 (15mg total) (hypertension and tachycardia)

Consider NTG Infusion: 5-50mcg/min IVPB, titrate to effect (hypertension, presumed true cardiac event, continued pain and/or relief with NTG SL)

• Use caution (if at all) with NTG and inferior wall STEMI. • NTG contraindicated with hypotension or use of E.D. medications. • Lopressor should be used only in presence of suspected cardiac event, with hypertension and

tachycardia both present. • Obtain EKG (multi-lead) prior to any treatment, if at all possible. • This guideline may be used for atypical presentation of MI when appropriate.

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Suspected STEMI Adult Treatment Guidelines

CPG Number ATG10



STEMI IS SUSPECTED

Continue to follow appropriate individual guidelines

PROVIDE NOTIFICATION TO RECEIVING FACILITY AS QUICKLY AS PRACTICLE AND POSSIBLE! • Transmit EKG if possible and practical • Follow Mercy Jefferson STEMI/AMI Checklist • Establish a second IV, ensure blood has been drawn • Ensure pacer-pads are on patient as a precaution

STEMI CRITERIA

• ST elevation of 2mm or more in 2 or more contiguous leads

• Reciprocal changes are present

• New or presumed new LEFT bundle branch block

STEMI PEARLS

• RAPID transport to PCI capable facility is key • Early and good communication with PCI capable facility will speed up the process; be

confident in your findings • STEMI recognized to PCI goal is 90 minutes or less • Be prepared for arrhythmias

57


Tachycardia Adult Treatment Guidelines

CPG Number ATG11



• For Atrial Fibrillation consider Cardizem 5-10mg SIVP, second bolus of 10-20mg SIVP for the purpose of rate control

o USE CAUTION: Hypotensive patients and elderly patients • For pulsing V-Tach consider Lidocaine bolus: 1.0-1.5mg/kg, followed by infusion if

conversion is successful • Consider underlying cause of the tachycardia; treat appropriately

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58


Bradycardia Adult Treatment Guidelines

CPG Number ATG12



• Consider underlying cause of the bradycardia; treat appropriately

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59


Cardiac Arrest BLS Resuscitation Adult Treatment Guidelines

CPG Number ATG13



• Switch to appropriate ACLS guideline as quickly as possible and practical

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60


Cardiac Arrest ACLS Resuscitation Adult Treatment Guidelines

CPG Number ATG14



• For VF/VT, consider Lidocaine bolus: 1.0-1.5mg/kg IVP, followed by

infusion if conversion successful – IN PLACE OF AMIODARONE.

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61


Post Resuscitative Care Adult Treatment Guidelines

CPG Number ATG15



GO TO SHOCK (NON-TRAUMA) GUIDELINE AS APPROPRIATE

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62


Shock (Non-Trauma) Adult Treatment Guidelines

CPG Number ATG16





IS PATIENT SYMPTOMATIC? NO YES

OVSERVE AND TRANSPORT

MAINTAIN SUPPORTIVE CARE

CONSIDER UNDERLYING CAUSES • PRIMARILLY CARDIAC CONCERNS • USE APROPRIATE GUIDLINE PRN

CONSIDER FLUID BOLUS: 20CC/KG • CONSIDER LUNG SOUNDS • CONSIDER ADDITIONAL FLUIDS PRN

CONSIDER DOPAMINE INFUSION • Indicated for HR and BP control • Dose is 5-20mcg/kg/min IVPB

CONSIDER EPINEPHERINE INFUSION • Indicated for HR and BP control • Dose is 2-20mcg/min IVPB

USE CAUTION WITH VASOPRESSORS

MAINTAIN INFUSION ON MEDICATION PUMP IF AVAILABLE

TAKE SERIOUS CONSIDERATION OF

UNDERLYING CAUSE INTO ACCOUNT

ENSURE PROPER PRE-LOAD IS PRESENT (FLUID STATUS) PRIOR TO

STARTING VASOPRESSORS

CONSIDER NOREPINEPHERINE INFUSION • Indicated for BP control • Dose is 2-20mcg/min IVPB

63

INFORMATION ON VASOPRESSORS

DOPAMINE

• Dopamine is an inotrope, alpha drug and beta drug. • Dopamine infusions will provide the following effects based on dose:

o 5mcg/kg/min: primarily isotropic and beta effects Increase contractility (squeeze on heart) Increase heart rate

o 10-15mcg/kg/min: alpha and beta effects Increase contractility (squeeze on heart) Increase heart rate Increase systemic vascular resistance (squeeze the pipes)

o 20mcg/kg/min: primarily alpha effects Increase systemic vascular resistance (squeeze the pipes)

• Dopamine is primarily used for true cardiogenic shock patients (IE: post arrest or impending arrest), at the 10-15mcg/kg/min range.

EPINEPHERINE

• Epinephrine is a naturally occurring hormone in the body. • Epinephrine has both alpha and beta effects on the body. • Epinephrine is to be used primarily for “COLD SHOCK” type states.

o Bradycardic patients that are also hypotensive • Epinephrine is to be used as the primary vasopressor for severe anaphylaxis.

NOREPINEPHERINE

• Norepinephrine (Levophed) is primarily an alpha medicine. • Norepinephrine will increase systemic vascular resistance (squeeze the pipes) but will

not affect the patient’s heart rate. • Norepinephrine is the drug of choice in severe sepsis. • Use caution and ensure the patient has appropriate pre-load (fluid status) prior to use.

FOR FURTHER DETAILED INFORMATION, PLEASE SEE EACH INDIVIDUAL DRUG PROFILE IN THE APPROVED MEDICATION FORMULARY AT THE END OF THIS DOCUMENT.

64


Overdose/Toxic Abnormalities Adult Treatment Guidelines

CPG Number ATG17



Abnormality History / Symptoms Treatment Opiate Overdose

• Pain Medicines • Heroine

- Unconsciousness - Inadequate breathing

Narcan: 2mg IN, IM, IV Titrate to effect and repeat as needed

Calcium Channel Blocker Overdose • IE: Cardizem

- Bradycardia Present - Hypotension Present

Calcium Chloride: 1gm IVP

Beta-Blocker Overdose • IE: Metoprolol


Glucagon: 2-5mg IVP

Tricyclic Overdose • IE: Amitriptyline

- Wide QRS Noted - V-Tach Noted

Sodium Bicarbonate: 1mEQ/kg IVP

Organo-Phosphate Poisoning • Most pesticides

- SLUDGE Noted Atropine: 1-5mg IVP Titrate to effect

Stimulant Ingestion • Cocaine • Meth • Bath Salts

- Tachycardia Present - Hypertension Present - Combative - Hallucinating

Ativan: 1-4mg IV or IM Valium: 5-15mg IV Versed: 5-10mg IV or IM

Hyperkalemia • History of Renal Failure or

insufficiency

- Bradycardia Present - Hypotension Present - Peaked “T Waves” - Wide QRS Noted

Sodium Bicarbonate: 1mEQ/kg IVP and Calcium Chloride: 1gm IVP


65


General Pain Management Adult Treatment Guidelines

CPG Number ATG18





ASSESS PAIN LEVEL • Pain is considered a vital sign; should be documented as such. • Pain should be interpreted as mild, moderate or severe

MINOR PAIN TREATMENT OPTIONS

• Position of Comfort • Verbal distractions

MODERATE PAIN TREATMENT OPTIONS • Morphine: 2-5mg, repeat PRN • Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN • Dilaudid: 1-2mg IVP or IM, repeat PRN

SEVERE PAIN TREATMENT OPTIONS • Morphine: 2-5mg, repeat PRN • Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN • Dilaudid: 1-2mg IVP or IM, repeat PRN

• Confirm all contraindications of medicines prior to use. • Confirm medication allergies prior to use of pain medicines. • Full patient monitoring must be used when narcotics are administered.

66


Procedural Sedation Adult Treatment Guidelines

CPG Number ATG19





CONFIRM THE NEED FOR SEDATION IS PRESENT (pacing, cardioversion, etc.)

ENSURE HEMODYNAMIC STABILITY

CONSIDER SEDATION • Ativan: 1-2mg IM or IVP, repeat PRN • Versed: 2-5mg IM or IVP, repeat PRN • Valium: 5-10mg IVP, repeat PRN

• The use of procedural sedation is intended for patients requiring invasive procedures not able to be tolerated in an awake and alert state.

• Most of these procedures are painful; be sure to treat for pain as well as providing sedation.

67


Nausea & Vomiting Adult Treatment Guidelines

CPG Number ATG20





PROVIDE GENERAL COMFORT MEASURES • Position of comfort • Consider: Fluid Bolus of 500cc

TREATMENT OPTIONS

• Zofran: 4mg IVP, may repeat x 2 (12mg total) • Phenergan (Promethazine): 12.5mg diluted in 10cc of NS IVP, may repeat x 1 (25mg total) • Benadryl (Diphenhydramine): 25mg IVP, may repeat x 1 (50mg total)

• Be sure to consider underlying causes of nausea and vomiting. • Be mindful of potential for Acute MI with unexplained nausea and/or vomiting. • Be mindful of the potential for dehydration with nausea and vomiting patients. • Consider potential electrolyte imbalances with nausea and vomiting, especially for prolonged

durations and in the elderly.

68


Altered Mental Status Adult Treatment Guidelines

CPG Number ATG21





CONSIDER UNDERLYING CAUSE • Overdose (intentional or unintentional) • Possible Stroke • Sepsis • Hyperglycemia or Hypoglycemia

FOR SUSPECTED OVERDOSE: GO TO OVERDOSE/TOXIC ABNORMALITIES GUIDELINE

FOR SUSPECTED STROKE: GO TO STROKE GUIDELINE

HYPOGLYCEMIC EMERGENCY IDENTIFIED • FINGER STICK BLOOD GLUCOSE: LESS THAN 70 MG/DL • Consider oral glucose or carbohydrate rich meal • Consider D50: 25gm IVP, repeat PRN • Consider Glucagon: 1mg IM, repeat PRN (if unable to obtain IV access)

HYPERGLYCEMIC EMERGENCY IDENTIFIED

• FINGER STICK BLOOD GLUCOSE: GREATER THAN 200 MG/DL • Provide supportive care as needed • Consider Fluid Bolus: 20cc/kg, repeat PRN when appropriate

69


Stroke Adult Treatment Guidelines

CPG Number ATG22





PERFORM CINCINATI STROKE SCALE

ANY ABNORMALITIES TO ABOVE = STROKE ALERT

FOR ENCOUNTERED HYPOGLYCEMIA: GO TO ALTERED MENTAL STATUS GUIDELINE

PROVIDE NOTIFICATION TO RECEIVING FACILITY AS QUICKLY AS PRACTICAL AND POSSIBLE! • Establish a second IV enroute, ensure blood has been drawn

ESTABLISHE LAST SEEN NORMAL TIME • Transport a witness to the event with the patient if at all possible and practical

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70


Seizures Adult Treatment Guidelines

CPG Number ATG23





CONSIDER UNDERLYING CAUSE • Overdose (intentional or unintentional) • Possible Stroke • Traumatic Event • Hyperglycemia or Hypoglycemia

REFER TO SPECIFIC UNDERLYING CAUSE GUIDELINE AS APPROPRIATE AND PRACTICAL

IF PATIENT ACTIVELY SEIZING • Consider Ativan: 1-2mg IVP, repeat PRN • Consider Versed: 2-5mg IM or IVP, repeat PRN • Consider Valium: 5-10mg IVP, IN or Rectal repeat PRN

• Special consideration should be paid to underlying cause. • Status Epilepticus as a primary cause is a true emergency and aggressive attempts to “break” the

seizure should take place. • Pay close attention to airway patency with the seizing patient. • In female patients who appear to be pregnant, be sure to rule out eclampsia as the cause for the

seizure. If that is the case, Magnesium will be required to control the seizure activity.

71


Allergic Reaction/Anaphylaxis Adult Treatment Guidelines

CPG Number ATG24





MILD REACTION (hives present, no respiratory distress noted)

• Position of comfort • Consider: Fluid Bolus of 500cc • Consider: Benadryl 25-50mg IV or IM • Consider: Solu-Medrol 125mg IV, IM or UDN

SEVERE REACTION (respiratory failure present, severe distress, impending arrest/shock)

• Consider: Fluid Bolus of 500cc • Consider: Epi 1:1,000 0.3-0.5mg SQ or IM • Consider: Epi 1:10,000 0.3-0.5mg IVP if no improvement with SQ or IM, or severe cases • Consider: Benadryl 25-50mg IV or IM • Consider: Solu-Medrol 125mg IV, IM or UDN • Consider: Albuterol 2.5mg via UDN, may repeat PRN

MODERATE REACTION (hives present, WITH wheezing noted)

• Position of comfort • Consider: Fluid Bolus of 500cc • Consider: Benadryl 25-50mg IV or IM • Consider: Solu-Medrol 125mg IV, IM or UDN • Consider: Albuterol 2.5mg via UDN, may repeat PRN

72


Abdominal Pain Adult Treatment Guidelines

CPG Number ATG25





CONSIDER UNDERLYING CAUSE • Cardiac Event • Abdominal Aortic Anurysm • Pregnancy Complications • Infection

CONSIDER ORTHOSTATIC VITAL SIGN ASSESSMENT

CONSIDER FLUID BOLUS: 20CC/KG, repeat PRN

PATIENT TO REMAIN NPO


73


Behavioral Emergencies Adult Treatment Guidelines

CPG Number ATG26





CONSIDER UNDERLYING CAUSE • Overdose (intentional or unintentional) • Trauma • Sepsis • Hyperglycemia or Hypoglycemia

ATTEMPT VERBAL DEESCELATION

CONSIDER PHYSICAL RESTRAINTS • Employ restraints only if necessary • 4-point technique should be used • Evaluate pulse, motor and sensation post restraint applications

CONSIDER SEDATION/CHEMICAL RESTRAINTS • Ativan: 1-2mg IM or IVP, repeat PRN • Versed: 2-5mg IM or IVP, repeat PRN • Valium: 5-10mg IVP, repeat PRN • Haldol: 5mg IM or IVP, repeat PRN

• The use of sedation/chemical restraints should be considered early • The use of physical restrains should only be used if necessary • Any patient being sedated or restrained deserves a full ALS work up and monitoring • Haldol 5mg and Ativan 2mg IM work very well as a combination • Any patient with witnessed Suicidal or Homicidal Ideations MUST be transported for evaluation

74


Hypertensive Emergencies Adult Treatment Guidelines

CPG Number ATG27





CONFIRM TRUE HYPERTENIVE EMERGENCY WITH SYMPTOMS

CONSIDER UNDERLYING CAUSE IF APPLICABLE, GO TO DIFFERENT GUIDLINE

(IE: CP, Pulmonary Edema, Pregnancy Complications, etc.)

CHECK BP IN BOTH ARMS AND CONFIRM HYPERTENSION WITH MANUAL CUFF

CONSIDER NTG: 400MCG SL, repeat PRN

CONSIDER NTG INFUSION: 5-50mcg/min IVPB, titrate to effect

Consider Lopressor: 5mg SIVP, repeat x 2 (15mg total) (hypertension and tachycardia)

• Pay very close attention to probable underlying cause of hypertension • Hypertension is often times a compensatory mechanism • Hypertension is very rarely treated as a primary complaint

75


Cold Related Emergencies Adult Treatment Guidelines

CPG Number ATG28





REMOVE PATIENT FROM THE EVNIRONMENT

HYPOTHERMIA • Initiate infusion of warm IV fluids • Provide heat packs to axillary areas and groin • Cover with warm blankets

HYPOTHERMIC CARDIAC ARREST CONSIDERATIONS • Obtain core temperature • Core temperature greater than 86 F = normal arrest • Core temperature less than 86 F

o Limit defibrillation to 1 total until re-warmed o CPR only; no drug therapy o Warm IV fluids only

76


Heat Related Emergencies Adult Treatment Guidelines

CPG Number ATG29





HEAT EXAUSTION (core temp less than 105)

• Passive cooling only o Cool PO fluids are acceptable

HEAT STROKE

(core temp greater than 105; with symptoms present) • Active cooling techniques

o Ice packs to axillary and groin areas o Cool fluids IV only

REMOVE PATIENT FROM THE EVNIRONMENT

77


Trauma Criteria Adult Treatment Guidelines

CPG Number ATG30



CONTINUED ON NEXT PAGE

TRIAGE PATIENT AND PROVIDED A TRAUMA LEVELING USE THE FOLLOWING CRITERIA & GUIDELINES FOR TRANSPORT DECISIONS

TRUMA LEVEL ONE CRITERIA

Physiologic Criteria • Glasgow Coma Scale < 14 • Systolic Blood Pressure: <90 at any time and/or clinical signs of shock • Respiratory rate: < 10 or > 29 • Heart Rate: >120

Anatomic criteria

• All penetrating injuries to head, neck, torso, and extremities (boxer short and T-shirt areas) proximal to elbow and knee

• Flail chest, airway compromise or obstruction, hemo- or pneumothorax, or • Any intubated trauma patient • Two or more proximal long-bone fractures • Extremity trauma with loss of distal pulse • Amputation proximal to wrist and ankle • Pelvic fractures • Open or depressed skull fractures • Paralysis or signs of spinal cord or cranial nerve injury • Active or uncontrolled hemorrhage • Burns greater than 20% BSA

LEVEL ONE TRAUMA PATIENTS SHOULD BE TRANSPORTED TO A LEVEL I OR II TRAUMA CENTER GOAL = PATIENT TO TRAUMA CENTER WITHIN 60 MINUTES FROM TIME OF INJURY

78

TRUMA LEVEL TWO CRITERIA

• Falls > or = 20 feet (one story = 10 ft.) • High-risk auto crash:

o Any auto crash > 40 mph or highway speeds o Passenger Space Intrusion > 12 inches o Ejection (partial or complete) from automobile o Rollover o Death in same passenger compartment

• High-risk Pedestrian, Cycle, ATV Crash • Auto v. Pedestrian/bicyclist thrown, run over, or with significant (> or = 20 mph) impact • Motorcycle or ATV crash > or = 20 mph with separation of rider or with rollover • Crush, degloved, or mangled extremity • All open fractures • Femur fracture • Trauma with prolonged Loss of Consciousness • Pregnancy with acute abdominal pain and traumatic event • Penetrating injuries distal to T-shirt and boxer area to wrist and to ankle

LEVEL TWO TRAUMA PATIENTS SHOULD BE TRANSPORTED TO A LEVEL I OR II TRAUMA CENTER GOAL = PATIENT TO TRAUMA CENTER WITHIN 90 MINUTES FROM TIME OF INJURY

TRUMA LEVEL THREE CRITERIA

• Age: > age 55 • Falls: 5-20 Feet • Burns less than 20% BSA • Lower-risk Crash:

o MVC < 40 MPH or UNK speed, o Auto v. Pedestrian/bicyclist with <20 mph impact o Motorcycle or ATV crash < 20 mph with separation of rider or rollover

• Anticoagulation and bleeding disorder • End-stage renal disease requiring dialysis • All pregnant patients involved in traumatic event • Near drowning/ Near hanging

LEVEL THREE TRAUMA PATIENTS MAY BE TRANSPORTED TO A LEVEL III TRAUMA CENTER GOAL = PATIENT TO TRAUMA CENTER WITHIN 120 MINUTES FROM TIME OF INJURY

79


General Trauma Care Adult Treatment Guidelines

CPG Number ATG31



PERFORM ROUTINE CARE (on scene or enroute to hospital as deemed appropriate)


RECOMMENDED ON SCENE TRAUMA CARE • Expose patient for appropriate assessment • Identify and address obvious life threats • Consider spinal immobilization

PERFORM TRAUMA TRIAGE • If Level I or II trauma criteria met, transport to Level I or II trauma center UNLESS IN EXTREMIS

REFER TO DESTINATION DECISION GUIDELINE

CONSIDER AIR TRANSPORT IF APPROPRIATE - REFER TO AIR AMBULANCE UTILIZATION GUIDLINE

RECOMMENDED ENROUTE TO HOSPITAL TRAUMA CARE • Provide constant re-assessment • Ensure 2 points of large bore vascular access are achieved, ensure blood is drawn • Consider Fluid Bolus: 20cc/kg, titrate to SBP of 90mm/hg. • Consider splinting any fractures • Ensure patient is warm

• Trauma care should focus on rapid assessment, appropriate trauma triage and rapid transport to the APPROPRIATE facility.

• Most, if not all treatments can and should be done while enroute to the hospital. • A major trauma victim (level I or II) should ONLY be transported to a level III or lower center if the

patient is in extremis (see destination decision guideline). • When in doubt, up-triage the trauma patient and transport to a level I or II trauma center.

80


Traumatic Arrest Adult Treatment Guidelines

CPG Number ATG32



CONFIRM PATIENT IN FULL ARREST FROM APPARENT TRAUMATIC EVENT

CONSIDER NOT RESUSITATING THE PATIENT – GO TO OF DEATH GUIDLINE AS APPROPRIATE

INITIATE BLS CPR • BLS Airway if adequate and appropriate • Compressions at 100/min

ADVANCED AIRWAY MANAGEMENT

BILATERAL NEEDLE THORACENTESIS

OBATAIN LARGE BORE VASCULAR ACCESS X 2

RAPID FLUID ADMINISTRATION • ALL ACCESS POINTS TO NS AT W/O RATE

CONSIDER BINDING PELVIS IS APPROPRIATE AND PRACTICAL

CONSIDER SPLINTING LONG BONE FRACTURES IF APPROPRIATE AND PRACTICAL

CONSIDER SODIUM BICARBONATE: 1MEQ/KG IVP

CONSIDER EPI 1:10,000: 1MG IVP, repeat every 3-5 minutes

CONSIDER UNDERLYING MEDICAL CAUSE FOR ARREST

YES: RESUSCITATION IS INDICATED • Rapid transport to closest facility; all interventions to be done enroute

RETURN OF SPONTANEUS CIRCULATION ACHIEVED? YES: CONSIDER TRANSPORT TO LEVEL I OR II TRAUMA CENTER

SEE DESTINATION DECISION GUIDELINE AS APPROPRIATE

81


Crush Injuries Adult Treatment Guidelines

CPG Number ATG33





CONSIDER SODIUM BICARBONATE: 1MEQ/KG IN 1L OF NS, WIDE OPEN

FLUID BOLUS: 2L OF NORMAL SALINE

REFER TO GENERAL TRAUMA GUIDELINE AS APPROPRIATE AND PRACTICAL

REFER TO OVERDOSE/TOXIC AMBNORMALITIES GUIDELINE IF S/S OF HYPERAKELMIA

• Crush injuries should be suspected with entrapment/compression of greater than one hour, especially when a large muscle mass/group is involved

• Treatment of the patient at risk for Crush Syndrome should begin before the patient is removed when practical

82


Amputations Adult Treatment Guidelines

CPG Number ATG34





CARE OF THE AMPUTATED PART • Rinse off contaminates with sterile water or saline • Wrap amputated part with sterile dressing moistened with saline and place in sealed bag • Place sealed bag in into ice

REFER TO GENERAL TRAUMA GUIDELINE AS APPROPRIATE AND PRACTICAL

83


Burns Adult Treatment Guidelines

CPG Number ATG35





THE FOLLOWING SHOULD TRIAGE A PATIENT TO A BURN CENTER (Mercy Hospital St. Louis)

• Partial thickness burns greater than 10% total body surface area (TBSA) • Any burn that involve the face, hands, feet, genitalia, perineum, or major joints • Any full thickness (3rd degree) burns • Any electrical burns, including lightning injury • Any chemical burns • Any inhalation injury

STOP THE BURNING PROCESS

COVER THE BURN AREA WITH DRY STERILE DRESSINGS

FLUID RESUSCITATE USING THE PARKLAND FORMULA

• Use the rule of 9’s for calculation

• Consider RSI early, if any signs of airway burn / inhalation injury • Burns are very painful, treat pain very aggressively • Be cautious to over fluid resuscitate

84

RULE OF 9’S CRITERIA FOR ADULT PATIENTS

PARKLAND FORMULA

2CC X %BSA X WEIGHT (KG)

THIS AMOUNT TO BE ADMINISTERED OVER THE FIRST 8 HOURS

REMEMBER: FLUID RESCUSITATION AS NEEDED FOR HEMODYNAMIC STATUS OVER-RULES PARKLAND FORMULA

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85


Envenomation Adult Treatment Guidelines

CPG Number ATG36





PROVIDE SUPPORTIVE CARE

CONSIDER TRANSPORT TO BARNES-JEWISH HOSPITAL FOR TOXICOLOGY SPECIALTY SERVICES FOR SEVERE CASES OF ENVENOMATION

SEE DESTINATION DECISION GUIDELINE AS APPROPRIATE

86


Child Birth Adult Treatment Guidelines

CPG Number ATG37





NORMAL PRESENTATION • Assist with delivery

LIMB PRESENTATION

• Create an airway for the infant with a gloved hand • Rapid transport

BREECH PRESENTATION

• Allow buttocks and limbs to deliver • If head does not deliver; create an airway for the infant with a gloved hand • Rapid transport

PROLAPSED CORD PRESENTATION

• Lift the infants head off of the wall of the vaginal wall • Attempt to slip the umbilical cord off from around the infants neck • Rapid transport

POST DELIVERY CARE

• Basic care for the new-born as needed; keep warm • Clamp and cut umbilical cord; 10 inches from the infants body • Prepare for delivery of the placenta • For post-partum hemorrhage: Pitocin 10mg/1000cc NS @ w/o rate

87


Pregnancy Complications Adult Treatment Guidelines

CPG Number ATG38





GENERAL OB COMPLAINTS • Transport in the left-lateral recumbent position • Provide routine care as appropriate

PRE-ECLAMPSIA

• Defined as 3rd trimester hypertension with noted edema; no seizure activity • Consider: Magnesium Sulfate 4gm/100cc D5W, IVPB over 20 minutes • Transport in the left-lateral recumbent position

ECLAMPSIA • Defined as 3rd trimester hypertension, noted edema and with seizure activity • Consider: Magnesium Sulfate 4gm/100cc D5W, IVPB over 20 minutes • Transport in the left-lateral recumbent position

88

SECTION THREE PEDIATRIC TREATMENT GUIDELINES

FOR THE PURPOSE OF THESE GUIDELINES, A PEDIATRIC PATIENT WILL BE CONSIDERED ANY HUMAN UNDER THE AGE OF 18 YEARS OLD.

CLINICIANS WILL HAVE TO USE THEIR BEST JUDGEMENT FOR MEDICATION DOSEAGES WITH REGARDS TO THEIR PATIENTS SIZE.

AS A GENERAL RULE, IF THE PATIENT IS TOO TALL TO USE THE LENGTH BASED RESUSITATION TAPE AS A GUIDE; USE ADULT MEDICATION DOSEAGES.

89


Routine Care Pediatric Treatment Guidelines

CPG Number PED1



It is the policy of Valle Ambulance District to provide quality clinical care in the safest manner possible. Through that vision, we have developed the following routine care procedures that shall be used on every pediatric patient encounter.

Ensure scene safety Bring all necessary equipment to the patient’s side

Demonstrate professionalism and courtesy

Don personal protective equipment Airborne or droplet precautions if indicated

Assess CABs, and intervene if indicated

Control any major bleeding Provide oxygen and assist ventilations if indicated

Spinal immobilization if indicated Obtain chief complaint, associated signs/symptoms

Obtain complete set of vital signs Obtain past medical history and SAMPLE-type history

Where appropriate, provide routine ALS care:

• Establish vascular access, draw blood • Monitor cardiac rhythm • Perform multi-lead EKG as appropriate • Measure and monitor waveform ETCO2 • Measure and monitor SPO2 • Measure blood glucose

CONTACT MEDICAL CONTROL PHYSICIAN AT ANY TIME DURING PATIENT ENCOUNTER WHEN GUIDANCE IS NEEDED

TRANSPORT PATIENTS ACCORDING TO DESTINATION DECISION OPERATIONAL POLICY

REFER TO LENGTH BASED RESUSCITATION TAPE FOR ALL MEDICIATION DOSEAGES

90


General Airway Management Pediatric Treatment Guidelines

CPG Number PED2



mO

Assess ABC’s Assess Respiratory Rate, Rhythm Quality

Assess Airway Patency ADEQUATE

INADEQUATE

Provide Appropriate Monitoring • Consider monitoring SPO2 • Consider monitoring ETCO2

Provide BLS Airway Management • Position/Adjunct/Suction • Ventilatory Support w/ O2

Provide Basic Treatment • Provide Oxygen as appropriate • Transport in position of comfort

Provide Appropriate Monitoring • SPO2 & ETCO2 • EKG & NIBP

Provide ALS Airway Management • Intubation (Oral/Nasal) • RSI as needed

Package & Transport • Follow Post Intubation Management

Guideline as appropriate

IF UNABLE TO MAINTAIN AIRWAY, UNABLE TO VENTILATE, AND/OR

UNABLE TO OXYGENATE AT ANY TIME:

GO DIRECTLY TO: FAILED AIRWAY GUIDELINE

IF AIRWAY OBSTRUCTION ENCOUNTERED AT ANY TIME:

GO DIRECTLY TO: AIRWAY OBSTRUCTION GUIDELINE

91


Airway Obstruction Pediatric Treatment Guidelines

CPG Number PED3



CONFIRM AIRWAY OBSTRUCTION IS PRESENT • Assess Mental Status

CONSCIOUS PATIENT

• Perform Heimlich maneuver or back blows/chest thrusts until: C. Obstruction is removed or D. Patient becomes unconscious

UNCONSCIOUS PATIENT • Check for foreign body visible in mouth; remove if found • Begin CPR with compressions first

IF ABOVE IS UNSUCCESSFUL: INITIATE ALS PROCEDURES • Perform direct laryngoscopy and attempt to remove obstruction

o Suction o Forceps

• If able to remove obstruction, go to Airway Management Guideline • If unable to remove obstruction, go to Failed Airway Guideline

IF SUCCESSFUL: GO TO AIRWAY MANAGEMENT GUIDELINE


92


Failed Airway Pediatric Treatment Guidelines

CPG Number PED4



The encountered failed airway is something that each clinician at Valle Ambulance District must be prepared for. Proper reaction to the failed pediatric airway is paramount in the survivability of the critically ill patient. Should a failed airway be encountered, use the following algorithm.

FALL BACK TO BASICS – BLS AIRWAY MANAGEMENT

• Good positioning of patient • BLS airway adjuncts • Good suction • 2 person BVM technique

CONSIDER RESCUE AIWAY

(if unable to ventilate/oxygenate with BVM)

• King Tube

EMERGENCY CRICOTHYROTOMY (if unable to ventilate/oxygenate with BVM and unable to place rescue airway)

• Needle Cricothyrotomy (under 8 years old) • Quick-Trach (over 8 years old) • Surgical Cricothyrotomy (over 8 years old)

GO TO POST INTUBATION MANAGEMENT GUIDELINE AS APPROPRIATE

93


Rapid Sequence Intubation Pediatric Treatment Guidelines

CPG Number PED5



CONFIRM RSI IS INDICATED (one of the items below)

• Inadequate ventilation and/or oxygenation is present • Patient is unable to maintain airway • Predicted clinical course indicates need for airway management

PREPERATION

• Gather and assemble all tools, 2 IV’s in place • Ready all medications (RSI and post intubation)

PREOXYGENATION • Provide 100% FiO2 by LEAST INVASIVE means possible • Avoid BVM if at all possible

PREMEDICATION • Consider Fentanyl for pain: 0.5-2.0mcg/kg IV or IO • Consider Atropine: .02mg/kg (max 0.5mg) IV or IO • Fluid bolus if patient is hypotensive or borderline hypotensive

PARALYSIS WITH INDUCTION (simultaneous administration of sedative & paralytic is required)

• SEDATION (pick one) o Etomidate: 0.3mg/kg IV or IO o Versed: 0.1mg/kg IV or IO

• PARALYTIC (pick one) o Succinylcholine: 1.0-1.5mg/kg IV or IO (max single dose 200mg) o Rocuronium: 1.0mg/kg IV or IO (if Succinylcholine is contraindicated)

PLACEMENT WITH PROOF • Oral Intubation, use bougie


IF SUCCESSFUL GO TO POST INTUBATION MANAGEMENT GUIDELINE

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INFORMATION ON RAPID SEQUENCE INTUBATION

The process of Rapid Sequence Intubation is designed to take an airway from a patient that has one of the following at the time of exam:

A. Inadequate ventilation and/or oxygenation present and not responding to conventional treatments (Oxygen by mask, CPAP, other treatments, etc.).

B. Inability to maintain airway (altered mental status, unconsciousness, etc.). C. Predicted clinical course that indicates a need for airway management (severe

combative nature, obvious head injury, major trauma, etc.). Rapid Sequence Intubation should not be taken lightly. This is a skill that by definition, is taking away something the patient has. The clinician performing the RSI should be completely confident in his or her ability to manage the patient’s airway. Prior to performing the RSI, the clinician should perform a thorough risk vs. benefit analysis on the patient to confirm that RSI is in fact the indicated and appropriate treatment. The clinician should perform a complete assessment of the airway and predict any difficulties that may arise. The clinician should go into the RSI situation with the “worst case scenario” in mind, and be prepared to manage that scenario. Use a length based resuscitation tape to guide your medication doses. Please Note: After any attempt at RSI, the Chief Medical Officer will be contacted by the on-duty crew immediately after transferring care to discuss the case.

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Post Intubation Management Pediatric Treatment Guidelines

CPG Number PED6



The post intubation management guideline was developed for the treatment of any patient who has an artificial airway in place (ET tube, rescue airway, emergency cricothyrotomy).

CONFIRM AIRWAY IS PATENT AND SECURED • Lung sounds remain present, epigastric sounds remain absent • Continuous monitoring of waveform ETCO2 is REQUIRED (ideal range is 35-45) • Secure the airway with a commercial device, when available

CONSIDER PLACEMENT A GASTRIC TUBE • Oral route is preferred; see length based resuscitation tape for sizing.

CONSIDER SEDATION • Versed: 0.1mg/kg max 5mg IV or IO every 10-20 minutes (used for normotensive patients) • Ativan: 0.1mg/kg, max 2mg IV or IO every 10-20 minutes (used for hypotensive patients)

CONSIDER ANALGESIA

• Fentanyl : 0.5-2.0mcg/kg IV or IO every 10-20 minutes o Consider half dose or withholding if patient is hypotensive

CONSIDER CONTINED PARALYSIS

• Vecuronium: 0.1mg/kg IV or IO (will last 60 minutes)

PROVIDE CONTINUOUS REASSESSMENT • Maintain constant ETCO2 monitoring • Vital signs every 5 minutes • Assume intubated patients are under sedated and in pain; treat accordingly

ENSURE ADEQUATE VENTILATION & OXYGENATION • Provide 100% FIO2 • Either with bag valve device or mechanical ventilator • Ensure adequate tidal volume (6-8cc/kg) • Ensure adequate respiratory – normal ETCO2 35-45 • Consider adding mechanical PEEP, unless contraindicated (usually 5-10cm/H2O)

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Bronchospasm Pediatric Treatment Guidelines

CPG Number PED7






• Consider assisting ventilations as needed • Consider RSI at any time in this guideline

Consider Albuterol: 2.5mg via UDN, repeat PRN (respiratory distress – wheezing and/or rhonchi)

Consider Decadron: 0.6mg/kg, max 10mg, IVP or IM (presumed lung injury – patient under the age of 6 years)

Consider Magnesium Sulfate: Infusion 40mg/kg (max 2gm) in 100cc IVPB over 10 minutes (severe distress)

Consider Xopenex: .63mg via UDN, repeat x 2 PRN (if patient is tachycardic for age)

Consider Solu-Medrol: 125mg IVP, IM or UDN (presumed lung injury – patient over the age of 6 years)

Consider Nebulized Epinephrine: .25mg 1:1,000 in 3cc of NS via UDN, 1 time only (for suspected croup only)

97


Tachycardia Pediatric Treatment Guidelines

CPG Number PED8



• For pulsing V-Tach consider Lidocaine bolus: 1.0-1.5mg/kg, followed by infusion if conversion is successful

• Consider sedation and pain management for the purpose of cardioversion, when possible and practical

• Consider underlying cause of the tachycardia; treat appropriately

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Bradycardia Pediatric Treatment Guidelines

CPG Number PED9



• Consider underlying cause of the bradycardia; treat appropriately • The presence of bradycardia in pediatric patients is hypoxia until proven otherwise

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Cardiac Arrest BLS Resuscitation Pediatric Treatment Guidelines

CPG Number PED10



• Switch to appropriate ACLS guideline as quickly as possible and practical

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100


Cardiac Arrest PALS Resuscitation Pediatric Treatment Guidelines

CPG Number PED11



For VF/VT, consider Lidocaine bolus: 1.0-1.5mg/kg IVP, followed by infusion if conversion successful IN PLACE OF AMIODARONE

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Shock (Non-Trauma) Pediatric Treatment Guidelines

CPG Number PED12





IS PATIENT SYMPTOMATIC? NO YES

OVSERVE AND TRANSPORT

MAINTAIN SUPPORTIVE CARE

CONSIDER UNDERLYING CAUSES • PRIMARILLY CARDIAC CONCERNS • USE APROPRIATE GUIDLINE PRN

CONSIDER FLUID BOLUS: 20CC/KG • CONSIDER LUNG SOUNDS • CONSIDER ADDITIONAL FLUIDS PRN

CONSIDER DOPAMINE INFUSION • Indicated for HR and BP control • Dose is 5-20mcg/kg/min IVPB

CONSIDER EPINEPHERINE INFUSION • Indicated for HR and BP control • Dose is 0.1-1.0mcg/kg/min IVPB

USE CAUTION WITH VASOPRESSORS

MAINTAIN INFUSION ON MEDICATION PUMP IF AVAILABLE

TAKE SERIOUS CONSIDERATION OF

UNDERLYING CAUSE INTO ACCOUNT

ENSURE PROPER PRE-LOAD IS PRESENT (FLUID STATUS) PRIOR TO

STARTING VASOPRESSORS

CONSIDER NOREPINEPHERINE INFUSION • Indicated for BP control • Dose is 0.1-1.0mcg/kg/min IVPB

102

INFORMATION ON VASOPRESSORS

DOPAMINE

• Dopamine is an inotrope, alpha drug and beta drug. • Dopamine infusions will provide the following effects based on dose:

o 5mcg/kg/min: primarily isotropic and beta effects Increase contractility (squeeze on heart) Increase heart rate

o 10-15mcg/kg/min: alpha and beta effects Increase contractility (squeeze on heart) Increase heart rate Increase systemic vascular resistance (squeeze the pipes)

o 20mcg/kg/min: primarily alpha effects Increase systemic vascular resistance (squeeze the pipes)

• Dopamine is primarily used for true cardiogenic shock patients (IE: post arrest or impending arrest), at the 10-15mcg/kg/min range.

EPINEPHERINE

• Epinephrine is a naturally occurring hormone in the body. • Epinephrine has both alpha and beta effects on the body. • Epinephrine is to be used primarily for “COLD SHOCK” type states.

o Bradycardic patients that are also hypotensive • Epinephrine is to be used as the primary vasopressor for severe anaphylaxis.

NOREPINEPHERINE

• Norepinephrine (Levophed) is primarily an alpha medicine. • Norepinephrine will increase systemic vascular resistance (squeeze the pipes) but will

not affect the patient’s heart rate. • Norepinephrine is the drug of choice in severe sepsis. • Use caution and ensure the patient has appropriate pre-load (fluid status) prior to use.

FOR FURTHER DETAILED INFORMATION, PLEASE SEE EACH INDIVIDUAL DRUG PROFILE IN THE APPROVED MEDICATION FORMULARY AT THE END OF THIS DOCUMENT.

103


Overdose/Toxic Abnormalities Pediatric Treatment Guidelines

CPG Number PED13



Abnormality History / Symptoms Treatment Opiate Overdose

• Pain Medicines • Heroine

- Unconsciousness - Inadequate breathing

Narcan: 0.1mg/kg IN, IM, IV Titrate to effect; repeat PRN

Calcium Channel Blocker Overdose • IE: Cardizem


Calcium Chloride: 20mg/kg IVP

Beta-Blocker Overdose • IE: Metoprolol


Glucagon: 0.5-5mg IVP

Tricyclic Overdose • IE: Amitriptyline

- Wide QRS Noted - V-Tach Noted

Sodium Bicarbonate: 1mEQ/kg IVP

Organo-Phosphate Poisoning • Most pesticides

- SLUDGE Noted Atropine: 0.02mg/kg IVP Titrate to effect; repeat PRN

Stimulant Ingestion • Cocaine • Meth • Bath Salts

- Tachycardia Present - Hypertension Present - Combative - Hallucinating

Ativan: 0.5-4mg IV or IM Valium: 1-15mg IV Versed: 1-10mg IV or IM

Hyperkalemia • History of Renal Failure or

insufficiency

- Bradycardia Present - Hypotension Present - Peaked “T Waves” - Wide QRS Noted

Sodium Bicarbonate: 1mEQ/kg IVP and Calcium Chloride: 20mg/kg IVP


104


General Pain Management Pediatric Treatment Guidelines

CPG Number PED14





ASSESS PAIN LEVEL • Pain is considered a vital sign; should be documented as such. • Pain should be interpreted as mild, moderate or severe

MINOR PAIN TREATMENT OPTIONS

• Position of comfort • Verbal distractions • Ice or heat pack for comfort

MODERATE PAIN TREATMENT OPTIONS • Morphine: 0.01mg/kg IVP or IM, max single dose 5mg, repeat PRN • Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN • Dilaudid: 0.02mg/kg IVP or IM, max single dose 2mg, repeat PRN

SEVERE PAIN TREATMENT OPTIONS • Morphine: 0.01mg/kg IVP or IM, max single dose 5mg, repeat PRN • Fentanyl: 0.5-2.0mcg/kg IVP or IM, repeat PRN • Dilaudid: 0.02mg/kg IVP or IM, max single dose 2mg, repeat PRN

• Confirm all contraindications of medicines prior to use. • Confirm medication allergies prior to use of pain medicines. • Full patient monitoring must be used when narcotics are administered.

105


Procedural Sedation Pediatric Treatment Guidelines

CPG Number PED15





CONFIRM THE NEED FOR SEDATION IS PRESENT (pacing, cardioversion, etc.)

ENSURE HEMODYNAMIC STABILITY

CONSIDER SEDATION • Ativan: 0.1mg/kg, max 2mg IVP or IM, repeat PRN • Versed: 0.1mg/kg, max 5mg IVP or IM, repeat PRN • Valium: 1-5mg IVP, repeat PRN

• The use of procedural sedation is intended for patients requiring invasive procedures not able to be tolerated in an awake and alert state.

• Most of these procedures are painful; be sure to treat for pain as well as providing sedation. • The need for procedural sedation in the pediatric patient in the field should be very rare.

106


Nausea & Vomiting Pediatric Treatment Guidelines

CPG Number PED16





PROVIDE GENERAL COMFORT MEASURES • Position of comfort • Consider: Fluid Bolus of 20cc/kg, repeat PRN

TREATMENT OPTION

• Zofran: 0.15mg/kg, max 4mg IVP or IM, may repeat x 2

• Be mindful of the potential for dehydration with nausea and vomiting patients. • Consider potential electrolyte imbalances with nausea and vomiting, especially for prolonged

durations.

107


Seizures Pediatric Treatment Guidelines

CPG Number PED17





CONSIDER UNDERLYING CAUSE • Overdose (intentional or unintentional) • Possible Stroke • Traumatic Event • Hyperglycemia or Hypoglycemia


IF PATIENT ACTIVELY SEIZING • Consider Ativan: 0.1mg/kg, max 2mg IVP or IM, repeat PRN • Consider Versed: 0.2mg/kg, max 5mg IVP or IM, repeat PRN • Consider Valium: 1-5mg IVP, IM, IN or Rectal, repeat PRN

• Special consideration should be paid to underlying cause. • Status Epilepticus as a primary cause is a true emergency and aggressive attempts to “break” the

seizure should take place. • Pay close attention to airway patency with the seizing patient. • In pediatric patients, fever is a very common cause of seizures.

108


Allergic Reaction/Anaphylaxis Pediatric Treatment Guidelines

CPG Number PED18





MILD REACTION (hives present, no respiratory distress noted)

• Position of comfort • Consider: Fluid Bolus of 20cc/kg • Consider: Benadryl Consider: Benadryl: 2-5mg/kg, max 50mg IVP • Consider: Solu-Medrol: 30mcg/kg, max of 125mg IVP, IM or UDN

SEVERE REACTION (respiratory failure present, severe distress, impending arrest/shock)

• Consider: Fluid Bolus of 20cc/kg • Consider: Epi 1:1,000: 0.01mg/kg, max of 0.3mg IM • Consider: Epi 1:10,000: 0.01mg/kg, max of 0.1mg IVP • Consider: Benadryl: 2-5mg/kg, max 50mg IVP • Consider: Solu-Medrol: 1-2mg/kg, max of 125mg IVP, IM or UDN • Consider: Albuterol: 2.5mg via UDN, repeat PRN

MODERATE REACTION (hives present, WITH wheezing noted)

• Position of comfort • Consider: Fluid Bolus of 20cc/kg • Consider: Benadryl: 2-5mg/kg, max 50mg IVP • Consider: Solu-Medrol: 1-2mg/kg, max of 125mg IVP, IM or UDN • Consider: Albuterol: 2.5mg via UDN, repeat PRN

109


Fever Pediatric Treatment Guidelines

CPG Number PED19





CONSIDER UNDERLYING CAUSE

PROVIDE GENERAL COMFORT MEASURES • Position of comfort • Consider: Fluid Bolus of 20cc/kg, repeat PRN

Consider Tylenol: 10mg/kg PO

Consider Ibuprofen: 10mg/kg PO (patient must be older than 6 months)

110


Altered Mental Status Pediatric Treatment Guidelines

CPG Number PED20





CONSIDER UNDERLYING CAUSE • Overdose (intentional or unintentional) • Possible Stroke • Sepsis • Hyperglycemia or Hypoglycemia

FOR SUSPECTED OVERDOSE: GO TO OVERDOSE/TOXIC ABNORMALITIES GUIDELINE

HYPOGLYCEMIC EMERGENCY IDENTIFIED • FINGER STICK BLOOD GLUCOSE: LESS THAN 70 MG/DL • Consider oral glucose or carbohydrate rich meal • Consider D25 (1 y/o to 6 y/o): 1gm/kg IVP, repeat PRN • Consider D10 (less than 1 y/o): 1gm/kg IVP, repeat PRN

HYPERGLYCEMIC EMERGENCY IDENTIFIED

• FINGER STICK BLOOD GLUCOSE: GREATER THAN 200 MG/DL • Provide supportive care as needed • Consider Fluid Bolus: 20cc/kg, repeat PRN when appropriate

111


Abdominal Pain Pediatric Treatment Guidelines

CPG Number PED21





CONSIDER UNDERLYING CAUSE

CONSIDER ORTHOSTATIC VITAL SIGN ASSESSMENT

CONSIDER FLUID BOLUS: 20CC/KG, repeat PRN

PATIENT TO REMAIN NPO


112


Behavioral Emergencies Pediatric Treatment Guidelines

CPG Number PED22





CONSIDER UNDERLYING CAUSE • Overdose (intentional or unintentional) • Trauma • Sepsis • Hyperglycemia or Hypoglycemia

ATTEMPT VERBAL DEESCELATION

CONSIDER PHYSICAL RESTRAINTS • Employ restraints only if necessary • 4-point technique should be used • Evaluate pulse, motor and sensation post restraint applications

CONSIDER SEDATION/CHEMICAL RESTRAINTS • Ativan: 0.1mg/kg, max 2mg IVP or IM, repeat PRN • Versed: 0.1mg/kg, max 5mg IVP or IM, repeat PRN • Valium: 1-5mg IVP, repeat PRN

• The use of sedation/chemical restraints should be considered early • The use of physical restrains should only be used if necessary • Any patient being sedated or restrained deserves a full ALS work up and monitoring • Any patient with witnessed Suicidal or Homicidal Ideations MUST be transported for evaluation

113


Trauma Criteria Pediatric Treatment Guidelines

CPG Number PED23



TRIAGE PATIENT AND ESTABLISH IF CRITERIA IS MET USE THE FOLLOWING CRITERIA & GUIDELINES FOR TRANSPORT DECISIONS

PEDIATRIC TRUMA CRITERIA

Physiologic Criteria • Glascow Coma Scale < 14 • Respiratory distress or failure • Any intubated trauma patient • Shock of any type, compensated or uncompensated

Anatomic Criteria

• Fractures and penetrating injuries to an extremity which may be complicated by neurovascular and/or compartment injury

• Fracture of two or more long bones • Suspected Injury to the axial skeleton or spinal cord • Traumatic amputation and crush injuries • Significant head injury • Penetratingwounds to the head, neck, thorax, abdomen, pelvis or proximal extremity • Pelvic fracture • Blunt injury to the chest or abdomen • Ocular injuries • Burns greater than 10% or any 3rd degree burns

PEDIATRIC TRAUMA PATIENTS SHOULD BE TRANSPORTED TO A PEDIATRIC LEVEL I TRAUMA CENTER (ST. LOUIS CHILDRENS HOSPITAL OR CARDINAL GLENNON).

GOAL = PATIENT TO TRAUMA CENTER WITHIN 60 MINUTES FROM TIME OF INJURY

114


General Trauma Care Pediatric Treatment Guidelines

CPG Number PED24



PERFORM ROUTINE CARE (on scene or enroute to hospital as deemed appropriate)

• Assess and monitor vital signs and EKG • Assess and support ABC’s as needed • Provide Oxygen, as appropriate, titrate SPO2 >94% • Provide routine monitoring: EKG, NIBP & SPO2, as appropriate • Establish vascular access, draw blood

RECOMMENDED ON SCENE TRAUMA CARE • Expose patient for appropriate assessment • Identify and address obvious life threats • Consider spinal immobilization

PERFORM TRAUMA TRIAGE • If trauma criteria met, transport to PEDIATRIC Level I trauma center UNLESS IN EXTREMIS

REFER TO DESTINATION DECISION GUIDELINE

CONSIDER AIR TRANSPORT IF APPROPRIATE - REFER TO AIR AMBULANCE UTILIZATION GUIDLINE

RECOMMENDED ENROUTE TO HOSPITAL TRAUMA CARE • Provide constant re-assessment • Ensure 2 points of access are achieved, ensure blood is drawn • Consider Fluid Bolus: 20cc/kg, titrate to low end of normal BP for patient’s age. • Consider splinting any fractures • Ensure patient is warm

• Trauma care should focus on rapid assessment, appropriate trauma triage and rapid transport to the APPROPRIATE facility.

• Most, if not all treatments can and should be done while enroute to the hospital. • A major trauma victim (meeting trauma criteria) should ONLY be transported to a level III or lower

center if the patient is in extremis (see destination decision guideline). • When in doubt, up-triage the trauma patient and transport to a PEDIATRIC level I trauma center.

115


Burns Pediatric Treatment Guidelines

CPG Number PED25





THE FOLLOWING SHOULD TRIAGE A PATIENT TO A BURN CENTER (St. Louis Children’s Hospital)

• Partial thickness burns greater than 10% total body surface area (TBSA) • Any burn that involve the face, hands, feet, genitalia, perineum, or major joints • Any full thickness (3rd degree) burns • Any electrical burns, including lightning injury • Any chemical burns • Any inhalation injury

STOP THE BURNING PROCESS

COVER THE BURN AREA WITH DRY STERILE DRESSINGS

FLUID RESUSCITATE USING THE PARKLAND FORMULA

• Use the modified rule of 9’s for calculation

• Consider RSI early, if any signs of airway burn / inhalation injury • Burns are very painful, treat pain very aggressively • Be cautious to over fluid resuscitate

116

RULE OF 9’S CRITERIA FOR PEDIATRIC PATIENTS

PARKLAND FORMULA

2CC X %BSA X WEIGHT (KG)

THIS AMOUNT TO BE ADMINISTERED OVER THE FIRST 8 HOURS

REMEMBER: FLUID RESCUSITATION AS NEEDED FOR HEMODYNAMIC STATUS OVER-RULES PARKLAND FORMULA

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SECTION FOUR MEDICATION FORMULARY

118


Adenosine Medication Formulary

CPG Number MED1



CLASS: Antiarrhythmic

ACTION: Slows AV conduction

INDICATIONS: SVT

CONTRAINDICATIONS: Second or third degree heart block

Sick-sinus syndrome

Known hypersensitivity to the drug

SIDE EFFECTS: Facial flushing, headache, shortness of breath, dizziness, and nausea

ADULT DOSE: 1ST: 6mg rapid IVP

2ND: 12MG rapid IVP

PEDIATRIC DOSE: 1st: 0.1mg/kg rapid IVP

2nd: 0.2mg/kg rapid IVP

ROUTE: Rapid IV push

Should be given via IV in AC or EJ if at all possible

IO route is acceptable

Be cautious to consider underlying cause of tachycardia

119


Albuterol Medication Formulary

CPG Number MED2



CLASS: Beta-adrenergic; sympathomemetic bronchodilator

ACTION: Relaxes bronchial smooth muscles

INDICATIONS: Respiratory distress with evidence of bronchospasms

CAUTIONS: Patients with tachycardia

SIDE EFFECTS: Palpatations, tachycardia, nervousness, GI upset

ADULT DOSE: 2.5mg in 3cc, repeat as needed

PEDIATRIC DOSE: 0.05mg/kg, max single dose of 2.5mg, repeat as needed

ROUTE: Up-draft nebulizer

120


Amiodarone Medication Formulary

CPG Number MED3



CLASS: Class III Antiarrhythmic

ACTIONS: Sodium, Calcium, Potassium channel blocker

Prolongs intranodal conduction

Prolongs refractory period of AV node

INDICATIONS: Any ventricular arrhythmia, any malignant tachycardia

CONTRAINDICATIONS: Second and third degree heart blocks, bradycardia

SIDE EFFECTS: Hypotension, bradycardia

ADULT DOSE: Full Arrest: 300mg IVP, then 150mg IVP

Pulse Present or Post Conversion: 150mg/100cc D5W IVPB over 10min

Maintenance Infusion: 900mg/500cc D5W, 1mg/min or 33.3cc/hr

PEDIATRIC DOSE: 5mg/kg, max single dose 300mg, all situations

ROUTE: IVP, IVPB, IO

121


Aspirin Medication Formulary

CPG Number MED4



CLASS: Platelet inhibitor

ACTIONS: Blocks platelet aggregation

INDICATIONS: Chest pain of suspected cardiac origin

CONTRAINDICATIONS: Hypersensitivity

ADULT DOSE: 324mg

PEDIATRIC DOSE: NOT INDICATED

ROUTE: PO

122


Atropine Medication Formulary

CPG Number MED5



CLASS: Anticholinergic

ACTIONS: Blocks acetylcholine receptors

Increases heart rate

Decreases gastrointestinal secretions

INDICATIONS: Symptomatic Bradycardia

Organophosphate Poisoning

CONTRAINDICATIONS: None when used in emergency situations

ADULT DOSE: Bradycardia: 0.5mg every 5 minutes (max 3mg)

Organophosphate Poisoning: 2-5mg

PEDIATRIC DOSE: Bradycardia: 0.02mg/kg (min. dose 0.1mg)

Organophosphate Poisoning: 0.05mg/kg (max 3mg) ROUTE: IVP or IO

123


Calcium Chloride Medication Formulary

CPG Number MED6



CLASS: Electrolyte

ACTIONS: Increases cardiac contractility

INDICATIONS: Hyperkalemia

Calcium Channel Blocker overdose

Antidote for Magnesium Sulfate


ADULT DOSE: 1-4g, repeat PRN

PEDIATRIC DOSE: 2-4mg//kg, max single dose 4g, repeat PRN ROUTE: IVP or IO

124


Decadron Medication Formulary

CPG Number MED7



CLASS: Corticosteroid

ACTIONS: Anti-inflammatory

INDICATIONS: Pediatric respiratory distress with presumed lung injury


ADULT DOSE: Not recommended

PEDIATRIC DOSE: 0.6mg/kg x 1 only ROUTE: IM, IVP or IO

125


Dextrose Medication Formulary

CPG Number MED8



CLASS: Carbohydrate

ACTIONS: Elevates blood glucose level rapidly

INDICATIONS: Hypoglycemia


ADULT DOSE: D50%: 25g IVP, repeat PRN

PEDIATRIC DOSE: D25% (1yr-6yr): 1g/kg, repeat PRN

D10% (less than 1 year): 1g/kg, repeat PRN ROUTE: IVP or IO

126


D5W Medication Formulary

CPG Number MED9



CLASS: Water soluble carbohydrate source

ACTIONS: Provides calories for some metabolic needs The fluid is isotonic when in the container. After administration, the dextrose is quickly metabolized in the body, leaving only water which is a hypotonic fluid.

INDICATIONS: Vehicle for mixing medications for IV delivery for all age groups


ADULT DOSE: Dependant on specific medication mixed with solution

PEDIATRIC DOSE: Dependant on specific medication mixed with solution ROUTE: IVP or IO

127


Diazepam (Valium) Medication Formulary

CPG Number MED10



CLASS: Benzodiazepine, sedative-hypnotic, anticonvulsant

ACTIONS: Acts on the CNS to potentiate the effects of inhibitory neurotransmitters

INDICATIONS: Status epilepticus

Chemical restraint Acute alcohol withdraws

Muscle relaxant Procedural sedation

CONTRAINDICATIONS: Sever hypotension

ADULT DOSE: 1-10mg, repeat PRN

PEDIATRIC DOSE: 1-5mg, max single dose10mg, repeat PRN ROUTE: IN, IM, IVP, IO, Rectal

128


Dilaudid Medication Formulary

CPG Number MED11



CLASS: Narcotic, opiate

ACTIONS: Central nervous system depressant

Causes peripheral vasodilatation

Decreases sensitivity to pain

INDICATIONS: Severe pain CONTRAINDICATIONS: Profound hypotension


PEDIATRIC DOSE: 0.02mg/kg, max single dose 2mg, repeat PRN ROUTE: IM, IVP or IO

129


Diltiazem (Cardizem) Medication Formulary

CPG Number MED12



CLASS: Calcium Chanel Blocker

ACTIONS: Slows conduction through the AV node INDICATIONS: Atrial Fibrillation

Atrial Flutter

SVT CONTRAINDICATIONS: Bradycardia

WPW

ADULT DOSE: 5-10mg, SIVP, repeat at 10-20 mg x 1 only

Use Caution with Hypotensive patients

Use Caution with the elderly, consider lower dose range

PEDIATRIC DOSE: Not recommended ROUTE: IVP or IO

130


Diphenhydramine (Benadryl) Medication Formulary

CPG Number MED13



CLASS: Antihistamine

ACTIONS: Blocks histamine receptors

INDICATIONS: Anaphylaxis

Allergic reactions

Dystonic reactions


ADULT DOSE: 25-50mg

PEDIATRIC DOSE: 2-5mg/kg, max single dose 50mg ROUTE: IM, IVP or IO

131


Dopamine Medication Formulary

CPG Number MED14



CLASS: Sympathomimetic

ACTIONS: Increased cardiac contractility Increased heart rate Increased systemic vascular resistance

INDICATIONS: Cardiogenic shock CONTRAINDICATIONS: Tacycardia

ADULT DOSE: 5-20mcg/kg/min, titrate to effect

PEDIATRIC DOSE: 5-20mcg/kg/min, titrate to effect ROUTE: IVP or IO via infusion

132


Duo-Neb Medication Formulary

CPG Number MED15



CLASS: Beta 2 agonist & Anticholinergic

ACTIONS: Relaxes bronchial smooth muscle

Dries out secretions

INDICATIONS: Bronchospasms with suspected secretions CONTRAINDICATIONS: Profound tachycardia

ADULT DOSE: 3ml single dose vial

PEDIATRIC DOSE: Not recommended ROUTE: UDN

133


Epinephrine Medication Formulary

CPG Number MED16



CLASS: Sympathomimetic

ACTIONS: Increases heart rate

Increases cardiac contractility

Increases systemic vascular resistance

Causes Bronchodilation

INDICATIONS: Cardiac arrest Anaphylaxis Severe bronchospasms Suspected croup CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: Cardiac Arrest: 1:10,000 – 1mg IVP, repeat every 3-5min Anaphylaxis: 1:1,000 – 0.3mg IM; 1:10,000 – 0.1mg IVP Severe bronchospasms: 1:1,000 – 0.3mg IM Infusion: 2-20mcg/min, titrate to effect (1mg in 100cc D5W)

PEDIATRIC DOSE: Cardiac Arrest: 1:10,000 – 0.01mg/kg IVP (max 1mg single dose) repeat every 3-5min Anaphylaxis: 1:1,000 – 0.1mg/kg IM (max 0.03mg single dose); 1:10,000 – 0.01mg/kg IVP (max 0.1mg single dose) Severe bronchospasms: 1:1,000 – 0.1mg/kg IM (max 0.03mg single dose) Infusion: 0.1-1mcg/kg/min, titrate to effect (1mg in 100cc D5W) Suspected croup: 1:1,000 – 0.25mg in 3cc of NS via UDN

ROUTE: IM, IVP, IVPB, UDN

134


Etomidate Medication Formulary

CPG Number MED17



CLASS: Hypnotic sedative

ACTIONS: General sedation INDICATIONS: Sedation prior to RSI CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 0.3mg/kg, repeat x 1

PEDIATRIC DOSE: 0.3mg/kg, repeat x 1 ROUTE: IVP or IO

135


Fentanyl Medication Formulary

CPG Number MED18



CLASS: Narcotic analgesic

ACTIONS: Analgesia with sedation CNS depressant

INDICATIONS: Pain of any kind CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 0.5-2mcg/kg, repeat PRN

PEDIATRIC DOSE: 0.5-2mcg/kg, repeat PRN ROUTE: IM, IVP, IO, IN

136


Furosemide (Lasix) Medication Formulary

CPG Number MED19



CLASS: Loop diuretic

ACTIONS: Decreases sodium and chloride release

INDICATIONS: Pulmonary Edema CONTRAINDICATIONS: Hypotension

Renal failure

ADULT DOSE: 40mg or double the patient’s daily dose

PEDIATRIC DOSE: Not recommended ROUTE: SLOW IVP

137


Glucagon Medication Formulary

CPG Number MED20



CLASS: Non-Classified Metabolic Medicine

ACTIONS: Converts hepatic Glycogen to Glucose INDICATIONS: Hypoglycemia when unable to establish vascular access Beta Blocker overdose CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: Hypoglycemia: 1mg IM

Beta Blocker overdose: 2-5mg IVP/IO

PEDIATRIC DOSE: Hypoglycemia: 0.1mg/kg (max single dose 1mg) IM

Beta Blocker overdose: 0.5mg-5mg IVP/IO ROUTE: IM, IVP, IO

138


Glucose (oral) Medication Formulary

CPG Number MED21



CLASS: Simple Carbohydrate

ACTIONS: Elevates blood glucose levels INDICATIONS: Hypoglycemia with good mental status CONTRAINDICATIONS: Altered mental status

ADULT DOSE: One tube (25g)

PEDIATRIC DOSE: One tube (25g) ROUTE: PO

139


Haldol Medication Formulary

CPG Number MED22



CLASS: Antipsychotic

ACTIONS: Competitive Dopamine receptor blocker

INDICATIONS: Need for chemical restraint CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 5mg x 1 only

PEDIATRIC DOSE: Not recommended ROUTE: IM, IVP or IO

140


Ibuprofen Medication Formulary

CPG Number MED23



CLASS: NSAID

ACTIONS: Analgesic and Antipyretic INDICATIONS: Fever CONTRAINDICATIONS: Altered mental status

ADULT DOSE: Not recommended in the emergency setting

PEDIATRIC DOSE: 10mg/kg (patient must be 6months old) ROUTE: PO

141


Lidocaine Medication Formulary

CPG Number MED24



CLASS: Antiarrhythmic and local anesthetic

ACTIONS: Suppresses ventricular ectopic activity

Increases ventricular fibrillation threshold

Reduces velocity of electrical impulse through conductive system Alleviates pain, locally

INDICATIONS: Ventricular Arrhythmia Pain management with IO placement CONTRAINDICATIONS: High degree heart blocks

Known bifasicular block

ADULT DOSE: Cardiac Arrest: 1-1.5mg/kg, repeat every 3-5min, max 3mg/kg

Infusion: 1-4mg/min (2g in 500ml D5W)

Pain with IO: 0.5mg/kg, max 50mg x 1 only

PEDIATRIC DOSE: Cardiac Arrest: 1-1.5mg/kg, repeat every 3-5min, max 3mg/kg

Pain with IO: 0.5mg/kg, max 50mg x 1 only

ROUTE: IV or IO

142


Lorazapam (Ativan) Medication Formulary

CPG Number MED25




ACTIONS: Anticonvulsant

Skeletal muscle relaxant

Sedative INDICATIONS: Status epilepticus


Muscle relaxant Procedural sedation Sedation after intubation

CONTRAINDICATIONS: None in the emergency setting


PEDIATRIC DOSE: 0.1mg/kg (max single dose 2mg), repeat PRN ROUTE: IM or IVP

143


Magnesium Sulfate Medication Formulary

CPG Number MED26



CLASS: Electrolyte

ACTIONS: CNS Depressant Smooth muscle relaxer General electrolyte replacement INDICATIONS: Eclampsia Pre-Eclampsia Torsades de Pointes Severe bronchospasms CONTRAINDICATIONS: None in the emergency situation

ADULT DOSE: Eclampsia: 4g in 100cc D5W over 20min Pre-Eclampsia: 4g in 100cc D5W over 20min Torsades de Pointes: 2g IVP Severe bronchospasms: 2g in 100cc D5W over 10min

PEDIATRIC DOSE: Severe bronchospasms: 40mg/kg (max 2g) in 100cc D5W over 10min x 1 only

ROUTE: IVP, IVPB or IO

144


Methlprednisone (Solu-Medrol) Medication Formulary

CPG Number MED27



CLASS: Steriod

ACTIONS: Anti-inflammatory INDICATIONS: Respiratory distress with presumed lung injury Allergic reaction CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 125mg x 1 only

PEDIATRIC DOSE: 1-2mg/kg (max single dose 125mg) x 1 only ROUTE: IVP, IM or UDN

145


Metoprolol (Lopressor) Medication Formulary

CPG Number MED28



CLASS: Beta-Blocker

ACTIONS: Reduces heart rate Reduces blood pressure INDICATIONS: Acute STEMI with tachycardia Tachy-disrythmias Hypertensive emergencies CONTRAINDICATIONS: Bradycardia

Hypotension

ADULT DOSE: 5mg, repeat x 2 ever 5min (15mg max)

PEDIATRIC DOSE: Not recommended ROUTE: SLOW IVP

146


Midazolam (Versed) Medication Formulary

CPG Number MED29




ACTIONS: Anticonvulsant

Skeletal muscle relaxant

Sedative INDICATIONS: Status epilepticus


Muscle relaxant Procedural sedation Sedation after intubation


ADULT DOSE: Sedation for RSI: 0.1mg/kg x 1 only

All other indications: 2.5-5mg, repeat PRN

PEDIATRIC DOSE: Sedation for RSI: 0.1mg/kg x 1 only

All other indications: 0.1mg/kg (max single dose 5mg), repeat PRN

ROUTE: IV, IM or IO

147


Morphine Sulfate Medication Formulary

CPG Number MED30



CLASS: Narcotic analgesic

ACTIONS: Analgesia with sedation

CNS depressant

INDICATIONS: Pain of any kind CONTRAINDICATIONS: Hypotension


PEDIATRIC DOSE: 0.1mg/kg (max single dose 5mg), repeat PRN ROUTE: IV, IM or IO

148


Naloxone (Narcan) Medication Formulary

CPG Number MED31



CLASS: Narcotic antagonist

ACTIONS: Blocks the effects of opiates

INDICATIONS: Unresponsiveness and hypoventilation with a patient suspected of ingesting narcotics (opiates)


ADULT DOSE: 2mg, repeat PRN

PEDIATRIC DOSE: 0.1mg/kg (max single dose 2mg), repeat PRN ROUTE: IV, IM, IO or IN

149


Nitroglycerine Medication Formulary

CPG Number MED32



CLASS: Vasodilator

ACTIONS: Decreases SVR

Decreases pre-load

INDICATIONS: Chest pain with suspected cardiac origin Hypertensive emergency Pulmonary edema CONTRAINDICATIONS: Hypotension

Use of ED medicines (Viagra, Cialas, etc.)

ADULT DOSE: Via SL: 400mcg SL, repeat x 2 every 5 min

Infusion: 5-50mcg/min, titrate to effect

PEDIATRIC DOSE: Not recommended ROUTE: IVPB or SL

150


Norepinepherine (Levophed) Medication Formulary

CPG Number MED33



CLASS: Vasopresser

ACTIONS: Alpha antagonist

INDICATIONS: Hypotension S/P volume replacement, non-bradycardic CONTRAINDICATIONS: Hypotension in trauma

ADULT DOSE: 2-20mcg/min, titrate to effect

PEDIATRIC DOSE: 0.1-1mcg/kg/min, titrate to effect ROUTE: IVPB only

151


Normal Saline Medication Formulary

CPG Number MED34



CLASS: Isotonic Solution

ACTIONS: Volume replacement solution

Remains in the vasculature

INDICATIONS: Fluid replacement To keep vein open To saline lock vascular access Vehicle for medication delivery / flush CONTRAINDICATIONS: Pulmonary edema

ADULT DOSE: Fluid replacement: 20cc/kg, repeat PRN

PEDIATRIC DOSE: Fluid replacement: 20cc/kg, repeat PRN ROUTE: IV or IO

152


Oxygen Medication Formulary

CPG Number MED35



CLASS: Gas

ACTIONS: Maintenance of homeostasis

INDICATIONS: Hypoxia CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 2-15lpm, titrate to effect

PEDIATRIC DOSE: 2-15lpm, titrate to effect ROUTE: Inhaled via: NC, NRBM, CPAP, BVM or Ventilator

153


Oxytocin (Pitocin) Medication Formulary

CPG Number MED36



CLASS: Pituitary hormone

ACTIONS: Increases uterine tone

Promotes contractions (dose dependant)

INDICATIONS: Post partum hemorrhage CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 10mg in 1000cc of NS at w/o rate, x 1 only

PEDIATRIC DOSE: Not recommended ROUTE: IV or IO

154


Phenergan Medication Formulary

CPG Number MED37



CLASS: Antiemetic

ACTIONS: H1 antagonist

INDICATIONS: Nausea / Vomiting CONTRAINDICATIONS: Altered mental status

ADULT DOSE: 12.5mg in 10cc of NS, repeat x1

PEDIATRIC DOSE: Not recommended ROUTE: IV

155


Rocuronium Medication Formulary

CPG Number MED38



CLASS: Paralytic

ACTIONS: Non-depolarizing neuromuscular blocker

INDICATIONS: Paralysis for RSI when Succinylcholine is contraindicated CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 1mg/kg

PEDIATRIC DOSE: 1mg/kg ROUTE: IV or IO

156


Sodium Bicarbonate Medication Formulary

CPG Number MED39



CLASS: Buffer Agent

ACTIONS: Increases PH

Provides rapid influx of Sodium ions

INDICATIONS: Suspected severe acidosis TCA overdoses Crush syndrome Hyperkalemia CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 1 mEq/kg, repeat PRN

PEDIATRIC DOSE: 1 mEq/kg, repeat PRN ROUTE: IV or IO

157


Sterile Water Medication Formulary

CPG Number MED40



CLASS: Water

ACTIONS: None

INDICATIONS: Cleansing wounds Reconstitution on medications CONTRAINDICATIONS: None

ADULT DOSE: As needed

PEDIATRIC DOSE: As needed ROUTE: Topical, IV or IO

158


Succinylcholine Medication Formulary

CPG Number MED41



CLASS: Paralytic

ACTIONS: Rapidly depolarizing neuromuscular blocker

INDICATIONS: Paralysis for RSI CONTRAINDICATIONS: Hyperkalemia or potential for

History of malignant hyperthermia

ADULT DOSE: 1-1.5mg/kg (max single dose 200mg), repeat x 1

PEDIATRIC DOSE: 1-1.5mg/kg (max single dose 200mg), repeat x 1 ROUTE: IV or IO

159


Thiamine Medication Formulary

CPG Number MED42



CLASS: Vitamin

ACTIONS: Allows for normal breakdown of glucose

INDICATIONS: Alcoholism Malnutrition CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 100mg in 1000cc of NS at w/o rate

PEDIATRIC DOSE: Not recommended ROUTE: IV

160


Tylenol Medication Formulary

CPG Number MED43



CLASS: Acetaminophen

ACTIONS: Analgesic

Antipyretic

INDICATIONS: Fever CONTRAINDICATIONS: Altered mental status

ADULT DOSE: Not recommended

PEDIATRIC DOSE: 10mg/kg x 1 only ROUTE: PO

161


Vecuronium Medication Formulary

CPG Number MED44



CLASS: Paralytic

ACTIONS: Non-depolarizing neuromuscular blocker

INDICATIONS: Maintenance of paralysis after intubation CONTRAINDICATIONS: Lack of sedation & pain management after intubation

ADULT DOSE: 0.1mg/kg (dose normally lasts 60 minutes)

PEDIATRIC DOSE: 0.1mg/kg (dose normally lasts 60 minutes) ROUTE: IV or IO

162


Xopenex Medication Formulary

CPG Number MED45



CLASS: Beta2 Agonist

ACTIONS: Relaxes bronchial smooth muscles

INDICATIONS: Bronchospasms Usually used in place of Albuterol with tachycardic patients CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 1.25mg, repeat x 2 PRN

PEDIATRIC DOSE: 0.63mg, repeat x 2 PRN ROUTE: UDN

163


Zofran Medication Formulary

CPG Number MED46



CLASS: Antiemetic

ACTIONS: Selective 5-HT receptor antagonist

INDICATIONS: Nausea / Vomiting CONTRAINDICATIONS: None in the emergency setting

ADULT DOSE: 4mg, repeat x 2 PRN

PEDIATRIC DOSE: 0.15mg/kg (max single dose 4mg), repeat x 2 PRN ROUTE: IV, IM, IO or IN

164

SECTION FIVE SKILLS FORMULARY

165


Airway: Oxygen Administration Skills Formulary

CPG Number SKL1



INDICATIONS • Any patient suffering from hypoxia • Any patient deemed to benefit or potentially benefit from supplemental Oxygen

CONTRAINDICATIONS • No absolute contraindications • Use caution with COPD patients

PROCEDURE • Monitor SPO2 and ETCO2 as appropriate • Nasal Cannula: 2-6lpm • Up-Draft Nebulizer: 6-8lpm • Non-Rebreather Mask: 10-15lpm • Bag-Valve Mask: 10-15lpm

BLS

166


Airway: Suction Skills Formulary

CPG Number SKL2



INDICATIONS • Needed removal of substances from the airway

CONTRAINDICATIONS • None in the emergency setting

PROCEDURE (BASIC) • Manually open the airway • Insert suction catheter (soft or rigid) into the mouth or nare • Suction on the way out, in a circular motion; no longer than 15 seconds

BLS

PROCEDURE (ADVANCED) • Select the largest size suction catheter for the ET tube in place • Measure the catheter against an equally sized ET tube not being used • Insert the suction catheter into the ET tube to that pre-measured length • Suction on the way out; no longer than 15 seconds

167


Airway: CPAP Skills Formulary

CPG Number SKL3



INDICATIONS • Respiratory distress not improving or severe • Hypoxia • Hypercapnia • Pulmonary edema

CONTRAINDICATIONS • Altered mental status • Inability to maintain airway

PROCEDURE • Prepare the equipment • Turn on the oxygen; start at 5cm/H2O • Hold the mask firmly against the patient • After the patient has tolerated the mask the straps may be attached • Titrate up to 10cm/H2O if severe hypoxia does not improve

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168


Airway: PEEP Valve Skills Formulary

CPG Number SKL4



INDICATIONS • Any patient being ventilated via a confirmed ET tube placed in the trachea

CONTRAINDICATIONS

• Cardiac arrest • Hypotension

PROCEDURE • Place the PEEP valve on the end of the BVM • Start at 5cm/H2O • Titrate up to 10cm/H2O if severe hypoxia does not improve

ALS

169


Airway: Nasal Pharyngeal Airway Skills Formulary

CPG Number SKL5



INDICATIONS • Unconscious or semi-conscious patients that are unable to maintain their airway

CONTRAINDICATIONS

• None in the emergency setting

PROCEDURE • Pre-oxygenate the patient • Measure the tube from the tip of the patient’s nose to the tip of the earlobe • Lubricate the airway with water soluble jelly • Insert the airway with the bevel of the tube towards the septum, angling towards the base

floor of the nasopharynx • Reassess the airway

BLS

170


Airway: Oral Pharyngeal Airway Skills Formulary

CPG Number SKL6



INDICATIONS • Unconscious patients that are unable to maintain their airway

CONTRAINDICATIONS


PROCEDURE • Pre-oxygenate patient if possible • Measure from the corner of the mouth to the earlobe • Insert the airway inverted and rotate 1800 into place • Reassess the airway

BLS

171


Airway: Nasal Tracheal Intubation Skills Formulary

CPG Number SKL7



INDICATIONS • Need for airway management that oral tracheal intubation is contraindicated • Predicted difficult airway that RSI would be contraindicated

CONTRAINDICATIONS

• Head injuries (relative)

PROCEDURE • Lubricate both nasal passages by placing large NPA’s • Remove NPA’s and insert #7.0 ETT with bevel towards the septum • Advance tube aiming the tip down along the nasal floor • Gently advance the tube along the airway while rotating it medially slightly until the best

airflow is heard through the tube • Gently and swiftly advance the tube during inspiration • Inflate the cuff with 5-10 cc of air • Confirm patency and secure • Reassess airway

ALS

172


Airway: Oral Tracheal Intubation Skills Formulary

CPG Number SKL8



INDICATIONS • Patients requiring definitive airway management

CONTRAINDICATIONS

• Failed airway

PROCEDURE – DIRECT LARYNGOSCOPY • Insert Laryngoscope • Sweep tongue to the left, place blade in proper position • Lift the laryngoscope forward to displace the jaw • Visualize the vocal cords • Advance the tube past the vocal cords • If using a bougie, first pass bougie through vocal cords, then pass tube over the bougie • Inflate cuff with 5-10 cc air • Confirm patency and secure • Reassess airway

ALS

PROCEDURE – KING VISION • Insert King Vision • Sweep tongue to the left, place blade in proper position • Lift the King Vision forward as needed to displace the jaw • Visualize the vocal cords • Advance the tube past the vocal cords • If using a bougie, first pass bougie through vocal cords, then pass tube over the bougie • Inflate cuff with 5-10 cc air • Confirm patency and secure • Reassess airway

173


Airway: King Airway Skills Formulary

CPG Number SKL9



INDICATIONS • Patients requiring definitive airway management when intubation is not possible • Failed airway

CONTRAINDICATIONS

• Intact gag reflex • Airway swelling

PROCEDURE • Select appropriate size per manufacturer guidelines • Place head in sniffing position • Maintain c-spine stabilization on trauma patients • Hyperextend the neck slightly (non-trauma patients) • Grab hold of the patients bottom jaw and insert the King airway until resistance is felt • Inflate the cuff with the appropriate amount of air noted on the airway tube • Confirm patency and secure • Reassess airway

BLS

174


Airway: Per-Trach Skills Formulary

CPG Number SKL10



INDICATIONS • Failed airway

CONTRAINDICATIONS

• Inability to identify landmarks

PROCEDURE • Remove dilator from the package and protective sheath; advance it into the tracheotomy

tube. • Locate the landmarks to identify the cricothyroid membrane • Insert the splitting needle through the skin directly over cricothyroid membrane • While advancing the splitting needle perpendicular to the skin, lightly pull back on the plunger

of syringe. When air bubbles occur or you feel a break in resistance, stop advancing the splitting needle

• Incline needle more than 45o towards the carina and complete the insertion • Always maintain the tip of the needle midline of the airway • Remove syringe • Insert tip of the dilator into the hub of the splitting needle • Squeeze the wings of the needle together, then open them out completely split the needle • Remove the needle, continue pulling it apart in opposite directions, while leaving the dilator

in the trachea • Place thumb on dilator knob while first and second fingers are curved under flange of trachea

tube • By exerting pressure, advance dilator and tracheotomy tube into position until the flange is

against the skin • Remove the dilator • Inflate the cuff until you have control of the airway • Confirm patency and secure • Reassess airway

ALS

175


Airway: Surgical Cricothyrotomy Skills Formulary

CPG Number SKL11



INDICATIONS • Failed airway

CONTRAINDICATIONS

• Inability to identify landmarks

PROCEDURE • Stabilize the larynx with the thumb and index finger of non-dominant hand • Identify the landmarks for the cricothyroid membrane • Make 2-6cm vertical incision at the cricothyroid membrane • Visualize the cricothyroid membrane • Make an horizontal “puncture” into the trachea • Place a bougie into the trachea • Enlarge the incision site as needed to be able to pass ETT • Place an endotracheal tube into the incision • Inflate cuff with 5-10 cc air • Confirm patency and secure • Reassess airway

ALS

176


Airway: Gastric Tube Skills Formulary

CPG Number SKL12



INDICATIONS • Any patients with an ET tube in place

CONTRAINDICATIONS

• Esophageal avarices

PROCEDURE • Select appropriate size

o 18f is preferred in adult patients • Measure the distal end of the tube from the xiphoid process, up the center of the chest,

around the ear and to the corner of the mouth • Insert the lubricated tube in the mouth (or nose) and advance until resistance is felt • Insert 60cc of air while listening over the abdomen • Gurgling noises should be heard from the abdomen • After confirming patency, secure and attach to low suction

ALS

177


Diagnostics: Vital Signs Skills Formulary

CPG Number SKL13



INDICATIONS • Any patient contact

CONTRAINDICATIONS


PROCEDURE • Obtain appropriate readings per specific guideline as appropriate for the patient

o Heart rate o Blood pressure o Respiratory rate o Skin signs o Lung sounds o SPO2 o ETCO2 o Blood glucose o Glascow coma scale o Pain level

• Record findings

BLS

178


Diagnostics: Pulse Oximitery Skills Formulary

CPG Number SKL14



INDICATIONS • Any patient contact

CONTRAINDICATIONS


PROCEDURE • Place SPO2 probe at a suitable location

o Finger tip o Ear lobe

• Record findings

BLS

179


Diagnostics: ETCO2 Skills Formulary

CPG Number SKL15



INDICATIONS • Any patients with an artificial airway in place • Altered mental status • Respiratory distress


PROCEDURE – ARTIFICAL AIRWAY SAMPLING • Plug the selected testing device into the module in the right zipper pocket • Allow the device to warm up before trying to get reading • Zero the device per manufacturer recommendations • Place the sensor in-line between the airway and the ventilation device • Record findings

BLS

PROCEDURE – NASAL CANNULA SAMPLING • Plug the selected testing device into the module in the right zipper pocket • Allow the device to warm up before trying to get reading • Zero the device per manufacturer recommendations • Place the sensor on the patient like a nasal cannula • Record findings

180


Diagnostics: Multi-Lead EKG Skills Formulary

CPG Number SKL16



INDICATIONS • Chest pain, pressure or discomfort • Shortness of breath • General weakness • Syncope • Any diabetic patient • Abdominal pain or discomfort • Dizziness • Nausea

CONTRAINDICATIONS


PROCEDURE • 12 Lead EKG

o See lead placement reference on next page • 15 Lead EKG (right sided)

o V3R, V4R, V5R o See lead placement reference on next page

• 18 Lead EKG (right sided, plus posterior) o V7, V8, V9 o See lead placement reference on next page

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181

Please note, 18 lead is called such because it’s assumed you would complete a right sided EKG (15 lead) before doing a posterior EKG, adding 3 more views, making it 18 total.

182


Diagnostics: Blood Glucose Analysis Skills Formulary

CPG Number SKL17



INDICATIONS • Altered mental status • Known diabetic

CONTRAINDICATIONS

• None

PROCEDURE • Obtain blood specimen

o Finger stick o IV catheter

• Place drop of blood at the end of check strip that is inserted in the glucometer • Record the reading

BLS

183


Diagnostics: Doppler Skills Formulary

CPG Number SKL18



INDICATIONS • To verify pulses that cannot be felt or heart • To assess fetal heart tones

CONTRAINDICATIONS


PROCEDURE • Connect the probe to the unit with the arrow on the probe pointing up. • Place the ultrasonic gel on the probe tip or on the patients skin • Press the probe button to turn the unit on, make sure the power indicator is lit • Turn the volume control to MAXIMUM • Place the probe on the skin at a 45 degree angle and move slowly to locate the point where

the Doppler sounds are maximum • When using the probe to assess for fetal heart tones, the probe should be at a 90 degree

angle to the skin

BLS

184


Procedure: Mechanical Ventilator Skills Formulary

CPG Number SKL19



INDICATIONS • Any patient with an artificial airway in place

CONTRAINDICATIONS


PROCEDURE • Attach ventilator to 100% Oxygen • Attach disposable circuit to ventilator • Set rate (8-12/min for adults) • Set tidal volume (6-8cc/kg of IBW) • Attach circuit to patient • Reassess patient status; adjust ventilator settings as clinically indicated

ALS

185


Procedure: Medication Pump Skills Formulary

CPG Number SKL20



INDICATIONS • Any vasoactive medication infusion • Fluid administration to pediatric patients

CONTRAINDICATIONS


PROCEDURE • Attach pump tubing to desired infusion • Use medication library

o Enter medication o Enter concentration o Enter desired dose

• Verify accurate drip rate • If infusing fluids only, simply set desired drip rate • Reassess patient

ALS

186


Procedure: IO Access Skills Formulary

CPG Number SKL21



INDICATIONS • Any patient requiring vascular access where an IV is unable to be obtained • Critical patient where IV access success may be questionable

CONTRAINDICATIONS

• Fracture above where the IO will be placed • Obvious infection at the site

PROCEDURE • Identify IO Site:

o Proximal Tibia o Humeral Head

• Cleanse the puncture site • Stabilize the leg and skin over the site • Position the driver at the insertion site perpendicular (90o) to the bone surface. • Insert the needle set through the skin until resistance is met • Ensure one black line (minimum) is visible above the skin • Penetrate the bone by powering the drill while applying firm pressure • Release the trigger when the flange is against the skin or when a sudden give is felt • Flush or bolus with NS; consider Lidocaine for pain PRN • Confirm placement, and check for infiltration • Connect tubing and pressure bag to infuse if needed • Secure with dressing

ALS

187


Procedure: IV Access Skills Formulary

CPG Number SKL22



INDICATIONS • Any patient requiring vascular access

CONTRAINDICATIONS • None

PROCEDURE • Inform the patient about the procedure • Choose appropriate site and catheter size for patient condition • Clean site with approved antiseptic • Stabilize the vein with distal traction to the vein and skin • Pass the needle into the vein, bevel up until you get blood return in catheter hub • Advance the needle 2mm more into the vein • Slide the catheter off of the needle into the vein • Remove the needle and dispose of properly • Attach tubing and infuse about 10-20 cc to assure patency, watch for signs of infiltration. • Secure the IV and tubing

ALS

188


Procedure: Pre-Existing Catheter Access Skills Formulary

CPG Number SKL23



INDICATIONS • Any patient requiring vascular access with a pre-existing catheter in place

o Power Port o PICC Line

CONTRAINDICATIONS


PROCEDURE – PORT ACCESS • Palpate port site, indentify landmarks • Cleanse site with bedadine and alcohol • Insert the Huber needle at a 90 degree angle until access to the port is felt • Attached extension tubing, aspirate for blood return • Flush with NS to confirm patency • Attached fluids • Secure with dressing

ALS

PROCEDURE – PICC ACCESS • Identify PICC line (NOT DIALYSIS CATHEDER) • Unclamp the extension tubing • Flush and aspirate to confirm patency • Attach fluids • Secure with dressing

189


Procedure: Venous Blood Draw Skills Formulary

CPG Number SKL24



INDICATIONS • Any patient which may benefit from laboratory studies from the hospital

CONTRAINDICATIONS

• None

PROCEDURE • After establishing vascular access, attach vacutainer • Place tube in vacutainer, allow to fill with blood • Full all tubes available with blood, note time of draw • Flush line after draw is complete

ALS

190


Procedure: Maintenance of Vascular Access Skills Formulary

CPG Number SKL25



INDICATIONS • For use with any form of vascular access

o Peripheral I.V. o I.O. o Porta-Catheter o P.I.C.C. Line

CONTRAINDICATIONS • Patients requiring active fluid resuscitation • Patients requiring infusions of medications

PROCEDURE • Choose one of the following:

o Maintain at Keep Open (TKO) or Keep Vein Open (KVO) rate o Maintain with a saline lock, flush with NS as needed to verify line patency or flush

medicines

ALS

191


Procedure: Cardioversion/Defibrillation Skills Formulary

CPG Number SKL26



INDICATIONS • Tachycardic dysrythmias requiring electrical conversion per guidelines


PROCEDURE – CARDIOVERSION • Ensure appropriate pad placement per manufacturer guidelines • Charge to desired energy level • Clear the patient • Press the shock button

ALS

PROCEDURE – DEFIBRILATION • Ensure appropriate pad placement per manufacturer guidelines • Place into synchronized mode • Charge to desired energy level • Clear the patient • Press and hold the shock button until energy delivered

192


Procedure: Transcutaneous Pacing Skills Formulary

CPG Number SKL27



INDICATIONS • Bradycardic dysrythmias requiring external pacing per guidelines

CONTRAINDICATIONS


PROCEDURE • Ensure appropriate pad placement per manufacturer guidelines • Ensure 4-lead EKG is on patient and placed appropriately • Set rate on monitor to 70 BPM • Increase MA until electrical capture is achieved • Verify mechanical capture is achieved • Increase by 10 MA after capture (electrical and mechanical) verified • Ensure constant re-assessment; often MA will need to be increased to maintain both

electrical and mechanical capture

ALS

193


Procedure: Medication Administration Skills Formulary

CPG Number SKL28



INDICATIONS • Any patient requiring medication administration per guidelines

CONTRAINDICATIONS

• See specific drug reference for contraindications

PROCEDURE • Administer medicines as per specific guidelines and drug reference information • The following routes are approved:

o IVP (IV Push) o SIVP (Slow IV Push) o IVPB (IV Piggy Back) o IM (Intramuscular) o SQ (Subcutaneous) o IN (Intranasal) o PO (Oral) o PR (Rectal) o UDN (Up-Draft Nebulizer)

ALS

194


Procedure: Needle Thoracentesis Skills Formulary

CPG Number SKL29



INDICATIONS • Presumed Tension Pneumothorax • Presumed Tension Hemothorax • Presumed Pneumo/Hemothorax requiring positive pressure ventilation • Traumatic cardiac arrest

CONTRAINDICATIONS


PROCEDURE • Identify landmarks (affected side)

o 2nd or 3rd intercostal space, mid-clavicular line o 4th or 5th intercostal space, mid-axillary line

• Cleanse the site with antiseptic • Insert large bore needle with catheter over the top of the posterior rib at 90 degree angle • Remove needle leaving catheter in place • Attach one-way valve if available • Secure with dressing • Re-assess constantly; repeat PRN

ALS

195


Procedure: Restraints Skills Formulary

CPG Number SKL30



INDICATIONS • Combative patients posing a risk to self and/or others

CONTRAINDICATIONS


PROCEDURE • Assess for and correct underlying medical causes as appropriate • Consider chemical restraints • Employ 4-point restraint technique (wrists and ankles); secure to stretcher • Assess CSM every 15 minutes

BLS

196


Trauma: Commercial Tourniquet Skills Formulary

CPG Number SKL31



INDICATIONS • Extremity bleeding that cannot be controlled with direct pressure

CONTRAINDICATIONS


PROCEDURE • Route the band around the limb and pass the red tip through the inside slit of the buckle • Pull the band tight • Pass the red tip through the outside of the buckle • The friction buckle will lock the band in place • Pull the band VERY TIGHT and securely fasten the band back on itself • Twist the rod until the bleeding has stopped and the distal pulse is eliminated • Place the rod inside the clip locking it in place • Secure the rod inside the clip with the strap • Record the time the tourniquet was applied

BLS

197


Trauma: Spinal Immobilization Skills Formulary

CPG Number SKL32



INDICATIONS • Patient with potential spinal injury • Inability to clear the spine per guideline • The backboard was designed as an extrication tool and full body splint; use it as such

o If a patient is self extricated and ambulatory but has cervical neck tenderness; place patient on cot in position of comfort with c-collar in place

o If a patient requires c-collar placement but not a backboard, consider scoop stretcher or soft stretcher with c-collar in place

o Patients that are multi-system trauma victims or require extrication (non-mobile) meet criteria for full spinal immobilization


PROCEDURE – CERVICAL COLLAR ONLY • Appropriately size the c-collar per manufacturer recommendations • Place c-collar on patient • Assess CSM status

BLS

PROCEDURE – FULL SPINAL IMMOBILIZATION • Appropriately size the c-collar per manufacturer recommendations • Place patient on long spine board via means that produce the least manipulation • Secure the patient with all available straps • Place head blocks and secure with all available straps • Assess CSM status

198


Trauma: Spinal Clearance Skills Formulary

CPG Number SKL33



INDICATIONS • Patient awake, alert an oriented x 4 • Patient with GCS of 15 • Patient without drugs or alcohol ingestion (suspected or actual) • Patient without distracting injury • Patient without C-Spine tenderness in the presence of trauma • Patient without neurological deficits in the presence of trauma

CONTRAINDICATIONS • Altered mental status • Inability to answer questions • Obvious impairment

PROCEDURE • Clear the spine, no spinal immobilization is necessary • Clearly document the spinal immobilization clearance

ALS

199


Trauma: Sager Traction Splint Skills Formulary

CPG Number SKL34



INDICATIONS • Mid-shaft femur fracture

CONTRAINDICATIONS

• Multiple fractures or injuries to the extremity • Suspected pelvic fracture

PROCEDURE • Position the sager splint between the patient’s legs, resting the cushion saddle against the

ischial tuberosity with the shortest end of the cushion saddle toward the ground. • Apply the thigh strap around the upper thigh of the fractured limb. • Push the ischial cushion gently down while at the same time pulling the thigh strap laterally

under the thigh • Tighten the thigh strap snugly • Lift the spring clip to extend the inner shaft of the splint • Extend the inner shaft until the cross bar is even with the patients heel • Using the attached hook and loop straps wrap the ankle harness around the ankle • Pull the control tabs to secure the ankle harness tightly against the crossbar • Grasp the padded shaft with 1 hand and the traction handle with the other hand and gently

extend the inner shaft until the desired amount of traction is gained • At the knees wrap the large elastic strap and apply thee other straps to help stabilize the limb • Apply the strap around the feet to stop rotation • Reassess CSM

BLS

200


Trauma: General Splinting Skills Formulary

CPG Number SKL35



INDICATIONS • Presumed fracture or dislocation

CONTRAINDICATIONS

• Major trauma victim

PROCEDURE • Select the appropriate tool to stabilize the fracture

o SAM splint o Rigid splint o Pillow

• Immobilize the injury; include the joint above and joint below the injury • Secure with tape • Place and secure in position of comfort • Reassess CSM

BLS

201


Trauma: Pelvic Binder Skills Formulary

CPG Number SKL36



INDICATIONS • Suspected pelvic fracture

CONTRAINDICATIONS


PROCEDURE • Slide the pelvis wrap under the patients buttocks and situate around pelvic girdle • Remove excess wrap, leaving approximately 6” of opening on the front of the patient • Place securing device on the front of the pelvis wrap • Tighten the securing device until pelvis becomes stable • Secure in place • Document time pelvic binder was placed

BLS

Documents

VALLE AMBULANCE DISTRICTdrfpd.org/training/videos/Valle SOG 2014.pdfMED20 Glucagon 137 MED21 . Glucose (Instant Oral) 138 . MED22 ; Haldol . 139 ; MED23 . Ibuprofen ; 140 . MED24 Lidocaine