EMS PROTOCOLS - Lewis County EMS



2012EMS PROTOCOLSLewis County, Washington StateTable of Contents 1-4PREHOSPITAL PROVIDER SCOPE OF PRACTICE 5 Protocols Universal Patient Care ………………………………………………………………………………………………............... 6 CARDIAC Adult BLS Healthcare Providers....................................................................................................................... 7 Cardiac Arrest.………………………...…………………………………………………………………………………............… 8 V-Fib/Pulseless V-Tach/Pulseless Electrical Activity ……………………………………………………...... 8 Asystole………………………………………………………………………………………………………………………...…… 8 Cardiogenic Shock…………………………………………………………………………………………………………...… 9 Bradycardia…………………………………………………………………………………………………………………... 10 Adult Tachycardia............………………………………………………………………………………………………….…. 11 RESPIRATORY Airway (Adult)……………………………………………………………………………………………………………...……12 Failed Airway (Adult)………………………………………………………………………………………………...……… 13 Reactive Airway Disease……………………………………………………………………………………………....…… 14 Pulmonary Edema…………………………………………………………………………………………………………...…15 Post resuscitation Management……………………………………………………………………………………....… 16 Medical Abdominal Pain…………………………………………………………………………………………………………….…… 17 Allergic Reaction……………………………………………………………………………………………………………..… 18 Altered Mental Status / Diabetic Emergency…………………………………………………………………..… 19 General Illness………………………………………………………………………………………………………………..… 20 Overdose / Poisoning……………………………………………………………………………………………………..… 21 Pain Management…………………………………………………………………………………………………………..… 22 Psychological / Emotional Emergencies…………………………………………………………………………… 23 Seizure………………………………………………………………………………………………………………………………24 Stroke……………………………………………………………………………………………………………………………..… 25 OB/GYN Eclampsia………………………………………………………………………………………………………………………..… 26 Postpartum……………………………………………………………………………………………………………………..… 27 Environmental Environmental………………………………………………………………………………………………………………..… 28 Burns ……………………………………………………………………………………………………………………………..… 29 Decompression Illness / SCUBA Diving Related……………………………………………………………..…. 30 Drowning / Near Drowning……………………………………………………………………………………………..… 31 Head Injury…………………………………………………………………………………………………………………..…… 32 Multi-system Trauma …………………………………………………………………………………………………..……. 33Pediatric ProtocolsPediatric BLS Healthcare Provider............................................................................................................. 34 Pediatric Cardiac Arrest /Pediatric V-Fib / Pulseless V- Tach/Asystole/ Pediatric PEA …… 35Pediatric Bradycardia….……………………………………………………………………………………………………… 36 Pediatric Tachycardia..........................................................…………………………………………………………… 37 Pediatric Airway…………………………………………………………………………………………………………..…… 38 Pediatric Allergic Reaction…………………………………………………………………………………………………. 39 Pediatric ALOC..…………………………………………………………………………………………………………………… 40 Pediatric Breathing Difficulty……………………………………………………………………………………………… 41Pediatric Hypoglycemia………………………………………………………………………………………………………42 Pediatric Seizure .……………………………………………………………………………………………………………..…43 Pediatric Procedure Pediatric Assessment…………………………………………………………………………………………………………… 44 Pediatric References……………………………………………………………………………………………………………. 45 Airway Needle Cricothyrotomy (Pediatric)………………………………………………………………………… 46 APGAR Scale/AVPU Infant/Child/CUPS Pediatric……....………………………………………………………… 47 Neonatal Resuscitation………………………………………………………………………………………………………… 48 Pain Assessment and Documentation – Pediatric………………………………………………………………… 49 Rule of Nines Child………………………………………………………………………………………………………………50 Venous Access – Intraosseous Pediatric………………………………………………………………………………. 51 Procedures Adult Assessment……………………………………………………………………………………………………………..… 52-54Airway Capnography………………………………………………………………………………………………………..…… 55 Airway Combitube….………………………………………………………………………………………………………..…… 56 Airway Difficult Airway Assessment (LEMON)………………………………………………………………....…… 57 Airway Intubation Confirmation End-Tidal Co2 Detector ………………………………………………..……58 Airway Intubation Orotracheal…………………………………………………………………………………………..... 59 Airway Intubation with Eschmann Catheter, Tracheal Tube introducer or Gum Elastic Boughie 60Airway Laryngotracheal KING? ........................................................................................................................61-62Airway Nasotracheal Intubation …………………………………………………………………………………………….. 63 Airway Nebulizer Inhalation Therapy …………………………………………………………………………………...64 Airway Needle Cricothyrotomy (Adult) …………………………………………………………………………………. 65 Airway Non-invasive Positive Pressure Ventilation (NIPPV)…………………………………………………. 66 Airway RSI………………………………………………………………………………………………………………………………..67 Airway Suctioning –Basic....…………………………………………………………………………………………………...... 68 Airway Suctioning – Advanced ………………………………………………………………………………………………..69 Airway Tracheostomy Tube Change………………………………………………………………………………………… 70 Airway Ventilator Operation…………………………………………………………………………………………………… 71 Cardiac 12 Lead ECG………………………………………………………………………………………………………………… 72 Cardiac Cardioversion……………………………………………………………………………………………………………… 73 Cardiac Defibrillation Automated…………………………………………………………………………………………… 74 Cardiac Defibrillation Manual………………………………………………………………………………………………… 75 Cardiac Transcutaneous Pacing………………………………………………………………………………………………76 Chest Compression External Device…………………………………………………………………………………………77 Chest Decompression……………………………………………………………………………………………………………… 78 Childbirth………………………………………………………………………………………………………………………………… 79 Childbirth/Fundal Massage……………………………………………………………………………………………………… 80 Cincinnati Stroke Screen…………………………………………………………………………………………………………..81 CPR…………………………………………………………………………………………………………………………………………… 82 Discontinuation of CPR / Do Not Attempt Resuscitation / Determination of Field Death………… 83 Glucometry……………………………………………………………………………………………………………………………… 84 Glasgow Coma Score…………………………………………………………………………………………………………………85 Hemorrhage Control………………………………………………………………………………………………………………… 86 Injections – Subcutaneous, Intramuscular…………………………………………………………………………………87 Orthostatic Blood Pressure Measurement…………………………………………………………………………………88 Pain Assessment and Documentation – Adult……………………………………………………………………………89 Pulse Oximetry………………………………………………………………………………………………………………………… 90 Restraints……………………………………………………………………………………………………………………………….…91-92Rule of Nines Adult……………………………………………………………………………………………………………………93 Spinal Clearance……………………………………………………………………………………………………………………….94 Spinal Immobilization……………………………………………………………………………………………………………… 95 Splinting…………………………………………………………………………………………………………………………………… 96 Taser Dart Removal………………………………………………………………………………………………………………… 97 Temperature Measurement………………………………………………………………………………………………………98 Thrombolytic Screen…………………………………………………………………………………………………………………99 Venous Access – Blood Draw……………………………………………………………………………………………………… 100 Venous Access – External Jugular Access...........................................................................................................101Venous Access – Extremity ………………………………………………………………………………………………………… 102 Venous Access – Intraosseous Adult……………………………………………………………………………………………103 Wound Care………………………………………………………………………………………………………...…… 104 Drug Formulary Acetaminophen (APAP)………………………………………………………………………………………………………………… 105 Activated Charcoal ....................................................................................................................................................... 106 Adenosine (Adenocard)………………………………………………………………………………………………………………… 107 Afrin (Oxymetazoline)…………………………………………………………………………………………………………………… 108 Albuterol Sulfate (Proventil, Ventolin)………………………………………………………………………………………… 109Amiodarone (Cordarone)........................................................................................................................................... 110Aspirin (ASA, Acetylsalicylic Acid)………………………………………………………………………………………………… 111 Atropine Sulfate…………………………………………………………………………………………………………………............... 112Atrovent (Ipratropium Bromide)………………………………………………………………………………………………… 113 Calcium Chloride (CaCI2)……………………………………………………………………………………………………………… 114 Cardizem (Diltiazem)…………………………………………………………………………………………………………………… 115 Dextrose 50% in Water (D50W)…………………………………………………………………………………………………… 116 Dilaudid (Hydromorphone)………………………………………………………………………………………………………… 117 Diphenhydramine (Benadryl)……………………………………………………………………………………………………… 118 Dopamine (Intropin)…………………………………………………………………………………………………………………… 119 Epinephrine Hydrochloride (Adrenaline)…………………………………………………………………………………… 120 Etomidate (Amidate)…………………………………………………………………………………………………………………… 121 Fentanyl (Sublimaze)……………………………………………………………………………………………………………………. 122 Furosemide (Lasix)………………………………………………………………………………………………………………………. 123 Glucagon……………………………………………………………………………………………………………………………………… 124 Glucose Oral (Glucose Gel)…………………………………………………………………………………………………………… 125Hydroxocobalamin ..................................................................................................................................................... 126 Lidocaine……………………………………………………………………………………………………………………………………… 127 Lorazepam (Ativan)……………………………………………………………………………………………………………………… 128 Magnesium Sulfate (MgSo4)………………………………………………………………………………………………………… 129 Methylprednisolone (Solu-Medrol)………………………………………………………………………………………………. 130 Midazolam (Versed)……………………………………………………………………………………………………………………… 131 Morphine………………………………………………………………………………………………………………………………………. 132 Naloxone (Narcan)………………………………………………………………………………………………………………………… 133 Nitroglycerine (NitroStat)……………………………………………………………………………………………………………… 134Oxytocin (Pitocin)…………………………………………………………………………………………………………………………. 135 Promethazine (Phenergan)…………………………………………………………………………………………………………… 136 Rocuronium (Zemuron)………………………………………………………………………………………………………………… 137 Sodium Bicarbonate (NaHco3)………………………………………………………………………………………………………. 138 Succinylcholine (Anectine)………………………………………………………………………………………………… 139Thiamine (Betalina, Biamine, Vitamin B1)................................................................................................…........ 140 Vasopressin (Pitressin)……………………………………………………………………………………………………..............… 141 Vecuronium (Norcuron)…………………………………………………………………………………………………................… 142 Zofran (Ondansetron)…………………………………………………………………………………………………….................… 143 Drug Reference…………………………………………………………………………………………………………………………...... 144 Miscellaneous Air Ambulance Transports……………………………………………………………………………………..............…………… 145 Physician on Scene…………………………………………………………………………………………………………................… 145 Emergency at Physician’s Office……………………………………………………………………………………..............…… 146 Medical Incident Reports…………………………………………………………………………………………….............……… 146Law Enforcement Assists………………………………………………………………………………………………..............…… 146 10 Critical Steps for Handling Possible Bioterrorism Events…………………………………………................... 147-148 Medical Spanish…………………………………………………………………………………………………………….................... 149-151 Mnemonic’s…………………………………………………………………………………………………………………..................… 152-153 State of WA Prehospital Trauma Triage Procedure......................................................................................... 154-155 PCH Full and Modified Trauma Activation Criteria.......................................................................................... 156State of WA Prehospital Cardiac Triage Destination Procedure…………………………………………………… 157-158State of WA Prehospital Stroke Triage Destination Procedure…………………………………………………… 159-160 Prehospital Provider Conduct …………………………………………………………………………………………………… 161 Infection Control Standards……….……………………………………………………………………………………………… 161 Patient Refusal of Medical Evaluation………………………………………………………………………………………… 161 1e. Medical Control/Base station needs to be notified………………………………………………....……… 161 2e. Medical Control/Base Station needs to be notified. ..……………………………………………………… 161PREHOSPITAL PROVIDER SCOPE OF PRACTICELevel ofCertificationMedical control & Skills CapabilitiesMedication AdministrationFirst ResponderMPD protocols, patient assessment, CPR, AED, BVM, Bandaging, splinting, trauma, triage, medical, and pediatrics.02Emergency Medical TechnicianMPD protocols, patient assessment, CPR AED, BVM, Bandaging, splinting, trauma, triage, medical, pediatrics, OB/GYN02, Aspirin, Epinephrine auto-injector, Charcoal, Glucose, assist with patient’s own metered dose inhaler as well as other prescribed medicationEmergency Medical Technician-AdvancedMPD protocols, EMT skills and knowledge, IV Therapy skills, ET, Multi-lumen airway.02, IV Fluid Therapy, Nalonxone, Glucose, Aspirin, Dextrose 50/25, Albuterol Nebulizer, Nitroglycerin, Charcoal, Epinephrine for anaphylaxis by commercially preloaded measured-dose device.Emergency Medical Technician- ParamedicMPD protocols, EMT skills and knowledge, IV Therapy skills, ET, Multi-lumen airway, advanced airway control, ACLS w/manual defibrillation, and advanced patient assessment, trauma and medical skills.02, IV Fluid Therapy, Medications per MPD protocol.UNIVERSAL PATIENT CARE PROTOCOLLegendEMTAEMT-AAPEMT-PPMMC OrderMNotes:● Any patient contact which does not result in an EMS transport should be documented.● Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status, and location of Injury or complaint.● Required vital signs on every patient include blood pressure, pulse, respirations.● Pulse oximetry and temperature documentation is dependent on the specific complaint.● A pediatric patient is defined by the Broselow-Luten tape. If the patient does not fit on the tape, they are Considered Adult.● Timing of transport should be based on patient’s clinical condition and the Washington State Trauma Triage Tool. Cardiac ArrestOxygenConsider Pulse OximetryPConsiderCardiac Monitor 12 Lead ECGPMDoesn’t fit protocol?Contact Medical ControlMCardiac Arrest ProtocolAppropriate ProtocolVital Signs (Temperature if appropriate) Initial Assessment Pediatric Assessment Procedure Pg. Adult Assessment Procedure Pg. Scene Safety Adult BLS Healthcare ProvidersHigh-Quality CPR* Rate at least 100/min* Compression depth at least 2 inches (5cm)* Allow complete chest recoil after each compression* Minimize interruptions in chest compressions* Avoid excessive ventilationUnresponsiveNo breathing or no normal breathing(ie, only gasping)Activate emergency response systemGet AED/defibrillatoror send second rescuer (if available) to do this* Give 1 breath every 5 to 6 seconds*Recheck pulse every 2 minutesCheck pulse:DEFINATE pulsewithin 10 seconds? Definite Pulse No PulseBegin cycles of 30 COMPRESSIONS and 2 BREATHS AED/defibrillator ARRIVESCheck rhythmShockable rhythm?Shockable Not ShockableResume CPR immediatelyfor 2 minutesCheck rhythm every2 minutes; continue untilALS providers take over or victim starts to moveGive 1 shockResume CPR immediatelyfor 2 minutesCPR Quality●Push hard (≥2 inches [5cm]) and fast (≥100/min) and allow complete chest recoil●Minimize interruptions in compressions●Avoid excessive ventilation ●Rotate compressor every 2 minutes●If no advanced airway, 30:2 compression-ventilation ratio●Quantitative waveform Capnography -If PETCO? <10 mm Hg. attempt to improve CPR qualityReturn of Spontaneous Circulation (ROSC)●Pulse AND blood pressure●Abrupt sustained increase in PETCO? (typically ≥40 mm Hg)Shock Energy●Biphasic: Manufacturer recommendation (e.g., initial dose of 120-200 J); if unknown, use maximum available. Second and subsequent doses should be equivalent, and higher doses may be considered.●Monophasic: 300 JDrug Therapy●Epinephrine IV/IO Dose:1 mg every 3-5 minutes●Vasopressin IV/IO Dose:40 units can replace first or second dose of epinephrine●Amiodarone IV/IO Dose:First dose: 300 mg bolus. Second dose: 150 mg.Advanced Airway●Supraglottic advanced airway or endotracheal intubation●Waveform Capnography to confirm and monitor ET tube placement●8-10 breaths per minute with continuous chest compressionsReversible Causes-Hypovolemia-Hypoxia-Hydrogen ion (acidosis)-Hypo-/hyperkalemia-Hypothermia-Tension pneumothorax-Tamponade, cardiac-Toxins-Thrombosis, pulmonary-Thrombosis, coronary-Trauma Adult Cardiac Arrest Shout for Help/Activate Emergency ResponseLegendEMTAEMT-AAPEMT-PPMMC OrderMStart CPR* Give oxygen* Attach monitor/defibrillator Rhythm shockable?Asystole/PEA Yes No VF/VT 2 9 3 Shock 4ACPR 2 min* IV/IO accessA Rhythm shockable?No 5 Yes Shock PCPR 2 min*Epinephrine every 3-5 min*Consider advanced airway, capnographyPPCPR 2 min*IV/IO access*Epinephrine every 3-5 min*Consider advanced airway, capnographyP 10 Rhythm shockable?Rhythm shockable?No Yes 7 YesPCPR 2 min*Amiodarone*Treat reversible causesPShock 11PCPR 2 min*Amiodarone*Treat reversible causesPRhythm shockable?NoYes* If no signs of return of spontaneous circulation (ROSC), go to 10 to 11*If ROSC, go to Post-Cardiac Arrest Care Go to 5 or 7Cardiogenic ShockHistory:Cardiac ischemia (MI, CHF)MedicationsAllergic reactionSigns/Symptoms:Restlessness, confusionWeakness, dizzinessWeak, rapid pulsePale, cook, clammy skinDelayed capillary refillHypotensionRates & pulmonary edema on examDifferential:DysrhythmiasVasovagalPearls:Be cautious of impending pulmonary edemaHypotension can be defined as systolic blood pressure of less than 100Consider performing orthostatic vital signs on patients in nontrauma situations if suspected blood or fluid loss250cc-500cc fluid bolus and reevaluate lung soundsMeds:Dopamine 5 – 20 mcg/kg/prn titrate SBP>100Epinephrine mix 1mg 1:1000 in 250 NS titrate to SBP>100 drip 2-10 mcg/minLegendEMTAEMT-AAPEMT-PPMMC OrderMAObtain IV AccessAAFluid Bolus NSAP12 lead ECGPPDopamine OrEpinephrinePMContact Medical ControlMUniversal Patient Care Protocol Chest Pain Protocol prnAdult BradycardiaLegendEMTAEMT-AAPEMT-PPMMC OrderM (With Pulse)Assess appropriateness for clinical conditionHeart rate typically <50/min if bradyarrhythmia. Identify and treat underlying cause* Maintain patent airway; assist breathing as necessary* Oxygen (if hypoxemic)* Cardiac monitor to identify rhythm; monitor blood pressure and oximetry* IV access* 12-Lead ECG if available; don’t delay therapy Persistent bradyarrhythmia causing:* Hypotension?* Acutely altered mental status?* Signs of shock?* Ischemic chest discomfort?* Acute heart failure?Monitor and observeNoDoses/DetailsAtropine IV Dose:First dose: 0.5 mg bolusRepeat every 3-5 minutesMaximum: 3 mgDopamine IV Infusion:2-10 mcg/kg per minuteEpinephrine IV Infusion:2-10 mcg per minute YesPAtropineIf atropine ineffective:* Transcutaneous pacingOR* Dopamine infusionOR* Epinephrine infusionP Consider:* Expert consultation* Transvenous pacingAdult Tachycardia(With Pulse)Identify and treat underlying cause* Maintain patent airway; assist breathing as necessary* Oxygen (if hypoxemic)* Cardiac monitor to identify rhythm; monitor blood pressure and oximetryAssess appropriateness for clinical condition.Heart rate typically ≥150/min if tachyarrhythmia.Doses/DetailsSynchronized CardioversionInitial recommended doses:* Narrow regular: 50-100 J* Narrow irregular: 120-200 J biphasic or 200 J monophasic* Wide regular: 100 J* Wide irregular: defibrillation dose (NOT synchronized)Adenosine IV Dose:First dose: 6 mg rapid IV push; follow with NS flush.Second dose: 12 mg if requirdAntiarrhythmic Infusions for Stable Wide-QRS TachycardiaProcainamide IV Dose:20-50 mg/min until arrhythmia suppressed, hypotension ensures, QRS duration increases >50%, or maximum dose 17 mg/kg given. Maintenance infusion: 1-4 mg/min. Avoid if prolonged QT or CHFAmiodarone IV Dose:First dose: 150 mg over 10 minutes. Report as needed if VT recurs.Follow by maintenance infusion of 1 mg/min for first 6 hours.Sotalol IV Dose:100 mg (1.5 mg/kg) over 5 minutes.Avoid if prolonged QT.Persistent tachyarrhythmia causing:* Hypotension?* Actually altered mental status?* Signs of shock?* Ischemic chest discomfort?*Acute heart failure?Synchronized cardioversion* Consider sedation* If regular narrow complex, consider adenosine Wide QRS? ≥0.12 secondYes*IV access and 12-lead ECG if available* Consider adenosine only if regular and monomorphic* Consider antiarrhythmic infusion*Consider expert consultationNo * IV access and 12-lead ECG if available* Vagal maneuvers* Adenosine (if regular)* β-Blocker or calcium channel blocker* Consider expert consultation Yes No Airway, AdultLegendEMTAEMT-AAPEMT-PPMMC OrderMNotes:● For this protocol, adult is defined any person who does not fit the Broselow-Luten tape● EMT’s must have multi-lumen airway training to use Combitubes or King-LTD● Capnometry or Capnography is mandatory with all methods of intubation. Document result.● Maintain C-spine immobilization for patients with suspected spinal injury● Paramedics should consider combitube or King-LTD when unable to intubate● Reconfirm ETT placement each time patient is moved● Continuous pulse oximetry should be utilized in all patients with compromised respiratory functionPulse OximetryPulse OximetryMContact Medical ontrolMCombitube/King-LTDPOral-trachealIntubationPFailed Airway ProtocolUnsuccessfulUnsuccessfulObstructionObstructionSuccessfulSuccessful removal?InadequateInadequate Attempt to remove obstruction per AHA guidelinesSupplemental OxygenBasicManeuvers first-open airway; nasal/oral airway; bag-valve maskAssess ABC’s,respiratory rateeffort, adequacy Airway, Adult FailedContinue BVMLegendEMTAEMT-AAPEMT-PPMMC OrderMPSurgical AirwayPCombitube/ King-LTDNoNoYesYesTwo (2) failed intubation attempts By most proficient technician on sceneNO MORE THAN THREE (3)ATTEMPTS TOTALNoContinue ventilation with combitube/King-LTDSPO2 > 90%Notes:●If first intubation attempt fails, make an adjustment and then try again:●Different laryngoscope blade●Different ETT size●Eschmann stylet●Change cricoid pressure●Apply BURP maneuver (push trachea Back{posterior}, Up, and to patient’s Right)●Change head positioning●Continuous Pulse Oximetry should be utilized in all patients with inadequate respiratory function●Notify Medical Control AS EARLY AS POSSIBLE abou patients difficult/failed airway.Facial Trauma or Swelling?If SPO2 drops < 90 % or it becomes difficult to ventilate with BVMSPO2 ≥ 90%With BVMventilation?Reactive Airway DiseaseHistory: Asthma COPD – Emphysema, chronic Bronchitis Congestive Heart Failure Home treatment (0?, nebulizer) Medications, (Theophylline, Steroids, Inhalers) Toxic exposure SmokingSigns and Symptoms: Shortness of breath Pursed-lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi Use of accessory muscles Fever, cough TachycardiaDifferential: Asthma Anaphylaxis Aspiration COPD (Emphysema, Bronchitis) Pleural effusion Pneumonia Pulmonary Embolus Pneumothorax Cardiac (MI or CHF) Pericardial Tamponade Hyperventilation Inhaled Toxin (Carbon monoxide, etc.) Universal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderM Pt’s MDI per prescription AObtain IV accessAFebrile or Hypotensive? ― Yes AObtain IV accessAPECGP A Albuterol prnAp And prn Atroventp pMethylprednisolone prnp pEpinephrinep Pearls: Barotrauma is often caused by the over-ventilation of Reactive Airway Patients Consider NIPPV if availableMeds: Albuterol- 2.5 mg SVN Atrovent- 0.5 mg SVN Epinephrine- 1:1,000 0.1-03ml IM Magnesium- 2 g/100mg IV over 10-15 min Methylprednisolone- 125 mg IVpMagnesiump MContact Medical ControlMPulmonary EdemaHistory: ? Congestive Heart Failure ? Past Medical history ? Medications (Digoxin, Lasix) ? Viagra, Levitra, Cialis ? Cardiac history – past Myocardial Infarction Signs/Symptoms: ? Respiratory distress, rales ? Apprehension, Orthopnea ? Jugular vein distention ? Pink, frothy sputum ? Peripheral edema, Diaphoresis ? Hypotension, shock ? Chest painDifferential: ? Myocardial Infarction ? Congestive Heart Failure ? Asthma ? Anaphylaxis ? Aspiration ? COPD ? Pleural effusion ? Pneumonia ? Pulmonary Embolus ? Pericardial Tamponade Mild Moderate- able to speak sentences, crackles base only, 0? sat ≥ 92% Severe- respiratory distress, crackles throughout, 0? sat <92% Near Death- Decreased LOC, cyanosis, dropping sats, ineffective respiratory drive LegendEMTAEMT-AAPEMT-PPMMC OrderM Universal Patient Care Protocol AObtain IV AccessA PECG / 12 LeadPPConsider CapnographyP ANitroglycerin if SBP> 100APAnd / or FurosemidePPearls: ? Consider Non-Invasive Positive Pressure Ventilation (NIPPV) if available ? Avoid Nitroglycerin in any patient (man or woman) who have used sexual performance enhancement drugs (i.e. Viagra, Levitra, Cialis) In the past 48 hours due to possible severe hypotension. ? If patient has taken Nitroglycerin without relief, consider potency of the medication ? Consider Myocardial infarction in all these patients ? Allow the patient to be in their position of comfort to maximize their breathing effort.Meds: Furosemide- 0.5-1.0 mg/kg IV or double the patients single oral dose up to 160 mg IV Morphine- 2mg IV q 3-5 minutes to 20 max Diluadad- 0.5 mg IV increments total to 2mg. 1-2 mg IM Nitroglycerin- 0.4 mg SL may repeat q5 min up to 5 times if SBP>100 mmHgPMorphinePMContact Medical ControlMPost Resuscitation ManagementHistory: Respiratory arrest Cardiac arrestSigns/Symptoms: Return of pulseDifferential: Continue to address specific differentials associated with the original dysrhythmiaLegendEMTAEMT-AAPEMT-PPMMC OrderMRepeat Primary Assessment Continue ventilator support with 100% oxygen AObtain IV AccessAPMonitor ECG/ETCO2 if availablePVital Signs/Pulse oximetry s Hypotension ion Hypotension Bradycardia AConsider fluid bolusA Treat per Bradycardia Protocol PConsider Dopamine or EphinephrineP If arrest reoccurs, revert to appropriate protocol and/or initial successful treatment PMidazolam or Lorazepam prnp M Contact Medical ControlM Notes: *Sedate as neededMeds: Lorazepam 1-2 mg IV/IN/IM May repeat PRN Midazolam 2.5-10mg IV/IO over 2 minutes Dopamine IV Start at 5-20mcg/kg/min and titrate to SBP of 90-100 mmHg Epinephrine mix 1mg 1:1000 in 250mL NS, titrate 2-10 mcg/min for SBP> 100mmHgAbdominal PainHistory: Age Past Medical / Surgical history Medications Onset Palliation / Provocation Quality (crampy, constant, sharp, dull, etc.) Region / Radiation / Referred Severity (1-10) Time (duration / repetition) Fever Last meal eaten Last bowel movement / emesis Menstrual history (pregnancy) Signs/Symptoms: Pain (location / migration) Tenderness Nausea Vomiting Diarrhea Dysuria Constipation Vaginal bleeding / discharge PregnancyDifferential: AAA Ectopic pregnancy Bowel obstruction Cardiac Pregnancy (ectopic?) GI Bleed Appendicitis Cholecystitis Pancreatitis Kidney stonesUniversal Patient Care Protocol Signs/symptoms of shock YesNoAObtain IV AccessANausea/VomitingLegendEMTAEMT-AAPEMT-PPMMC OrderMPDiphenhydramine orZofranPConsider Chest Pain protocolConsider Pain Management Protocol Notes: Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise Antacids should be avoided in patients with renal disease The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 Appendicitis presents with vague, peri-umbilical pain which migrates to the RLQ over timeMeds: Diphenhydramine- 25-50 mg IV/IM/PO Zofran – 4mg IV/IO/IMMContact Medical ControlM Allergic ReactionHistory: ? Onset and Location ? Food Allergy ? Insect bite/sting ? Medication Allergy ? New Clothing, soap, detergent ? Past history of reactions ? Past Medical History ? Medication history Signs/Symptoms: ? Itching or hives ? Coughing/wheezing or respiratory distress ? Chest or throat constriction ? Difficulty swallowing ? Hypotension or shock ? EdemaDifferential:? Urticaria (rash only) ? Anaphylaxis (systemic effect) ? Shock (vascular effect) ? Angioedema (drug induced) ? Aspiration/airway obstruction ? Vasovagal event ? Asthma or COPD ? CHFLegendEMTAEMT-AAPEMT-PPMMC OrderM Universal Patient Care ProtocolEvidence of impending Epinephrine Respiratory Distress or shock Hives/Rash OnlyAObtain IV/IO accessA No Respiratory componentAFluid Bolus NSAPDiphenhydramineP PDiphenhydraminePReassess patient PMethylprednisonePPECG /Consider 12 leadP P Albuterol prnPP And prn AtroventPPEpinephrine Drip 2-10 mcg/minP MContact Medical ControlMPearls:· Signs of shock include SBP <90· The shorter the onset from contact to symptoms, the more severe the reaction.· A single dose of Epinephrine may not reverse the effects of Anaphylaxis. Administer additional doses as needed.· Obtain ECG tracing during pharmacological administrations.· EMT may assist with patients own MDI Meds: Epinephrine 0.1=0.3 cc IM; 0.1-0.3mg SQ, SL Repeat Epinephrine PRNDiphenhydramine 25-50 mg PO/IM/IVAlbuterol 2.5.mg Pt.’s MDI per prescription SVNAlbuterol 2.5 mg & Atrovent 0.5 mg SVNMethylprednisolone 125 mg IVHistory:Known diabetic, medic alert tagDrugs, drug paraphernaliaReport of illicit drug use or toxic ingestionPast Medical historyMedicationsHistory of TraumaGI HistorySyncopeSigns/Symptoms: Decreased mental statusChange in baseline mental statusBizarre behaviorHypoglycemia (cool, diaphoretic skin)Hyperglycemia (warm dry skin; fruity breath, Kussmal resps: signs of dehydration)DiabeticUniversal Patient Care ProtocolSyncopeDifferential:Head TraumaCNS (stroke, tumor, seizure, infectionCardiac (MI, CHF)Thyroid (hyper/hypo)ShockDiabetes (Hyper/hypoglycemia)ToxicologicAcidosis / AlkalosisEnvironmental exposurePulmonary (Hypoxia)Electrolyte abnormalityPsychiatric disorderSyncopeAltered Mental Status/Diabetic EmergencyLegendEMTAEMT-AAPEMT-PPMMC OrderMAObtain IV accessABlood Glucose check> 250 mg/dL< 60 mg/dL60-250 mg/dL ANormal SalineAAdminister Oral GlucoseConsider other causes: Head injury overdose stroke hypoxiaANormal SalineAConsider other causes: Head Injury Overdose Stroke Hypoxia YesPatient Malnourished? NoPThiaminePADextroseAANaloxone prnAPGlucagon prnPPECG / 12 leadP Pearls:· Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety.· It is safer to assume hypoglycemia than hyperglycemia if doubt exists.· Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia· Low glucose (,60), normal glucose (60 – 120), high glucose (>250).· Consider Restraints if necessary for patient’s and/or personnel’s protection per the restraint procedure.Meds:Dextrose - D50% 25-50 g IVGlucagon- 1 mg IMNaloxone- 0.4-2 mg IV /IM (Start with lower dose) MContact Medical ControlMGeneral IllnessFever / Nausea / Vomiting / UnknownHistory:· Age· Duration· Past medical history· Last Oral Intake· Medications· Immunocompromised· Blood emesis/diarrhea· Menstrual history· Environmental exposureSigns / Symptoms:·Warm·Sweaty· Flushed· Pain· Radiation· Abdominal distension· Chills/Rigors· Constipation· DiarrheaDifferential:· Infections / Sepsis· Cancer / Tumors / Lymphomas· GI or Renal disorders· Heat Stroke· Medication or drug reaction· Vasculitis· Hyperthyroid· CNS disease/trauma· Myocardial infarction· Diabetic ketoacidosis· Gynecologic disease (ovarian cyst, PID)· Electrolyte abnormalities · Pregnancy· PsychologicLegendEMTAEMT-AAPEMT-PPMMC OrderMUniversal Patient Care ProtocolCheck Blood Glucose *Perform Cincinnati Stroke* Test AObtain IV AccessAAFluid Bolus NS prnAPECG / 12 lead prnP PZofran or Diphenhydramine PNausea/Vomiting? Consider No Encourage PO Fluid Intake (unless abdominal pain or other potential surgical issue) PAcetaminophenP Fever? ConsiderCooling measures No PLorazepamPShivering?Or Hyperthermic? Consider MContact Medical ControlM Notes: Individual’s normal body temperature differ with 98.6°F (37°C) being average. Generally a temperature over 100°F (38°C) is considered a fever.If shivering or hyperthermic give Lorazepam*If indicated **Contact Medical ControlMeds:Acetaminophen- 500-1000mg PODiphenhydramine- 25-50 mg IV/IM/POZofran- 4mg / 2ml IV/IMOverdose/PoisoningHistory:· Ingestion or suspected ingestion of a potentially toxic substance· Substance ingested, route, quantity· Time of ingestion· Reason (Suicidal, accidental, criminal)· Past medical history, medications Signs / Symptoms: ·Mental status changes· Hypotension / Hypertension · Decreased respiratory rate? Tachycardia, dysrhythmias? SeizuresDifferential:· Tricyclic antidepressants (TCAs)· Acetaminophen (Tylenol)· Depressants· Stimulants· Anticholinergic· Cardiac medications· Solvents, Alcohol, Cleaning agents· Insecticides (organophosphates)Poison Control 800-222-1222Universal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMBlood glucose check <60 mg/dlGlucose GelAObtain IV AccessAA Dextrose prnA Above 60 mg/dl BLS Provider?No YesA Obtain IV Access AMContact Medical ControlWith nature of toxic exposureM A Respiratory depression? Naloxone PRN A Opiates Tricyclic Calcium Channel Blockers Beta Blockers Organophosphates CNS Stimulants PPRN Excess Airway Secretions? AtropinePPSodium Bicarb-onatePPCalcium ChloridePPLorazepam or MidazolamPANaloxoneA PConsider TCPPPDopamineP PDopamine P PGlucagonPPearls: Do not rely on patient history of ingestion, especially in suicide attempts.Bring bottles, contents, emesis to EDTreat medication Over Doses if symptomatic including EKG changes SPB <100, ALOC, ST>100Meds:Atropine 2mg IVP q 5-15 min. Max 20 mgCalcium Chloride- 500-1000 mg IV-SlowlyDextrose- 25-50 g IV PRNDopamine-5-20 mcg/kg/min Titrate to maintain systolic >100mmHg Glucagon- 3-5 mg IV over 5-10 minLorazepam- 0.5-4mg IV /IM- Repeat with MC OrderMidazolam- 0.5-2 mg IV slowly over 2-3 minutes. May slowly titrate to 5mg total if neededNaloxone- 0.4-2 mg IV/IM PRN Sodium Bicarbonate- 50 mEq IVP followed by 25 mEq in 250 ml NS and run 250 ml/hrMContact Medical ControlM Pain ManagementHistory:· Age· Location· Duration· Severity (1 – 10)· Past medical history ? Medications? Drug allergies ? Aggravating factors ? Alleviating factors Signs / Symptoms: ·Severity (pain scale)· Quality (sharp, dull, etc.) · Radiation? Relation to movement, respiration? Increased with palpation of areaDifferential:· Per the specific protocol· Musculoskeletal· Visceral (abdominal)· Cardiac· Pleural / Respiratory· Neurogenic· Renal (colic)Universal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderM Rest prn Ice/Immobilize Compression ElevationA Obtain IV Access APECG/ 12 Lead prnPPMorphine or Fentanyl prnOrDiluadadPHigh Pain level?Yes No Extremely anxious?PLorazepam or prn MidazolamP Yes Nausea?PDiphenhydramine or Zofran prnPYes NoMContact Medical ControlMPearls:The goal of pain management is patient comfort while maintaining alertness and the ability to communicate effectively with the medical care team.Patients given a parental medication must be transported by an ALS provider and should remain on oxygen. BLS pain management maneuvers are still the first line of action.Meds:Morphine 2-4 mg IV titrated, 1-3mg q 2 min to 20 mg maxFentanyl 50 mcg IV total 200mcgLorazepam 0.5-1 mg IV/IN/IMMidazolam 0.5-1 mg IVZofran – 4mg / 2ml IV/IMDiluadad 1mg = Morphine 8 mgPsychological / Emotional EmergenciesHistory:· Situational crisis· Psychiatric illness· Medications· Injury to self or threats to others· Medic Alert tag ? ? Substance abuse / overdose ? Diabetes Signs / Symptoms: ·Anxiety, agitation, confusion· Affect change, hallucinations· Delusional thoughts, bizarre behavior? Combative violent? Expression of suicidal / homicidal thoughtsDifferential:· Alcohol Intoxication· Toxin / substance abuse· Medication effect / overdose· Withdrawal symptoms· Depression· Bi-polar (manic-depressive)· Schizophrenia· Anxiety· See Altered Mental Status differentialUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMEvidence of immediate danger to crew?Leave scene immediatelyYesCall for police assistanceAttempt verbal control SuccessfulImmediate risk of harm to patient or others Yes No No Restraint Procedure prnOr monitor situation and await PoliceAwait Police A Obtain IV Access prn APECG/ 12 Lead prnP Assess and treat patient per appropriate protocolPLorazepam or prn MidazolamPPearls:Your Safety first!Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc)Do not irritate the patient with a prolonged exam.Do not overlook the possibility of associated domestic violence or child abuseMeds:Lorazepam 0.5-2 mg IV/IMMidazolam 2.5-5 mg IV/IMMContact Medical ControlM SeizureHistory:· Prior History of seizures· Seizure Medications· Reported seizure activity· History of recent Head Trauma· Congenital abnormality ? Pregnancy (see Eclampsia)? Medical Alert Tag Signs / Symptoms: ·Observed Seizure activity· Altered Mental Status· Tonic / Clonic Activity? Incontinence? Mouth TraumaDifferential:· Fever· Infection? Head Trauma · Medication or Toxin · Hypoxia or Respiratory failure· Hypoglycemia· Metabolic abnormality / acidosis· TumorUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMPosition patient on side to prevent aspirationBlood GlucoseADextroseAPGlucagonPAObtain IV AccessAActive Seizure Yes Yes PConsider IM MedicationsP PLorazepam OrMidazolamPAssess for cause of seizureAObtain IV accessATreat per appropriate protocol MContact Medical ControlM NoNotes:? Be prepared to assist ventilations especially if a Benzodiazepine is used? If Evidence or suspicion of trauma, spine should be immobilized.● In Status Epilepticus , If IV access not obtainable consider IO/IMMeds:Dextrose 12.5-25 gGlucagon 1 mg IV/IMLorazepam 1-2mg IV/IMMidazolam 2.5-5 mg IV/IM Repeat seizures? Yes StrokeHistory:· Previous CVA, TIA’s· Previous cardiac / vascular surgery· Associated diseases: Diabetes, Hypertension, CAD· Atrial fibrillation· Medications (blood thinners) ? History of Trauma Signs / Symptoms: ·Altered Mental Status· Weakness / Paralysis· Blindness or other sensory loss? Aphasia / Dysarthria? Syncope· Vertigo / Dizziness· Vomiting· Headache· Seizures· Respiratory pattern change· Hypertension / hypotensionDifferential:· See Altered Mental Status· TIA (Transient Ischemic Attack)? Hypoglycemia · Thrombotic stroke· Embolic stroke· Hemorrhagic stroke· Tumor· TraumaUniversal Patient Care ProtocolAObtain IV or IO accessABlood GlucoseA Dextrose prnAIf no IV accessGlucagon≤60Cincinnati Stroke TestLegendEMTAEMT-AAPEMT-PPMMC OrderMConsider other appropriate protocol as neededNotes:? Onset of symptoms is defined as the last witnessed time the patient was symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night when patient was symptom free)? The differential listed on the Altered Mental Status Protocol should also be considered.? Be alert for airway problems (swallowing difficulty, vomiting)? Hypoglycemia can present as a localized neurologic deficit, especially in the elderly.Meds:Dextrose 12.5-25 g IV PRNGlucagon 1 mg IV/IMHyperglycemia can be very dangerous in ischemia PPrehospital Thrombolytic ScreeningPMContact Medical Control“Code Stroke”MEclampsiaHistory:· Past Medical history· Prenatal care· Medications/drugs· Familial incidence· Primigravida ? Renal Disease Signs / Symptoms: ·Seizure· Hypertension· Tachycardia? Edema? Headache· Visual disturbance· Abdominal pain· Amnesia and/or other change in mental statusDifferential:· Hypertension· Multiple fetuses? Gestational diabetes · Micro thrombi· Embolic stroke· Improper placental implantationUniversal Patient Care ProtocolPlace in left lateral recumbent positionAObtain IV APECGPLegendEMTAEMT-AAPEMT-PPMMC OrderMPatient Seizing?PMagnesium SulfatePYesMContact Medical Control MPLorazepamP Notes:? Eclampsia can present up to two months postpartum? Severe headache, vision changes, or RUQ pain may indicate preeclampsia? In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a relative (pre-pregnancy) blood pressure.? Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome.? Transport gently and quietlyMeds:Magnesium Sulfate 4-6 mg IV or 10 mg IV (5mg each buttock if no IV access)Lorazepam 1-2 mg IV/IN/IMPostpartumHistory:· Due date and gestational age· Multiple gestation (twins, etc.)· Meconium· Delivery difficulties· Congenital disease ? Medications (maternal)· Maternal risk factors· Substance abuse· Smoking Signs / Symptoms: ·Respiratory distress· Peripheral cyanosis or mottling (normal)· Central cyanosis (abnormal)? Altered level of responsiveness? BradycardiaDifferential:· Secretions· Infection? Hypovolemia· Hypoglycemia· Congenital heart disease· HypothermiaLegendEMTAEMT-AAPEMT-PPMMC OrderMUniversal Patient Care ProtocolMassage FundusEncourage breast feedingAObtain IV prnAPlacenta delivered?ObserveYes NoMContact Medical ControlM Pearls:●Maternal sedation or narcotics will sedate infant (Naloxone effective)●Consider hypoglycemia in infant●Document 1 and 5 minute APGAR scores Environmental EmergenciesHistory:· Age· Exposure to increased temperatures and/or humidity· Past Medical history / medications· Extreme exertion· Time and length of exposure· Poor PO intake · Fatigue and / or muscle cramping Signs / Symptoms: ·Altered Mental status or unconsciousness· Hot, dry or sweaty skin· Hypotension or shock? Seizure? NauseaDifferential:· Fever (Infection)· Dehydration? Medications· Hyperthyroidism (Storm)· Delirium tremems (DT’s)· Heat cramps· Heat exhaustion· Heat stroke· CNS dysfunction· Environmental exposure· Hypoglycemia· Poisoning/overdoseUniversal Patient Care ProtocolHypothermic?Hyperthermic?Document patient temperatureCooling MeasuresWarming MeasuresShivering?PLorazepamPConsiderBlood Glucose check prnLegendEMTAEMT-AAPEMT-PPMMC OrderMAObtain IV access prnAAFluid bolus NS APECG / 12 lead prnPTreat per appropriate protocolMContact Medical ControlMMeds: Lorazepam- 1-2mg IV/ IMNotes: Extremes of age are more prone to temperature emergencies (i.e. young and old)Core temperature is the most reliable measure- for pts. with ALOC and pts. <2 years old this should be the method of measurement.Heat emergencies predisposed by use of: tricyclic antidepressants, phenothiazine, anticholinergic medications, and alcohol.Cocaine, Amphetamines, and salicylates may elevate body temperatures.Shivering stops below 32°C (90°F).Sweating generally disappears as body temperatures rises above 104°F (40°).Intense shivering may occur as patient is cooled. Consider Lorazepam.ATTEMPT REWARMING BEFORE CEASING EFFORTS.With temperature less than 31°C (88°F) ventricular fibrillation is common cause of death. Handling patients gently may prevent this (rarely responds to defibrillation). Hypothermia may produce severe Bradycardia.BurnsHistory:· Type of exposure (heat, gas, chemical)· Inhalation injury· Past Medical history· Medications· Other Trauma· Loss of Consciousness · Immunization status (tetanus) Signs / Symptoms: ·Burns, pain, swelling· Dizziness· Loss of Consciousness? Shock/Hypotension? Airway compromise / distress· Singed facial or nasal hair· Hoarseness/wheezingDifferential:· Superficial (1°) red and painful· Partial thickness (2°) blistering? Full thickness (3°) painless and charred or leathery skin· Chemical· Thermal· Electrical· RadiationLegendEMTAEMT-AAPEMT-PPMMC OrderMUniversal Patient Care ProtocolRemove rings, bracelets, other constricting itemsChemicalThermalIf burn <10% body surface area Cool down the wound with Normal SalineBrush off any excess chemicalCritical Burns Eye involvement?Continuous saline flush in the affected eye Airway ProtocolCover burn with a dry cleanSheet or dressing Expose area of burn Flush area with water or NormalSaline for 20 minutes (exceptMaterials that react with H20) AObtain IV accessAdminister fluid bolusAPain Management Protocol Notes: Exam: Mental Status, HEENT, Neck, Heart, Lungs, Abdomen, Extremities, Back, NeuroCritical Burns: >25% body surface area (BSA); 3° burns>10% BSARule of Nines Consider comorbid factors in treatment and report them to the receiving facility.Hypothermia is common in severe burns.Water reactive metals include Sodium (Na), Potassium (K), and Lithium (Li)Parkland Bun Fluid Formula: Body Weight (Kg) x % 2nd and 3rd degree Burn BSA x 4 ml/Kg; give half over the first 8 hours past burn occurrence.MContact Medical ControlMDecompression Illness SCUBADiving RelatedHistory:· Aspiration of fluid· Submersion in water-regardless of depth· Possible history of trauma· Duration of immersion· Temperature of waterSigns / Symptoms::· Unresponsive· Changes in mental status· Decreased or absent vital signs· Coughing· Joint pain or tooth painDifferential:· Trauma· Pre-existing medical problem· Pressure injury (diving) Barotrauma Decompression sickness LegendEMTAEMT-AAPEMT-PPMMC OrderMUniversal Patient Care ProtocolSpinal Immobilization ProtocolTransport all near drowning patients.Remove wet clothingCover with dry (warm) blanketsWarming MeasuresAObtain IV accessAMonitor and reassessMContact Medical ControlMNotes: Exam: Check Head, Neck, Abdomen, Pelvis, Extremities, Back, Neuro for TraumaWith cold water there is no time limit- resuscitate all.All near drowning victims should be transported- conditions may deteriorate during the next several hoursScene safety! Drowning is a leading cause of death in would be rescuersConsider transport to facility with hyperbaric chamber if any chance of decompression sickness.* For Air Embolism symptoms patient should be placed on high flow oxygen, and lie patient down on left side with feet neutral or up and head neutral and not up (unless suspected spinal injury).* Diver’s Alert network (DAN) (877) 595-0625Drowning / Near DrowningHistory:· Aspiration of fluid· Submersion in water-regardless of depth· Possible history of trauma· Duration of immersion· Temperature of water Signs / Symptoms: ·Unresponsive· Changes in Mental Status · Decreased or absent vital signs? CoughingDifferential:· Trauma· Pre-existing medical problem· Pressure injury (diving) Barotrauma Decompression sicknessUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMSpinal Immobilization ProtocolTransport all Near Drowning patientsAObtain Iv access (maintain SBP≥90 mm HgARemove wet clothingCover with dry (warm) blanketsWarming MeasuresMonitor and reassessMContact Medical ControlMPearls: Exam: Check Head, neck, Chest, Abdomen, Pelvis, Back, Extremities, Skin, Neuro for TraumaWith cold water there is no time limit – resuscitate all.All near drowning victims should be transported – conditions may deteriorate during the next several hours.Scene safety! Drowning is a leading cause of death in would-be rescuers. Consider transport to facility with hyperbaric chamber if any chance of decompression sickness.Head InjuryHistory:· Onset· Mechanism (blunt / penetrating)· Loss of consciousness· Bleeding· Medical history (ETOH…)· Medications (Coumadin…)· Geriatric Signs / Symptoms: ·Pain, swelling, bleeding, oto/rhinorrhea· Altered Level of Consciousness · Respiratory distress/failure? Vomiting? Significant mechanish of injurySigns of Herniation:? GCS <8? Fixed or asymmetric pupils? Neurologic Posturing? Cushings Triad? Intermittent apnea?Neurologic deterioration (decrease in GCS≥2)Differential:· Cerebral Concussion· Cerebral Contusion· Non-Traumatic causes of ALOC· Epidural hematoma· Scalp hematoma· Seizure· Skull fracture· Stroke· Subdural hematoma· Syncope· Subarachnoid hemorrhageUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMIsolated Head Trauma?Multi-system Trauma ProtocolpgNo YesSpinal Immobilization with head of board elevated approx.. 30?°Maintain Spo?≥90% GCS GCS ≥14 GCS 3-8 GCS 0-13 AObtain Iv access (maintain SBP≥90 mm HgATreat S/S Per Appropriate ProtocolAObtain Iv access (maintain SBP≥90 mm HgAPIntubate (RSI) prnPPCapnographyPPZofran Lorazepam Versed PSigns of Cerebral Herniation?NoYesVentilate at: Adult 10-12 bpm Child 20 bpm Infant 25 bpmVentilate at: Adult 20 bpm Child 25 bpm Infant 30 bpm PCapnography where available (maintain EtCO? 32-37 mmHg)PMContact Medical ControlMMeds: Zofran – 4mg / 2ml IV/IM/IO Lorazepam 1-2 mg IV/IM/IOVersed 2-4-mg IV/IM/IOMulti-System TraumaHistory:· Time and Mechanism of injury· Damage to structure or vehicle· Location in structure or vehicle· Others injured or dead· Speed and details of MVA· Restraints / protective equipment· Past medical history· Medications Signs / Symptoms:·Altered mental status or unconscious·Hypotension or shock · ArrestDeformityContusionsAbrasionsPunctures/PenetrationsBurnsTendernessLacerationsSwellingDifferential:· Chest Tension pneumothorax Flail Chest Pericardial Tamponade Open Chest wound Hemothorax· Intra-abdominal bleeding· Pelvis/femur fracture· Spine fracture / Cord injury· Extremity fracture / Dislocation· HEENT (Airway Obstruction)· HypothermiaUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMExpose injuriesArrange transport according to the Washington State Trauma Triage Tool Spinal Immobilization ProcedureAObtain Iv accessASigns of Shock?Yes NoNS bolus: repeat as needed to prnMaintain BP of 80-90 systolicReassess Airway/VentilationPAdvance Procedures as NeededPReassess Airway/VentilationAppropriate ProtocolMContact Medical ControlM“Full” or “Modified” Trauma Code based on criteria – Providence Centralia Emergency DepartmentNotes:· Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro· Mechanism is often a good indicator of serious injury? Do not overlook the possibility of associated domestic violence or abuseLegendEMTAEMT-AAPEMT-PPMMC OrderMPediatric BLS Healthcare Providers UnresponsiveNot breathing or only gaspingSend someone to activate emergency response system, get AED/defibrillatorHigh-Quality CPR●Rate at least 100/min●Compression depth to at least ? anterior-posterior diameter of chest, about 1 ? inches (4 cm) in infants and 2 inches (5 cm) in children●Allow complete chest recoil after each compression●Minimize interruptions in chest compressions●Avoid excessive ventilation Lone Rescuer: For SUDDEN COLLASPE, Activate emergency response system, get AED/defibrillator Check pulse: DEFININTE pulse within 10 seconds? ●Give 1 breath every 3 seconds●Add compressions if pulse remains <60/min with poor perfusion despite adequate oxygenation and ventilation●Recheck pulse every 2 minutes Definite Pulse No PulseOne Rescuer: Begin cycles of 30 COMPRESSIONS and 2 BreathsTwo Rescuers: Begin cycles of 15 COMPRESSIONS and 2 BREATHS After about 2 minutes, activate emergency response system and get AED/defibrillator (if not already done). Use AED as soon as possible. Check rhythmShockable rhythm? Shockable Not ShockableGive 1 shockResume CPR immediatelyFor 2 minutesResume CPR immediatelyFor 2 minutesCheck rhythm every2 minutes; continue untilALS providers take over orVictim starts to move Note: The boxes bordered with dashed lines are performed by healthcare providers and not by lay rescuersDoses/DetailsCPR Quality* Push hard (≥? of anterior-posterior diameter of chest) and fast (at least 100/min) and allow complete chest recoil.* Minimize interruptions in compressions.*Avoid excessive ventilation* Rotate compressor every 2 minutes* If not advanced airway, 15:2 compression-ventilation ratio. If advanced airway, 8-10 breaths per minute with continuous chest compressions.Shock Energy for DefibrillationFirst shock 2 J/kg, second shock 4 J/kg, subsequent shocks ≥4 J/kg, maximum 10 J/kg or adult dose.Drug Therapy*Epinephrine IO/IV Dose0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration). Repeat every 3-5 minutes. If no IO/IV access, may give endotracheal dose: 0.1mg/kg (0.1 mL/kg of 1:1000 concentration). *Amiodarone IO/IV Dose:5 mg/kg bolus during cardiac arrest. May repeat up to 2 times for refractory VF/pulseless VT.Advanced Airway*Endotracheal intubation or supraglottic advanced airway.*Waveform Capnography or capnometry to confirm and monitor ET tube placement*Once advanced airway in place give 1 breath every 6-8 seconds (8-50 breaths per minute)Return of Spontaneous Circulation (ROSC)*Pulse and blood pressure*Spontaneous arterial pressure waves with intra-arterial monitoringReversible Causes-Hypovolemia-Hypoxia-Hydrogen ion (acidosis)-Hypoglycemia-Hypo-/hyperkalemia-Tension pneumothorax-Toxins-Thrombosis, pulmonary-Thrombosis, coronary-TraumaPediatric Cardiac ArrestShout for Help/Activate Emergency ResponseLegendEMTAEMT-AAPEMT-PPMMC OrderMStart CPR* Give oxygen* Attach monitor/defibrillator 1 RhythmShockable? Yes NoAsystole/PEAVF/VT CPR 2 MIN* IO/IV accessShock NoRhythmShockable? Yes CPR 2 MIN*IO/IV access* Epinephrine every 3-5 min* Consider advanced airwayShockCPR 2 MIN* Epinephrine every 3-5 min* Consider advanced airway RhythmShockable? Yes NoNo RhythmShockable?CPR 2 MIN* Treat reversible YesNo Shock RhythmShockable? YesCPR 2 MIN* Epinephrine every 3-5 min* Consider advanced airway Go to 1 or 2* Asystole/PEA * Organized rhythm → check pulse* Pulse present (ROSC) →post-cardiac arrest care LegendEMTAEMT-AAPEMT-PPMMC OrderM Bradycardia AlgorithmPediatric BradycardiaWith a Pulse and Poor Perfusion AIdentify and treat underlying cause●Maintain patient airway; assist breathing as necessary●Oxygen●Cardiac monitor to identify rhythm; monitor blood pressure and oximetry●IO/IV access●12-Lead ECG if available; don’t delay therapyACardiopulmonarycompromisecontinue? Cardiopulmonary Compromise●Hypotension●Acutely altered mental status●Signs of shock Doses/DetailsEpinephrine IO/IV Dose:0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration). Repeat every 3-5 minutes. If IO/IV access not available but endotracheal (ET) tube in place, may give ET dose: 0.1 mg/kg (0.1 mL/kg of 1:1000).Atropine IO/IV Dose:0.02 mg/kg. May repeat once. Minimum dose 0.1 mg and maximum single dose 0.5 mg. No●Support ABC’s●Give oxygen●Observe●Consider expert consultation YesCPR if HR <60/minwith poor perfusion despite oxygenation and ventilationNoBradycardia persists?●Epinephrine●Atropine for increased vagal tone or primary AV block●Consider transthoracic pacing/transvenous pacing●Treat underlying causesIf pulseless arrest develops, go to Cardiac Arrest AlgorithmYes LegendEMTAEMT-AAPEMT-PPMMC OrderM Tachycardia Algorithm Pediatric TachycardiaWith a Pulse and Poor PerfusionIdentify and Treat underlying cause● Maintain patient airway; assist breathing as necessary● Oxygen● Cardiac monitor to identify rhythm; monitor blood pressure and oximetry ● IO/IV access● 12-Lead ECG if available; don’t delay therapyAA Narrow Wide (>0.09 sec)Evaluate QRS duration PEvaluate rhythmwith 12-lead ECGor monitorP Doses/DetailsSynchronizedCardioversion:Begin with 0.5-1 J/kg:If not effective, increase to 2 J/kg. Sedate if needed, but don’t delay Cardioversion.Adenosine IO/IV Dose:First dose: 0.1 mg/kg rapid bolus (maximum: 6mg)Second dose: 0.2 mg/kg rapid bolus (maximum second dose 12 mg)Amiodarone IO/IV dose: 5 mg/kg over 20-60 minutes PPossibleventriculartachycardiaPProbable sinus Tachycardia●Compatible history consistent with known cause●P waves present/normal●Variable R-R; constant PR●Infants: rate usually <220/min●Children: rate usually <180/minProbable supraventricular tachycardia●Compatible history (vague, nonspecific); history of abrupt rate changes●P waves absent/abnormal●HR not variable●Infants: rate usually ≥220/min●Children: rate usually ≥180/min Cardiopulmonarycompromise??Hypotension?Acutely altered mental status?Signs of shock 1 No Consider vagal maneuvers(No delays)Search for and treat causeConsider adenosine if rhythm regular and QRS monmorphic Yes Synchronized Cardioversion Expert consultation advised●Amiodarone●If IO/IV access present, give adenosineOR●If IO/IV access not available, or if adenosine ineffective, synchronized Cardioversion Pediatric AirwayAssess ABC’s, respiratory rate, effort, adequacySupplemental Oxygen prnAdequatePulse OximetryInadequate MContact Medical ControlMBasic Maneuvers first- open airway; nasal/oral airway; bag-valve maskAttempt to remove obstruction per AHA guidelinesObstruction Successful removalAdequateUnsuccessfulOxygenate, Ventilate, Position, Reassess InadequateDeterioratingPPediatric Cricothyrotomy procedurePRapid TransportPOral-tracheal IntubationPRapid TransportSuccessful StabilizedUnsuccessfulMContact Medical ControlMContinue BVMPulse OximetryLegendEMTAEMT-AAPEMT-PPMMC OrderMMContact Medical ControlMNotes: For this protocol, child is defined as less than 12 years old.EMT’s must have multi-lumen airway training to use Combitubes or KING LTDLimit intubation attempts to 3 per patientIf unable to intubate, continue BVM ventilations, transport rapidly, and notify receiving hospital early.Capnometry or Capnography is mandatory with all methods of intubation. Document results.Maintain C-spine immobilization for patients with suspected spinal injury.Reconfirm ETT placement each time patient is moved.Continuous pulse oximetry should be utilized in all patients with inadequate respiratory function.All choking victims need to be transported to the hospital. Children who have possibly aspirated anything may not be transported POV, but can be transported BLS if stable.Pediatric Allergic ReactionHistory:· Onset and location· Food Allergy- nuts, eggs, berries, shellfish· Insect bite/sting· Medication Allergy· New clothing, soap, detergent· Past history of reactions· Past medical history· Medication historySigns / Symptoms::· Itching or hives· Coughing/ wheezing or respiratory distress· Chest or throat constriction· Difficulty swallowing· Hypotension or shock· EdemaDifferential:· Urticaria (rash only)· Anaphylaxis (systemic effect)· Shock (vascular effect)· Angioedema (drug induced)· Aspiration/airway obstruction· Vasovagal event· Asthma or COPD· CHF LegendEMTAEMT-AAPEMT-PPMMC OrderMUniversal Patient Care Protocol Hives/Rash Only Evidence of impending No respiratory component Respiratory distress or shockEpinephrine PDiphenhydramineP A Obtain IV accessAAFluid Bolus NSAPDiphenhydramineP PMethylprednisoneP PECG / 12 leadPReassess patient PAlbuterol and Atrovent prnPPFluid Bolus NSPPDopamineP Notes: The shorter the onset from contact to symptoms, the more severe the reaction.A single dose of Epinephrine may not reverse the effects of Anaphylaxis. Administer additional doses as needed.Administer Epinephrine sublingually if no BPObtain ECG tracing during pharmacological administrationsMeds:Epinephrine 1:1000 Pediatric Auto-injector SQ, 0.1- 0.3 mg SQ, SL, IV Repeat Epinephrine PRNAlbuterol 2.5.mg Pts. MDI per prescription SVNAlbuterol 2.5 mg & Atrovent 0.25 mg SVNMethylprednisolone 2mg/kg IVDopamine 5-20 mcg/kg/min IVGreyGrey/pinkPinkPurpleYellowWhiteBlueOrangeGreenGreenGreenWeight1.5 kg3.5 kg4 kg10 kg15 kg20 kg25 kg30 kg35 kg40 kg45 kgAgePreemieTerm6 mos.1 yr.3 yrs.6 yrs.8 yrs.10 yrs.11 yrs.12 yrs.14 yrs.Diphenhydramine1mg/kg3mg7mg14mg20 mg30 mg40 mg50 mg60 mg70 mg80 mg90 mgAlbuterol(5mg/ml)<15 kg 1st dose=2.5mg/high dose 5 mg>15 kg 1st dose 5mg/high dose 10mgAtrovent.25 mg SVN.25 mg SVNMethylprednisolone 2mg/kg3mg7mg14 mg20mg30 mg40 mg50 mg60 mg70 mg80 mg90 mgDopamine 1-20mcg/kg/min9mg/ 100 mL21mg/ 100 mL42mg/ 100 mL60mg/ 100 mL90mg/ 100mL120mg/ 100 mL150mg/ 100mL180mg/ 100mL210mg/ 100mL240mg/ 100mL270mg/ 100mLMContact Medical ControlM Pediatric Altered Level Of Consciousness (ALOC)History: DiseasesMedicationsAllergiesIngestions (when, what?)Medical Alert tagsBreast feeding-mother’s intakeSigns/Symptoms:ConfusionLethargySkin temp (vs. environment)Differential:HypoglycemiaHyperglycemiaTraumaHypoxiaIntracranial bleedToxic ingestionPoison Control 800-709-0911Universal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMC-spine immobilization if indicatedVentilation Adequate?NoPediatric Airway Protocol YesBP, Perfusion Adequate?No YesPediatric HypotensionProtocolCheck Blood Glucose<60Pediatric Hypoglycemia ProtocolAConsiderNaloxoneA>60MContact Medical ControlMGreyGrey/pinkPinkPurpleYellowWhiteBlueOrangeGreenGreenGreenWeight1.5 kg3.5 kg7 kg10 kg15 kg20 kg25 kg30 kg35 kg40 kg45 kgAgePreemieTerm6 mos.1 yr.3 yrs.6 yrs.8 yrs.10 yrs.11 yrs.12 yrs.14 yrs.Naloxone0.1mg/kg0.4mg / ml0.15 mg 0.38mL0.35mg 0.88mL0.7mg 1.75mL1mg 2.5mL1.5mg 3.75mL2mg 5mL5mg 2.5mL2mg 5mL2mg 5mL2mg 5mL2mg 5mLPediatric Breathing DifficultyHistory: Time of onsetPossibility of foreign bodyMedical HistoryMedicationsFever or respiratory infectionHistory of traumaSigns/Symptoms: Wheezing or stridorRespiratory retractionsIncreased heart rateAltered level of consciousnessAnxious appearanceDifferential:AsthmaAspirationForeign BodyInfectionPneumoniaCroupEpiglottitisCongenital heart diseaseMedication or ToxinTrauma – Yes NoLegendEMTAEMT-A APEMT-PPMMC OrderMUniversal Patient Care ProtocolAdminister Pts MDI per PrescriptionNO YESPt in extremis?P Epinephrine prnPCalming MeasuresP Albuterol prn andAtroventPPMethylprednisolonePPECG / 12 LeadPMContact Medical ControlMNotes:- Exam: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro - Pulse oximetry should be monitored continuously if initial saturation is <96%, or there is a decline in patient status despite normal pulse oximetry readings.-Do not force a child into a position. They will protect their airway by their body position.-The most important component of respiratory distress is airway control.-Croup typically affects children<2 years of age. It is viral, possible fever, gradual onset, no drooling is noted.-Epiglottitis typically affects children >2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient wants to sit up to keep airway open, drooling is common. Airway manipulation may worsen the condition.Meds: Epinephrine 2.5mg 1:1000 in 2.5ml NS nebulized SVN Albuterol 2.5mg Pt’s MDI per prescription SVN Albuterol 2.5mg & Atrovent 0.25mg SVN Methylprednisolone 2mg/kg IVGreyGrey/PinkPinkPurpleYellowWhiteBlueOrangeGreenGreenGreenWeight1.5 kg3.5 kg7 kg10 kg15 kg20 kg25 kg30 kg35 kg40 kg45 kgAgePreemieTerm6 mos.1 yr.3 yrs.6 yrs.8 yrs.10 yrs.11 yrs.12 yrs.14 yrs.Naloxone.1mg/kg0.15/mg 0.38mL0.35mg 0.88mL0.7mg 1.75mL1mg 2.5mL1.5mg 3.75mL2mg 5mL5mg 2.5mL2mg 5mL2mg 5mL2mg 5mL2mg 5mLAtrovent0.25mg SVN0.25mg SVNAlbuterol (5mg/ml)<15 kg 1st dose=2.5mg/high dose 5mg>15 kg 1st dose 5mg/high dose 10mgMethylprednisolone 2mg/kg3mg7mg14mg20mg30mg40mg50mg60mg70mg80mg90mgPediatric HypoglycemiaHistory:Last oral intakeHistory of DiabetesMaternal intakesMedical historySigns/Symptoms:ALOCDiaphoresisLethargyDifferential:DiabetesUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMCheck blood glucose <60Pt able to swallow?YesAdminister oral glucose NoCondition improves?AObtain IV accessAADextroseAUnable to gain IV accessNoPGlucagonP YesMContact Medical ControlMNotes: Keep patient warm. An inadequate amount of glucose for heat production, combined with profound diaphoresis, many hypoglycemic patients are at risk for hypothermiaUse D10 for Neonates (birth – 30 days)Meds:Oral Glucose Paste PRNDextrose D25 2cc/kg IV/IO repeat once PRN D10Glucagon SQ 1 mg or 0.5mg<20kgPediatric SeizureHistory: FeverPrior history of seizuresSeizure MedicationsReported seizure activityHistory of recent head traumaCongenital abnormalitySigns/Symptoms: Observed seizure activityAltered mental statusHot, dry skin or elevated bodyTemperatureDifferential:FeverInfectionHead TraumaMedication or ToxinHypoxia or Respiratory failureHypoglycemiaMetabolic abnormality / acidosisTumorUniversal Patient Care ProtocolLegendEMTAEMT-AAPEMT-PPMMC OrderMPosition patient on side to prevent aspirationYes Febrile?Cooling measures ABlood Glucose <60 ? D25APGlucagonPPAcetaminophenPNo YesAcute Seizure?AObtain IV or IO accessANo PLorazepam or MidazolamPPConsider IM MedicationsPAssess for cause of seizure AObtain IV or IO accessATreat per appropriate protocol Repeat Seizure? MContact Medical ControlMNotes:Be prepared to assist ventilations especially if a benzodiazepine is used.If evidence or suspicion of trauma, spine should be immobilized.If febrile, remove clothing and sponge with room temperature water.In an infant, a seizure may be the only evidence of a closed head injuryMeds:D25 2mL/kgGlucagon 0.1 mg/kg IM to 1 mg maxLorazepam 0.1 mg/kg IV/IOMidazolam 0.1 mg/kg IV/IO/IMAcetaminophen 20 mg/kgGreyGrey/PinkPinkPurpleYellowWhiteBlueOrangeGreenGreenGreenWeight1.5 kg3.5 kg7 kg10 kg15 kg20 kg25 kg30 kg35 kg40 kg45 kgAgePreemieTerm6 mos.1 yr.3 yrs.6 yrs.8 yrs.10 yrs.11 yrs.12 yrs.14 yrs.Acetaminophen30 mg70mg140mg200mg300mg400mg500mg600mg700mg800mg900mgLorazepam0.15mg 0.075mL0.35mg 0.175mL0.7mg 0.35mL1mg 0.5mL1.5mg 0.75mL2mg 1mL2.5mg 1.25mL3mg 1.5mL3.5mg 1.75mL4mg 2mL4.5mg 2.25mLMidazolam0.15mg 0.075mL0.35mg 0.175mL0.7mg 0.35mL1mg 0.5mL1.5mg 0.75mL2mg 1mL2.5mg 1.25mL3mg 1.5mL3.5mg 1.75mL4mg 2mL4.5mg 2.25mLGlucagon0.15mg0.35mg0.7mg1mg1mg1mg1mg1mg1mg1mg1mgPediatric AssessmentAirway & Appearance(Open/Clear – Muscle Tone/Body Position)Work of Breathing(Visible movement/Respiratory Effort) AAAbnormal: Abnormal or absent cry or Abnormal: Increased/excessive (nasal Speech. Decreased response to parents A B flaring, retractions or abdominal muscle or environmental stimuli. Floppy or rigid use) or decreased/absent respiratorymuscle tone or not moving. effort or noisy breathing.Normal: Normal cry or speech. Normal: Breathing appears regularResponds to parents or to environmental C without excessive respiratory muscle stimuli such as lights, keys, or toys. Good effort or audible respiratory sounds.muscle tone. Moves extremities well.Circulation to skin (Color / Obvious Bleeding) Abnormal: Cyanosis, mottling, paleness/pallor or obvious significant bleeding. Normal: Color appears normal for racial group of child. No significant bleeding.Decision/Action Points:Any abnormal findings or life-threatening chief complaint such as major trauma/burns, seizures, diabetes, asthma attack, airway obstruction, etc. (urgent) – proceed to Initial Assessment. Contact ALS if not already on scene/enroute. All findings normal (non-urgent) – proceed to Initial Assessment.Initial Assessment (Primary Survey)Airway & Appearance(Open/Clear – Mental Status)Breathing(Effort / Sounds / Rate / Central Color) Abnormal: Presence of retractions, nasal flaring, stridor, wheezes, grunting, gasping or gurgling. Respiratory rate outside normal range. Central cyanosis. Normal: Easy, quiet respirations. Respiratory rate within normal range. No central cyanosis Abnormal: Obstruction to airflow Gurgling, stridor or noisy breathing. Verbal, Pain or Unresponsive on AVPU scale Normal: Clear and maintainable. Alert on AVPU Scale. Circulation to skin (Color / Obvious Bleeding) Continue assessmentt throughout transport Abnormal: Cyanosis, mottling, or pallor. Absent or weak peripheral or central pulses; Pulse or systolic BP outside normal range; Capillary refill >2 sec with other abnormal findings. Normal: Color normal. Capillary refill at palms, soles, forehead or central body ≤2 sec. Strong peripheral and central pulses with regular rhythm.Decision/Action Points:Any abnormal findings (C, U or P) – Immediate transport with ALS. Open airway & provide oxygen. Assist ventilations, Start CPR, suction, or control bleeding as appropriate. Check for causes such as diabetes, poisoning, trauma, seizure, etc. Assist patient with prescribed bronchodilators or epinephrine auto-injector, if appropriate. All findings on assessment of child normal (S) – Continue assessment, detailed history & treatment at scene or enroute. Pediatric ReferencesGreyGrey/PinkPinkPurpleYellowWhiteBlueOrangeGreenGreenGreenWeight1.5 kg3.3 lbs3.5 kg7.7 lbs7 kg15.4 lbs10 kg22lbs15 kg33lbs20 kg44lbs25 kg55kbs30 kg66lbs35 kg77lbs40 kg88lbs45 kg99lbsAgePreemieTerm6 mos.1 yr.3 yrs.6 yrs.8 yrs.10 yrs.11 yrs.12 yrs.14 yrs.Pulse120 -18095-14598-145110-120100-11090-10090-10090-10075-8075-8075-80Respiratory Rate60+35-4535-4522-3020-2620-2418-2218-2214-2014-2014-20Blood Pressure50-60/40 mmHg60-70/50mmHg60-70/50mmHg80-120/53mmHG90-130/55mmHg95-130/60mmHg95-130/60mmHg100-130/60 mmHg100-140/70 mmHg100-140/70 mmHg100-140/70 mmHgEndotracheal2.5-3mm3.5mm3.5mm4.0mm5.0mm5.5mm6.5mm6.5mm7.0mm7.0-7.5mm7.0-7.5mmSuction Catheter5-6 F8 F8 F8 F10 F12 F12 F12-14 F14 F14 F14 FNasogastricTube5 F8 F8 F10 F12 F 14 F14 F14 F18 F18 F18 FDefibrillation3 JRepeat @6 J7 JRepeat @14 J14 JRepeat @28 J20 J Repeat @40 J30 J Repeat @60 J40 J Repeat @80 J50 Jrepeat@100 J60 Jrepeat@ 120 J70 Jrepeat@ 140 J80 Jrepeat@ 160 J90 Jrepeat@ 180 JCardioversion7.5-1.5 J1.25-3.5 J3.5-7 J5-20 J7.5-30 J10-40 J12.5-50 J15-60 J17.5-70 J20-80 J22.5-90 JFluid Challenge(20cc/kg)30cc70cc140cc200cc280cc400cc500cc600cc700cc800cc900ccAirwayNeedle Cricothyrotomy (Pediatric)Clinical Indications:Failed Airway ProtocolManagement of an airway when standard airway procedures cannot be accomplished or have failed in a patient less than or equal to 8 years of age.Procedure:Have suction supplies available and ready. Collect supplies including the endotracheal adapter of a 3.0 mm- ID ET tube.Place a roll of sheets or towels under the child’s shoulders to hyperextend the neck and position the larynx as far anterior as possible.Prep the area with antiseptic swab.Locate the cricothyroid membrane utilizing anatomical landmarks.Use the non-dominant hand to secure the membrane.Use commercially prepared kit or:Attach a 5-cc syringe to a 16-18-20 gauge catheter-over-needle device; insert the needle throughthe cricothyroid membrane at a 45 to 60 degree caudal angle. Aspirate for air with the syringe throughout the procedure.Once air returns easily, stop advancing the device.Thread the catheter off the needle gently at a 60 degree caudal angle.Maintain stabilization of the membrane remove the safely dispose of the needle.Attach the previously sized ET adapter to the end of the catheter and begin ventilation with a Bag Valve Mask connected to high flow oxygen source.Assess breath sounds. Make certain ample time is used not only for inspiration but expiration as well. A 1:4 ratio is not unreasonable.Gentle ventilation is necessary to avoid barotrauma and subsequent pneumothorax.Secure by best method available, recognizing that this method may be direct hands-on control of the device throughout the entire transport.If unable to obtain an adequate airway, resume basic airway management and transport the patient as soon as possible.Regardless of success or failure of needle cricothyrotomy, notify the receiving hospital at the earliest possible time of a surgical airway emergency.Document time/procedure/confirmation/change in patient condition/time on the patient care record (PCR)APGAR Scale0 Points1 Point2 PointsA – Appearance(Skin Color)Blue / PaleNormal, except for extremitiesNormal over entire bodyP – PulseAbsentBelow 100Above 100G – Grimace(Reflex Irritability)No ResponseGrimaceSneeze, cough Pulls awayA – ActivityAbsentArms and Legs FlexedActive MovementR – RespirationAbsentSlow, irregular Good, strong cryAVPU Infant / ChildResponseInfantChildA – AlertCurious / Recognizes parentsAlert / Aware of surroundingsV – Responds to VoiceIrritable / CriesOpens eyesP – Responds to PainCries in response to painWithdraws from painU – UnresponsiveNo responseNo responseCUPS PediatricC – CriticalAbsent airway, breathing or circulation(cardiac or respiratory arrest or severe traumatic injury)U – UnstableCompromised airway, breathing or circulation(Unresponsive, respiratory distress, active bleeding, shock, active seizure, significant injury, shock, near-drowning, etc.)P – Potentially UnstableNormal airway, breathing & circulation but significantMechanism of injury or illness(Post-seizure, minor fractures, infant <3 months with fever, etc.)S – StableNormal airway, breathing & circulation No significant mechanism of injury or illness(small lacerations or abrasions, infant ≥3 months with fever)Neonatal Resuscitation Birth Yes, stay with motherTerm gestation?Breathing or crying?Good tone?Routine care* Provide warmth* Clear airway if necessary* Dry* Ongoing evaluation NoLabored breathing or persistent cyanosis?HR below 100,gasping, or apnea?Warm, clear airway if necessary, dry, stimulateNo30 secNoPPVSpo? monitoringYesYesPost resuscitation careHR below 100?Clear airwaySpo? monitoringConsider CPAP60 secNoYesTake ventilation corrective stepsHR below 60?NoConsider intubationChest compressionsCoordinate with PPVYesTARGETED PREDUCTAL SpO2 After Birth 1 min 60-65%2 min 65-70%3 min 70-75%4 min 75-80%5 min 80-85%10 min 85-95%HR below 60?IV epinephrineTake ventilation corrective stepsIntubate if no chest rise!NoConsider:* Hypovolemia*PneumothoraxYesPain Assessment and DocumentationPediatricCritical Indications:Any pediatric patient with painDefinitions:Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.Pain is subjective (whatever the patient says it is).Procedure:Initial and ongoing assessment of pain intensity and character is accomplished through the patient’s self-report.Pain should be assessed and documented during initial assessment, before starting pain control treatment, and with each set of vitals.Pain should be assessed using the appropriate approved scale.0 – 10 Scale: the most familiar scale used by EMS for rating pain based on the patient beingable to express their perception of the pain as related to numbers. Avoid coaching the patient; simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever. Visual Analog Scale 0 1 2 3 4 5 6 7 8 9 10 No pain Worst Pain Wong – Baker “faces” scale: may be used with any patient with a language barrier. The faces correspond to numeric values from 0-10.From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.BEHAVIORAL TOOLFace0No particular expression or smile1Occasional grimace or Frown, withdrawn, disinterested2Frequent to constant frown Clenched jaw, quivering chinLegs0Normal or relaxed position1Uneasy, restless, tense2Kicking, or legs drawn upActivity0Lying quietly, normal position, moves easily1Squirming, tense, shiftingBack and forth2 Arched, rigid or jerkingCry0No cry (awake or asleep)1Moans or whimpers;Occasional complaint2Cries steadily, screams, sobs, frequent complaintsConsol ability0Content, relaxed1Reassured by “talking to” Hugging; distractible2Difficult to consoleOr comfort Relative percentage of body surface area (%BSA) affected by growthAGEBody Part0 yr1 yr5 yr10 yr15 yr a = ? of head9 ?8 ?6 ?5 ?4 ?b = ? of 1 thigh2 2/33 ?44 ?4 ?c = ? of 1 lower leg2 ?2 ?2 3/433 ?Venous Access IntraosseousPediatricClinical Indications:Life threatening illness or injury in a child <6 years of age (72 months) after effective ventilation is established.Procedure:Expose the lower legIdentify the tibial tubercle (bony prominence below the knee cap) on the proximal tibiaThe insertion location will be 1-2 cm (2 finger widths) below this and medially.Prep the site as per peripheral IV site.If using a commercially prepared device follow manufacturer’s recommendation.Holding the intraosseous needle perpendicular to the skin, twist the needle handle with arotating grinding motion applying controlled downward force until a “pop” or “give” is feltindicating loss of resistance. Do not advance the needle any further.Remove the trocar and attach the IV Stabilize and secure the needle.Routinely check insertion point for extra vasation.Document the procedure, time, and result (success) on/with the patient care report (PCR).Adult AssessmentClinical Indications:Any patient requesting a medical evaluation that is too large to be measured with a Broselow-Luten Resuscitation Tape.A. ResponseReview the dispatch information and select appropriate response.B. Scene Arrival and Size-up1. Consider appropriate level of Body Substance Isolation (NOI).2. Consider Personal Protective Equipment (PPE).3. Evaluate the scene safety.4. Determine the number of patients.5. Consider the need for additional resources.C. Patient Approach 1. Determine the Mechanism of Injury (MOI) / Nature of Illness (NOI). 2. If appropriate, begin triage and initiate Mass Casualty Incident (MCI) procedures.D. Initial Assessment Correct life-threatening problems as identified. Airway Open and establish airway.Head tilt – chin lift if no suspicion of cervical spine injuryJaw thrust if evidence of potential cervical spine injurySuction as necessaryIf necessary, insert airway adjunct.Oral airway if gag reflex is absentNasal airway if gag reflex is present Stabilize cervical spine when appropriate.BreathingDetermine if breathing is adequate.If patient’s ventilations are not adequate, provide assistance with 100% oxygen using Bag-Valve-Mask (BVM).Administer oxygen as appropriate.12-15 lpm NRB to all patients (including COPD) experiencing cardiovascular,respiratory or neurological compromise.2-6 lpm by nasal cannula or 6-15 lpm mask delivery device to ALL other patients withno history of prescribed home oxygen.Patients with a history of prescribed home oxygen for chronic conditions should receivetheir prescribed home dosage of oxygen.Consider pulse oximetry, if available. Never withhold oxygen from a patient in respiratory distress! Adult Assessment cont’d Circulation Assess brachial, radial, or carotid pulse.Infants and children less than 8 years of age:If patient is symptomatic with poor perfusion (unresponsive or only responds to painfulstimuli) and pulse is less than 60 bpm or absent begin CPR. If pulse is greater than 60 bmp, continue assessment.Patients 1 year of age or greater: If pulse is absent, begin CPR and attach AED. Assess for and manage profuse bleeding.Assess skin color, temperature, and capillary refill.All patients greater than 35 years of age complaining of chest pain or shortness of breath should have 12 lead EKG performed, if equipment is available, to search for cardiac ischemia. 4. Disability a. Assess mental status using AVPU Scale 1) Alert 2) Responds to Verbal stimuli 3) Responds to Painful stimuli 4) Unresponsive b. Perform Mini-Neurologic Assessment (Pulse / Motor / Sensory). c. Cervical Spine Immobilization. 1) If patient presents with a traumatic mechanism which could cause cervical spine injury and meets ANY of the following criteria, complete spinal immobilization (C-spine and back) should occur:History of Loss of Consciousness (LOC) or Unconscious?Disoriented or Altered LOC?Suspected use of Drugs or Alcohol?Midline Cervical Tenderness or Pain?Focal Neurologic Deficit?Has a painful distracting injury that could mask cervical pain or injury? 2) If NO to all of the above, transport as appropriate. 5. Exposure To assess patient’s injuries, remove clothing as necessary, considering condition and environment.E. History and Physical Examination 1. For UNSTABLE / UNRESPONSIVE trauma patients: a. Conduct Rapid Trauma Assessment, assessing for DCAP-BTLS: 1) Head a) Crepitation 2) Neck a) JVD b) Tracheal Deviation 3) Chest a) Crepitation b) Respiration c) Paradoxical Motion d) Breath Sounds 4) Abdomen a) Rigidity b) Distention 5) Pelvis / GU a) Pain on Motion b) Blood, Urine, Feces 6) Extremities a) Pulse / Motor / Sensory 7) Posterior Adult Assessment cont’dE. History and Physical Examination (cont’d) b. Obtain Baseline Vital Signs c. Obtain SAMPLE History 2. For STABLE / RESPONSIVE trauma patients: a. Determine Chief complaint b. Perform focused examination of the injured site and areas compatible with given MOI. c. Obtain Baseline Vital Signs d. Obtain SAMPLE History 3. For UNSTABLE / UNRESPONSIVE medical patients: a. Perform Rapid Physical Examination 1) Head and Neck a) JVD b) Medical Alert Device 2) Chest a) Breath Sounds 3) Abdomen a) Rigidity b) Distention 4) Pelvis / GU a) Blood, Urine, Feces 5) Extremities a) Motor / Sensory / Pulse b) Medical Alert Device 6) Posterior b. Obtain Baseline Vital Signs c. If possible, obtain history of episode from family or bystanders (OPQRST) d. If possible, obtain SAMPLE History from family or bystanders. 4. For STABLE / RESPONSIVE medical patients: a. Obtain history of episode (OPQRST). b. Obtain Baseline Vital Signs c. Obtain SAMPLE history d. Perform a Focused Physical Exam, checking areas suggested by NOI.Perform Detailed and Ongoing Assessments as dictated by patient condition.Reassess unstable patients frequently (recommended every 5 minutes).Reassess stable patients at a minimum of every 15 minutes. Airway CapnographyClinical Indications:Capnography shall be used with all endotracheal or Combitube/KING LTD airways.Procedure: Attach Capnography sensor to Combitube, KING LTD or endotracheal tube.Note CO? level and waveform changes. These will be documented on each respiratory failure or cardiac arrest patient.The capnometer shall remain in place with airway and be monitored throughout the Prehospital care and transport.Any loss of CO? detection or waveform indicative of an airway problem should be documented.The capnogram should be monitored as procedures are performed to verify or correct the airway problem.Document the procedure and results on/with the Patient Care Report (PCR) NORMAL: “Square box” waveform; baseline CO? = 0; ETCO2 = 35 – 45 mm Hg Management: Monitor DISLODGED ETT / ESOPHOGEAL INTUBATION:Loss of waveform, Loss of ETCO@ readingManagement: Monitor“SHARKFIN’ with / without prolonged expiration = Bronchospasm (asthma, COPD, allergic rxn):Management: Bronchodilators (Albuterol, Atrovent, or Epinephrine)RISING BASELINE = Patient is rebreathing CO2: Management: Check equipment for adequate oxygen flowAllow intubated patient more time to exhaleHYPERVENTILATION: ? RR; shortened waveform; baseline ETCO2 – 0;ETCO2 < 35 mm HgManagement: Biofeedback if conscious, decrease assisted ventilation rateIf unconscious/intubatedPATIENT BREATHING AROUND ET TUBE:Angled, sloping downstroke on waveform. Broken cuff or tube is too smallManagement: Assess patient, oxygenation, ventilation; may need to reintubate **Important: Severe metabolic acidosis (DKA, sepsis, salicylate poisoning, acute renal failure, methanol ingestion, tricyclic overdose) will cause tachypnea, but ETOC02 will be HIGH. THIS IS NOT NORMAL Airway CombitubeClinical Indications:Apneic patient when endotracheal intubation is not possible or not available.Patient must be > 5 feet and > 16 years of age.Patient must be unconscious without a gag reflex.No history of esophageal disease or caustic ingestion.Failed Airway ProtocolProcedure:Preoxygenate and hyperventilate the patient.Lubricate the tube.Maintain the head in a neutral inline positionGrasp the patient’s tongue and jaw with your gloved hand and pull forward.Gently insert the tube until the teeth are between the printed rings.Inflate line 1 (blue pilot balloon) leading to the pharyngeal cuff with 100 cc air.Inflate line 2 (white pilot balloon) leading to the distal cuff with 15 cc of air.Ventilate the patient through the longer blue tube.Auscultate for breath sounds and sounds over the epigastrium.Look for the chest to rise and fall.If breath sounds are positive and epigastric sounds are negative, continue ventilation through theblue tube. The tube is in the esophagus.In the esophageal mode, stomach contents can be aspirated through the #2, white tube relievinggastric distention.If breath sounds are negative and epigastric sounds are positive, attempt ventilation through the shorter,#2 white tube and reassess for lung and epigastric sounds. if breath sounds are present and the chest rises, you have intubated the trachea and continue ventilation through the shorter tube.The device is secured by the large pharyngeal balloon.Confirm tube placement using end-tidal CO? detector.Endotracheal intubation with a Combitube in Place: (Not necessary if the ventilations are adequate with the Combitube.)The tube must be in the esophageal mode.Prepare all equipment needed for endotracheal intubation.Decompress the stomach.Hyperoxygenate the patient.Deflate the balloons on the Combitube and remove. Suction equipment must be ready.Rapidly proceed with endotracheal intubation.AirwayDifficult Airway AssessmentLEMONPhysical signsLess difficult airwayMore difficult airwayL ook externallyNormal face and neckNo face or neck pathologyAbnormal face shapeSunken cheeksEdentulous“Buck teeth”Narrow mouthObesityFace or neck pathologyE valuate the 3-3-2 ruleMouth opening >3FHyoid-chin distance >3FThyroid cartilage-mouth floor distance >2FMouth opening <3FHyoid-chin distance <3FThyroid cartilage-mouth floor distance <2FM allampatiClass I and II (can see the soft palate, uvula, fauces +/- base of uvula)Class III and IV (can only see the hard palate +/- soft palate base of uvula)O bstuctionNonePathology within or surrounding the upper airway (e.g. peri-tonsillar abscess, epiglottis, retro-pharyngeal abscess)N eck MobilityCan flex and extend the neck normallyLimited ROM of the neckAirwayIntubation ConfirmationEnd-Tidal CO? DetectorClinical Indications:The End-Tidal CO? detector shall be used with all endotracheal or Combitube airways.Procedure:Attach End-Tidal CO? detector to Combitube or endotracheal tube. Ventilate six (6) times.Note color change. a color change or CO? detection will be documented on each respiratory failureor cardiac arrest patient.The CO? detector shall remain in place with the airway and monitored throughout the Prehospitalcare and transport. Any loss of CO? detection or color change is to be documented and monitoredas procedures are done to verify or correct the airway problem.Tube placement should be verified frequently and always with each patient move or loss of colorchange in the End-Tidal CO? detector.Document the procedure and the results on/with the Patient Care Report (PCR).AirwayIntubation OrotrachealClinical Indications:An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort.Any patient medicated for rapid sequence intubation.Procedure:Prepare all equipment and have suction ready.Preoxygenate the patient.Medicate according to appropriate RSI procedure.Open the patient’s airway and holding the laryngoscope in the left hand, insert the blade into the right side the mouth and sweep the tongue to the left.Use the blade to lift the tongue and epiglottis (either directly with the straight blade or indirectly with thecurved blade).Once the glottis opening is visualized, slip the tube through the cords and continue to visualize until the cuffis past the cords.Number of attempts at ventilation shall not further compromise oxygenation. Oxygenate between each attempt and record SAO2. If unable to intubate after two (2) ATTEMPTS PROCEED TO Failed Airway protocol.Remove the stylet and inflate the cuff (5-10cc until no cuff leak).Auscultate for absence of sounds over the epigastrium and bilaterally equal breath sounds.This should be repeated frequently and after movement or manipulation.Confirm the placement using a minimum of two (2) methods. CO2 detection device mandatory.Secure the tube.Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient’steeth or lips on/with the patient care report (PCR).Document all devices used to confirm initial tube placement. Also document positive or negative breath sounds before and after each movement of the patient.AirwayIntubation with Eschmann Catheter,Tracheal Tube Introducer orGum Elastic BougieTechniquePerform direct laryngoscopy after thorough preoxygenation.Insert bougie under direct visualization (grade II) or semi blind (grade III) using epiglottisas a guide. Maintain midline bent end facing anteriorly.With the tip directed anteriorly guide the bougie toward the epiglottis.Advance the bougie posterior to the epiglottis and into the glottis opening.Cricoid pressure may facilitate correct placement (when the tip of the introducer passesthe cricoid cartilage and enters the trachea it also may be palpable at the anatomic location)The operator may be able to feel the bougie “click” or “bump” over the anterior tracheal rings(“wash boarding or railroading”)Use the laryngoscope to elevate the pharyngeal soft tissueSubtle maneuvering may be required to traverse the vocal cords.Advance to the carina (resistance to passage) to verify placement (approximately 45 cm). Onceadvanced to the carina, further insertion causes the bougie to rotate on entrance into a bronchus as an additional criterion to confirm correct placement. Failure to meet resistance after inserting nearly the full length of bougie indicates esophageal placement. Withdraw and align the black “lip-line marker” with the lips (1cm band located 40cm (4 stripes) from proximal end).Pass endotracheal tube (larger than 6.0 mm) over the bougie.If the endotracheal tube catches on the arytenoid or aryepiglottic folds, withdraw the tube slightlyand rotate it 90° counterclockwise and advance it forward (allows beveled end to pass)For optimal passage of the tube over the bougie into trachea, the laryngoscope may be left in place as the endotracheal tube is advanced with the bevel facing posteriorlySecure the tube (remove bougie) and verify tube placement.Airway LaryngotrachealKING?LT-D Scope EMREMTAEMTINTPMINDICATIONSThe KING LT Airway is an airway device designed for emergency or difficult intubation in the apneic or unresponsive patient without a gag reflex.CONTRAINDICATIONSResponsive patient with an intact gag reflex.Patients with known esophageal disease.Patients who have ingested caustic substances.Dextrose, naloxone or glucagon to be administered to the patient (precaution only). WARNINGSThe KING LT airway does not protect the airway from the effects of regurgitation and aspiration.High airway pressures may divert gas either to the stomach or to the atmosphere. Intubation of the trachea cannot be ruled out as a potential complication of the insertion of the KING LT airway.After placement, perform standard checks for breath sounds and utilize an appropriate carbon dioxide monitor as required by protocol.Lubricate only the posterior surface of the KING LT airway to avoid blockage of the ventilation apertures or aspiration of the lubricant.The KING LT airway is not intended for re-use.PROCEDURE – INSERTION LT-D MODELSUsing the information provided, choose the correct KING LT airway size based on patient height.Table 5-x: King LT Airway SizesTypeSizeDescriptionConnectorColorODIDInflation VolumeLT-D235-45 inches 12-25 kgGreen11 mm7.5 mm25-35 mlLT-D2.541-51 inches25-35 kgOrange11 mm7.5 mm30-40 mlTest cuff inflation system by injecting the maximum recommended volume of air into the cuffs (size 3 – 60 ml; size 4 – 80 ml; size 5 – 90 ml). Remove all air from both cuffs prior to insertion.Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube, taking care to avoid introduction of lubricant in or near the ventilator openings.Pre-oxygenate.Position the head. The ideal head position for insertion of the KING LT-D is the “sniffing position”. However, the angle and shortness of the tube also allows it to be inserted with the head in a neutral position.Hold the KING LT airway at the connector with dominant hand. With non-dominant hand, hold mouth open and apply chin lift.With the KING LT airway rotated laterally 45 - 90° such that the blue orientation line is touching the corner of the mouth, introduce tip into mouth and advance behind base of tongue. Never force the tube into positionAs tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin.)Without exerting excessive force, advance KING LT airway until the base of connector (LT-D model) is aligned with teeth or gums.Inflate cuffs with the minimum volume necessary to seal the airway at the peak ventilator pressure employed (just seal volume).Typical inflation volumes are as follows:Size 2 – 25-35 mlSize 2.5 – 30-40 mlSize 3 - 45-60 mlSize 4 – 60-80 mlSize 5 – 70-90 mlIf necessary, add additional volume to cuffs to maximize seal of the airway. Attach the bag-valve mask the 15 mm connector of the KING LT airway. While gently bagging the patient to assess ventilation simultaneously withdraw the airway until ventilation is easy and free flowing (large tidal volume with minimal airway pressure).Depth markings are provided at the proximal end of the KING LT airway which refer to the distance from the distal ventilatory openings. When properly placed with the distal tip and cuff in the upper esophagus and the ventilatory openings aligned with the openings to the larynx, the depth markings give an indication of the distance, in cm, from the vocal cords to the upper teeth.Deliver several breaths with the bag-valve-mask and confirm proper tube placement as follows:Auscultate over the epigastrium.Auscultate the chest bilaterally at the apices and the bases for the presence of equal, bilateral lung sounds.Observe for symmetrical chest rise and fall with each breath.Look for moisture condensation in the tube with an exhaled breath.Observe patient for clinical improvement (i.e., pulse oximetry, skin condition).Confirm proper tube placement with a CO? detection device:END-TIDAL CO2 DETECTION / MONITORING, CAPNOGRAPHYEND-TIDAL CO2 DETECTION, COLORIMETRIC15. Ventilate the patient with the bag-valve-mask supplied with 100% oxygen as indicated.During CPR: Deliver 8 to 10 breaths per minute. Deliver each breath over about 1 second while chest compressions are delivered at a rate of 100 per minute, and do not attempt to synchronize the compressions with the ventilations.Patients with a perfusing rhythm: Deliver approximately 10 to 12 breaths per minute (1 breath ever 5 to 6 seconds). Deliver these breaths over 1 second.16. Secure the KING LT airway in place with a commercial device while continuing ventilatory support.17. Re-confirm airway placement after the device is secured, after every patient movement and at regular intervals. Application of a cervical collar and immobilization device will help prevent the patient from moving in such a way as to dislodge the KING LT airway.KING LTS-D MODEL NOTESDO NOT COVER THE PROXIMAL OPENEING OF THE GASTRIC ACCESS LUMEN.The gastric access lumen allows the insertion of up to an 18 French diameter gastric tube into the esophagus and stomach.PROCEDURE – REMOVALOnce it is in the correct position, the KING LT airway is well tolerated until the return of protective reflexes.Ensure suctioning equipment is ready.Deflate both cuffs completely. Turn the patient onto sideRemove the King LT airway carefully, suctioning as needed.Insert an oropharyngeal or nasopharyngeal airway as needed.Continue ventilations with a BVM and oxygen at 10-15 LPM as needed. Airway Nasotracheal IntubationClinical Indications:A spontaneously breathing patient in need of intubation (inadequate respiratory effort, evidenceof hypoxia or carbon dioxide retention, or need for airway protection).Patient must be 12 years of age or older.Procedure:Premedicate the patient with nasal spray (0xymetazoline) Afrin? Select the largest and least obstructed nostril and insert a lubricated nasal airway to help dilate the nasal passage.Preoxygenate the patient. Lubricate the tube with water soluble lubricant. Remove the nasal airway and gently insert the tube keeping the bevel of the tube toward the septum.Inset the tube along the floor of the nasopharynx angling toward the posterior hypopharynx.Continue to pass the tube listening for air movement and looking for vapor condensation in the tube. As the tube approaches the larynx, the air movement gets louder.Open the patient’s mouth to assure the tube is centered behind the uvula.Gently and evenly advance the tube through the glottis opening on inspiration. This facilitates passageof the tube and reduces the incidence of trauma to the vocal cords.Upon entering the trachea, the tube may cause the patient to cough, buck, strain, or gag. Do not remove the tube! This normal, but be prepared to control the cervical spine and the patient, and be alert for vomiting.Auscultate for bilaterally equal breath sounds and absence of sounds of the epigastrium. Observe forsymmetrical chest expansion. The 15mm adapter usually rests close to the nostril with proper positioning.Inflate the cuff with 5-10 cc of air. Confirm tube placement using an end-tidal CO? monitoring oresophageal bulb device.Medicate patient according to physician order.Secure the tube. Document the procedure, time, and result (success) on/with the patient carereport (PCR).AirwayNebulizer Inhalation TherapyClinical Indications:Patients experiencing bronchospasm.Procedure:Gather the necessary equipment.Assemble the nebulizer kit.Instill appropriate medication into the reservoir well of the nebulizer.Connect the nebulizer device to oxygen at 4-6 liters per minute or adequate flow to produce a steady, visible mist.Instruct the patient to inhale normally through the mouthpiece of the nebulizer. The patient needs to have a good lip seal around the mouthpiece.If the patient is unable to maintain good lip seal around the mouth piece, nebulizer may be connected to a face mask.In the intubated patient, nebulizer should be placed in line for effective medication delivery.The treatment should last until the solution is depleted. Tapping the reservoir well near the end of the treatment will assist in utilizing all of the solution.Monitor the patient for medication effects. This should include the patient’s assessment of his/her response to the treatment and reassessment of vital signs, ECG, and breath sounds.Assess and document peak flows before and after nebulizer treatments.Document the treatment, dose, and route on/with the patient care report (PCR).AirwayNeedle Cricothyrotomy (Adult)Clinical Indications:Failed Airway ProtocolManagement of an airway when standard airway procedures cannot be accomplished orhave failed in a patient greater than or equal to 8 years of age.Procedure:Have suction supplies available and ready.Collect supplies including the endotracheal adapter of a 3.0 mm- ID ET tube.Locate the cricothyroid membrane utilizing anatomical landmarks.Use the non-dominant hand to secure the membrane.Prep the area with antiseptic swab.Using the syringe and the finder needle supplied in the commercial needle cricothyroid kit (or a 5-cc syringe attached to a 10 to 14 gauge catheter-over-needle device if needed). Insert the needle through the cricothyroid membrane at a 45 to 60 degree caudal angle.Aspirate for air with the syringe throughout the procedure.Once air returns easily, stop advancing the device. If using an over the needle catheter, thread the catheter off the needle gently at a 60 degree caudal angle.Attach the previously sized ET adapter to the end of the catheter and begin ventilation with a Bag Valve Mask connected to high flow oxygen source.Assess breath sounds. Make certain ample time is used not only for inspiration but expiration as well. A 1:6 ratio is not unreasonable.Secure needle by best method available, recognizing that this method may be direct hands-on control of the device throughout the entire transport.If unable to obtain an adequate airway, resume basic airway management and transport the patient as soon as possible.Regardless of success or failure of needle Cricothyrotomy, notify the receiving hospital at the earliest possible time of a surgical airway emergency.Document time/procedure/confirmation/change in patient condition/time on the patient care record (PCR).AirwayNon-invasive Positive Pressure Ventilation (NIPPV)(CPAP/BiPAP)Clinical Indications:Respiratory distress in the conscious patient suffering from presumed pulmonary edema COPD exacerbation, pulmonary distress, non-responsive to simple oxygenation via non-rebreathing mask.Continue medical management of Cardiogenic pulmonary failure while preparing and during use of NIPPV.Procedure:Assemble equipment and assure proper functioning.Ensure adequate oxygen supply to ventilation device.Assess and document initial SP02 and Work of breathing.Explain the procedure to the patient.Calmly and continuously reassure patient.Consider placement of a nasopharyngeal airway.Place the delivery mask over the mouth and nose.Secure the mask with provided straps or other provided devices.CPAPBegin with a low pressure (e.g., 5 cm H20) and increase as patient tolerates/clinical situation dictates at 2.5 cm H20 to maximum of 10cm H20.BIPAP (PEEP = IPAP, Pressure support = IPAP)Begin with setting 10cm H20/5 cm H20. Increase IPAP in increments of 2cm H20. The need for IPAP > 20cm H20 requires an MD/DO order. The need for EPAP > 5cm H20 requires an MD/DO order.Monitor the patient’s respiratory status and vital signs with frequent reassessment.If rapid improvement is not noted, discontinue NIPPV and manage oxygenation via other means.Notify receiving facility of NIPPV use.Document time and response on patient care report (PCR) and attach completed NIPPV QA sheet.Contraindications:Severe respiratory failure without a spontaneous respiratory driveRisk of aspiration of gastric contentsObtunded or comatose patients who are unable to protect their airwayPatients in which the mask/head gear cannot be secured secondary to the refusal or inability to cooperate or tolerate the maskPatients with respiratory greater than 30 breaths/minuteHistory of allergy or hypersensitivity to the mask material where the risk from allergic reaction outweighs the benefit.Pediatric patients <14 y/o (due to mask fitting issues and ability to cooperate) Airway Rapid Sequence Induction (RSI) Suspected Brain Without Injury Suspected Brain InjuryINDICATIONS●Need for airway control GSC ≤ 8●Significant burns between 24 hours and 2 weeks old.●Massive crush injury●Known neuromuscular disease●Chronic renal failure and on dialysis●Patient or family history of malignant hyperthermia ● Need for airway control in patient with GSC ≤ 8 ● No contradictions to procedureCONTRAINDICATIONSPatients with spontaneous BreathingPatients with adequate OxygenationPatients with adequate ventilationPatients who would be difficult to intubatePatients with distorted facial or laryngeal anatomyPROCEDUREPreoxygenate with 100% O? Via NRB or BVMMonitor oxygen saturation with pulse oximetry and cardiac rhythm with ECGEnsure functioning vascular accessEvaluate for difficult airway (LEMON)Prepare equipment (intubation kit, BVM, suction, RSI medications, alternate Airway devices/adjuncts: Eschmann, cric kit, multilumen airway.)PREMEDICATE ADULTLidocaine 1.5 mg/kgNonePREMEDICATEPEDIATRICLidocaine 1.5 mg/kgAtropine .02 mg/kg min 0.1mgAtropine 0.02 kg/kg IV min dose 1mgSEDATEADULTEtomidate 0.3 mg/kg IV over 15 sec ORMidazolam 2.5-10 mg IV SLOWSEDATEPEDIATRICMidazolam <6 years .05 mg/kg to .1 mg/kg IV<7 years .025 mg/kg to .05 mg/kg IVNEUROMUSCULARBLOCKADEVecuronium 0.01 mg/kg IV Succinylcholine 1.5 mg/kg IV OrRocuronium 1mg /kg IVSuccinylcholine 1.5 mg/kg IVORRocuronium 0.6-1.2 mg/kg IVCONTINUEDMAINTENANCE/SEDATEMidazolam 0.05-1.0 mg/kg max 5 mg q 5-10 min PRNORLorazepam 0.05-0.1 mg/kg max 2 mg q 5 min PRNANDRocuronium 0.6 mg/kgVecuronium .1 mg/kgAirwaySuctioning-BasicClinical Indications:Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient who cannot maintain or keep the airway clear.Procedure: OropharyngealEnsure suction device is in proper working order with rigid suction tip in place.Prexoygenate the patient as much as possible.Explain the procedure to the patient if they are coherent.Examine the oropharynx and remove any potential foreign bodies or material which may occlude the airway if dislodged by the suction device.If applicable, remove ventilation devices from the airway.Use the suction device to remove any secretions, blood, or other substances.Be aware that a patient with altered mentation may bite on the catheter resulting in a foreign body obstruction.The alert patient may assist with this procedure.Reattach ventilation device (e.g., bag-valve mask) and ventilate or assist the patient.Record the time and result of the suctioning in the patient care report (PCR).Nasopharyngeal Ensure suction device is in proper working order with flexible suction tip in place.Lubricate the end of the suction catheter with water soluble lubricant.Preoxygenate the patient as much as possible.Explain the procedure to the patient if they are coherent.Examine the oropharynx and remove any potential foreign bodies or material which may occlude the airway if dislodged by the suction device.If applicable, remove ventilation devices from the airway.Insert the flexible catheter through the largest nare following the floor of the nasal passage angling toward the posterior pharynx.Use the suction device to remove any secretions, blood, or other substance.Reattach ventilation device (e.g., bag-valve mask) and ventilate or assist the patient.Record the time and result of the suctioning in the patient care report (PCR).AirwaySuctioning-AdvancedClinical Indications:Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient currently being assisted by an airway adjunct such as:* a naso-tracheal tube* endotracheal tube* Combitube* tracheostomy tube* Cricothyrotomy tubeProcedure:Ensure suction device is in proper working order.Collect supplies including flexible suction catheter, sterile saline in container, clean gloves.Preoxygenate the patient as much as possible. Do not over inflate the lungs.Attach suction catheter to suction device, keeping end of catheter aseptic.Measure length of catheter for proper depth of insertion based on the type of device in place.If applicable, remove ventilation devices from the airway.With the thumb port of the catheter uncovered, insert the catheter through the airway device.Once the desired depth (measured in #5 above) has been reached, occlude the thumb port and remove the suction catheter slowly. Interrupt ventilations for no more than 30 seconds.Reattach ventilation device (e.g., bag-valve mask) and ventilate the patient.Clear the suction catheter of thick secretions by aspirating sterile saline.If thick secretions prevent effective suctioning instill 3-5 cc of sterile saline in the tube and ventilate the patient 3-4 breaths. Then repeat suctioning as described.Document time and result including SpO? readings before and after procedure in the patient care report (PCR)AirwayTracheostomy Tube ChangeClinical Indications:Presence of Tracheostomy site.Urgent or emergent indication to change the tube such as: obstruction that will not clear with suction,dislodgement,inability to oxygenate/ventilate the patient without other obvious explanation.Procedure:Have all airway equipment prepared for standard airway management, including equipment for orotracheal intubation and failed airway.Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (e.g., if the patient has a #6.0 and a 5.5 tube).Lubricate the replacement tube(s) and check the cuffRemove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to ore-oxygenate the patient as much as possible.Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages.If applicable, deflate the cuff on the tube.Remove the tracheostomy tube.Insert the replacement tube. Confirm placement via standard measures except for esophageal detection (which is in effective for surgical airways).If there is any difficulty placing the tube, reattempt procedure with the smaller tube.If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal intubation (as per protocol). More difficulty with tube changing can be anticipated for tracheostomy sites that are immature – i.e., less than two weeks old.Great caution should be exercised in attempts to change immature tracheotomy sites.Document procedure, confirmation, patient response, and any complications in the PCR.AirwayVentilator OperationClinical Indications:Transport of an intubated patientProcedure:Confirm the placement of tube as per airway protocol.Ensure adequate oxygen delivery to the ventilator device.Preoxygenate the patient as much as possible with bag-valve mask.Remove BVM and attach tube to ventilator device.Per instructions of device, set initial values. For example, set inspiratory / expiratory ration of 1:4 with a rate of 12 to 20.Assess breath sounds. Allow for adequate expiratory time. Adjust ventilator setting as clinically indicated.If any worsening of patient condition, decrease in oxygen saturation, or any question regarding the function of the ventilator, remove the ventilator resume bag-valve mask ventilations.Document time, SPO2 / ETCO2 trends, complications, and patient response on the patient care report (PCR).Cardiac12 Lead ECGClinical Indications:Suspected cardiac patientSuspected tricyclic overdoseElectrical injuriesSyncopeProcedure:Assess Patient and monitor cardiac status.Administer oxygen as patient condition warrants.If patient presents with pain or complaint suspect of a cardiac related emergency perform a 12 Lead ECG.Prepare ECG monitor and connect patient cable with electrodes.Enter the required patient information (patient name, etc.) into the 12 lead ECG device.Expose chest and prep as necessary. Modesty of the patient should be respected.Apply chest leads and extremity leads using the following landmarks:RA –Right armLA –Left armRL –Right leg LL –Left legV1 -4th intercostal space at right sternal borderV2 -4th intercostal space at left sternal borderV3 –Directly between V2 and V4V4 -5th intercostal space and midclavicular lineV5 –Level with V4 at left anterior axillary lineV6 –Level with V5 at left midaxillary lineInstruct patient to remain still.Press the appropriate button to acquire the 12 Lead ECG.If the monitor detects signal noise (such as patient motion or a disconnected electrode), the Lead acquisition will be interrupted until the noise is removed.Once acquired, transmit the ECG data by fax (where available) to the appropriate hospital.Contact the receiving hospital to notify them that a 12 Lead ECG has been sent.Monitor the patient while continuing with the treatment protocol.Download data as per guidelines and attach a copy of the 12 lead to the Patient Care Report.Document the procedure, time, and results on/with the patient care report (PCR). I Lateral aVR V1 Septal V4 Anterior II Inferior aVL Lateral V2 Septal V5 Lateral III Inferior aVL Inferior V3 Anterior V6 LateralCardiacCardioversionClinical Indications:Unstable patient with a tachydysrhythmia (rapid atrial fibrillation, supraventricular tachycardia, ventricular tachycardia)Patient is not pulseless (the pulseless patient requires unsynchronized Cardioversion, i.e., defibrillation)Procedure:Ensure the patient is attached properly to a monitor/defibrillator capable of synchronized cardioversion.Have all equipment prepared for unsynchronized Cardioversion/defibrillation of the patient fails synchronized Cardioversion and the condition worsens.Consider the use of pain or sedating medications.Set energy selection to appropriate level per AHA guidelines.Set monitor/defibrillator to synchronized Cardioversion mode.Make certain all personnel are clear of patient.Press the button to cardiovert. Stay clear of the patient until you are certain the energy has been delivered. NOTE: It may take the monitor/defibrillator several cardiac cycles to “synchronize”, so there may be a delay between activating the Cardioversion and the actual delivery of energy.Note patient response and perform immediate unsynchronized Cardioversion/defibrillation if the patient’s rhythm has deteriorated into pulseless ventricular tachycardia/ventricular fibrillation, following the procedure for Defibrillation-Manual.If the patient’s condition is unchanged, repeat steps 2 to 8 above, using appropriate energy lever per AHA guidelines.If the patient has not improved after two attempts of Cardioversion, contact medical control.Note procedure, response, and time in the patient car report (PCR)CardiacDefibrillation – AutomatedClinical Indications:Non-traumatic cardiac arrest in patients older than 1 year of ageProcedure:Confirm the cardiac arrest. Instruct partners or First Responders to initiate CPR while the defibrillator is set up. If defibrillation is underway by Frist Responders, continue resuscitation as outlined.Turn the defibrillator on and begin documentation.Attach the cables to the appropriate pads and then apply the pads to the patient’s chest in the proper position.Stop CPR and clear the patient prior to rhythm analysis.Analyze the patient’s rhythm by pushing the “analyze” button.Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient prior to defibrillation.Defibrillate if appropriate by depressing the “shock” button.The sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic defibrillators will determine the correct joules accordingly.Immediately resume CPR for two minutes and then repeat steps 4 – 7 three more times if indicated.If “no shock advised” appears, perform CPR for two minutes and then reanalyze.Transport and continue treatment as indicated.CardiacDefibrillation – ManualClinical Indications:Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardiaProcedure:Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation.After application of an appropriate conductive agent if needed, apply defibrillation paddles or hands free pads to the patient’s chest in the proper position (right of the sternum at 2nd ICS and left anterior axillary line at 5th ICS).Set the appropriate energy level according to AHA guidelines and device type (mono vs. biphasic).Charge the defibrillator to the selected energy level.Assure proper placement of the paddles or pads.Make sure fast patch pads have good skin contact.Assertively state, “CLEAR” and visualize that no one, including yourself, is in contact with the patient.Deliver the countershock by depressing the shock button.Assess the patient’s response.Document the dysrhythmia and the response to defibrillation with ECG strips on/with the PCR.Repeat the procedure as indicated by patient response and ECG rhythm.CardiacTranscutaneous PacingClinical Indications:Patients with symptomatic Bradycardia.Pediatric patients requiring external transcutaneous pacing require the appropriate placement of pads for pediatric patients per the manufacturer’s guidelines.If used in Asystole, it must be used early.Procedure:Oxygen, ECG monitor, IV (if possible) should be in place prior to pacing.Confirm the presence of the dysrhythmia (include a copy of the ECG strip) and evaluate the patients hemodynamic statue.Adjust the QRS amplitude so the machine can sense the intrinsic QRS activity.Apply pacing pads to the patient’s chest in either of the following positions – anterior-anterior or anterior-posterior.Attach the pacing pads to the therapy cable from the machine.Consider the use of sedation and or analgesia if patient is uncomfortable.Turn the pacer on.Observe the ECG screen for a “sense” marker on each QRS complex. If a “sense” marker is not present, readjust ECG size or select another lead.Set the desired pacing rate (60-80).Start at the lowest setting and increase the current slowly while observing the ECG screen for evidence of electrical pacing capture.Assess the patient’s response to the pacing therapy.Document the dysrhythmia and the response to external pacing with ECG strips.Chest CompressionExternal DeviceClinical Indications:Cardiac ArrestNeed for the automated performance of chest compressionsPatient age of 12 years or greaterProcedure:Place the patient supine and position the device over the inferior 1/3 of the patients sternum.Adjust the device such that compression depth is 1.5 to 2 inches or 1/3 of the anterior-posterior dimension of the chest.Adjust the rate for 80 to 100 compressions/minute.Ensure you have carotid and/or femoral pulsations with the device-provided compressions.If there are any difficulties, resume manual chest compressions as directed under the cardiopulmonary resuscitation procedure.Chest DecompressionClinical Indications:Tension pneumothoraxProcedure:Confirm presence of a tension pneumothorax or identify strong clinical evidence in a rapidly deteriorating patient in the setting of major trauma. Consider in the setting of refractory PEA.Locate the insertion site at the second intercostal space at the midclavicular line on the affected side of the chest. May consider fifth intercostal space in the midaxillary line.Prep the insertion site.Insert the 2 inch, 10/ 12/ 14/ 16 gauge angiocath (1? inch, 18 gauge angiocath in patients less than 8 years) with a 10cc syringe attached, by directing the needle just over the top of the third rib (2nd intercostal space) or (fifth intercostal space in the midaxillary line) to avoid intercostal nerves and vessels which are located on the inferior rib borders.Advance the catheter 1-2 inches (3/4 -1 inch in patients less than 8 years) through the chest wall. Pull back on the plunger of the syringe as the need is advanced. Tension should be felt until the needle enters the pleural space. A “pop” or “give” may also be felt. Do not advance the needle any further.Withdraw the needle and advance the catheter until flush with the skin. Listen for a gush or “hiss” of air which confirms placement and diagnosis. Caution: this is frequently missed due to ambient noise.Dispose of the needle properly and never reinsert into the catheter.Secure the catheter and rapidly transport the patient providing appropriate airway assistance.ChildbirthClinical Indications:Imminent delivery with crowningProcedure:Delivery should be controlled so as to allow a slow controlled delivery of the infant. This will prevent injury to the mother and infant.Support the infants head as needed.Check the umbilical cord surrounding the neck. If it is present, slip it over the head. If unable to free the cord from the neck, double clamp the cord and cut between the clamps.Suction the airway with a bulb syringe. Mouth then nose.Grasping the head with hands over the ears, gently aim the baby down to allow delivery of the anterior shoulder.Gently aim the baby up to allow the delivery of the posterior shoulder.Slowly deliver the remainder of the infant.Clamp the cord 2 inches from the abdomen with 2 clamps and cut the cord between the clamps.Record APGAR scores at 1 and 5 minutes.Follow the Newly Born Protocol for further treatment.The placenta will deliver spontaneously, usually within 5 minutes of the infant. Do not force the placenta to deliver.Continue rapid transport to the hospital.Child Birth / Fundal MassageClinical Indications:Post partum hemorrhage AFTER placental deliveryProcedure:Assure complete delivery of placenta.Place absorbent material underneath pelvis of patient to facilitate the estimation of blood loss.Place the ulnar aspect of your non dominant hand perpendicular to the abdomen, parallel and just superior to the symphysis pubis.Exert moderate pressure up and in toward the spine.With your dominant hand find the uterine fundus and begin a “kneading” motion using moderate pressure.This procedure will be uncomfortable to the patient but should not be painful.Uterine massage should result in uterine contracture and the feeling of a firm “grapefruit” sized mass.Continue procedure until bleeding subsides.Document patient condition, procedure and response on PCR.Cincinnati Stroke ScreenClinical Indications:? Suspected Stroke PatientProcedure:1. Assess and treat suspected stroke patients as per protocol.2. Use Cincinnati stroke test scale to evaluate three major physical findings to identify a stroke patient who requires rapid transport to the hospital.3. If possible, prehospital care providers should establish the time of onset of stroke signs and symptoms.Stroke test1. Facial droop – Have patient show their teeth or smile. a. Normal – Both sides of face move equally b. Abnormal – One side of the face does not move as well as the other.2. Arm drift – the patient closes their eyes and holds both arms out. a. Normal – Both arms move the same direction or do not move at all (pronator grip may be helpful). b. Abnormal – One arm does not move or one arm drifts down compared to the other.3. Speech – Have the patient say “you can’t teach an old dog new tricks”. a. Normal – the patient uses the correct words with no slurring b. Abnormal – The patient slurs their words, uses inappropriate words or is unable to speak.4. Time – Try to determine exact time of onset of symptoms.Report specific findings for example: left side facial drooping, slurred speech. CPRCPRAdult andOlder Child(Puberty andolder)Child(I year old topuberty)Infant(Less than oneyear old)EstablishUnresponsivenessConsider/call for additional resourcesOpen the AirwayHead tilt – chin lift (suspected spinal trauma: Jaw thrust)Check BreathingOpen the airway- look, listen and feel.Take at least 5 seconds and no more than 10 secondsFirst 2 breathsGive 2 breaths(1 second each)Check PulseAt least 5 seconds andno more than 10secondsCarotid Pulse(if no pulse,start chestcompressions)Carotid Pulse (if nopulse or pulse < 60bpm with signs ofpoor perfusion,start chestcompressions)Brachial Pulse (ifno pulse or pulse< 60 bpm withsigns of poorperfusion, startchestcompressionsStart CPR? Compression locationCenter of breastbone between nipplesJust below nippleline onbreastbone? Compression depthHeel of 1 hand, other on top(or 1 hand for small patients)2 fingers(thumb-encirclinghands for 2-person)? Compression depth1 ? to 2 inches1/3 to ? depth of chest● Compression rate100 per minute? Compression- ventilation ratio30:215:2 Discontinuation of CPRDo not attempt ResuscitationDetermination of Field DeathProcedure:ALS/BLS Treatment: CPR may be discontinued without Base Station contact and the patient determined to be dead for the following reasons ONLY IF:1. Upon further examination it is determined that the patient meets the “Determination of Death Criteria” and CPR was initiated prior to this discovery. a. Field EMS providers may declare apparent death but may not pronounce death. Once CPR has been initiated and there is no favorable response, consider discontinuation of CPR as outlined. Category I – Obvious death? Decomposition of body tissue? Total decapitation? Total incineration? Total separation or destruction of the heart or brainNote: Prehospital care providers desiring support in the field maycontact the Base Station Hospital at any time for Determination of DeathCategory II (must meet 3 requirements)? Non-breathing? Pulselessness? Rigor Mortis? Asystole in two leadsNote: Exception – suspected hypothermia requires full resuscitation efforts Category III – Traumatic Arrest (Non-breathing and pulseless withprolonged extrication time)? Trauma deaths which do not meet the criteria in Category I or II, require resuscitation2. CPR was initiated but upon the arrival of the Paramedic, it is determined that patient is in blunt trauma arrest.3. Endotracheal intubation and drug therapy appropriate to the presenting rhythm, according to AHA guidelines, have been initiated and the patient remains apneic, pulseless, and in asystole or PEA. 4. DNR or POLST form has been presented after CPR was initiated.a. Prehospital care providers need not initiate CPR if: I. POLST form or DNR papers are dated and signed by the patient with appropriate witnessed signatures and there is no question they belong to the patient. The patient may be of any age.II. Banded with the State Banding system or EMS-NO CPR Form is present Once death has been determined and resuscitation efforts discontinued, all ALStherapeutic modalities initiated during the resuscitation must be left in place untilit has been determined that the patient will not be a Coroners’ case. Thisincludes such equipment as endotracheal tubes, IV catheters, monitor electrodesand personal items including clothes, jewelry etc. If the coroner releases thebody while the prehospital care provider is still on scene, remove all medicalequipment used during the resuscitation.5. Base Station contacted. Time of death recorded on MIR.Note: Children fourteen years and under are excluded from this procedure unless ALS personnel make Base Contact for consultation with the Base Hospital Physician. GlucometryClinical Indications:? Patients with suspected hypoglycemia (diabetic emergencies, change in mental status, bizarre behavior, etc.)? Patients with Altered Mental StatusProcedure:1. Gather and prepare equipment.2. Blood samples for performing glucose analysis should be obtained according to device manufacturers recommendations.3. Place correct amount of blood on reagent strip or site on glucometer per the manufacturer's instructions.4. Time the analysis as instructed by the manufacturer.5. Document the glucometer reading and treat the patient as indicated by the presenting symptoms, analysis, and protocol.6. Repeat glucose analysis as indicated for reassessment after treatment and document patient response on the PCR.7. Follow manufacture recommendations for device calibration. Glasgow Coma ScoreGlasgow Coma Score Infants Children/AdultsEye OpeningSpontaneous4SpontaneousTo speech/sound3To speechTo pain2To painNo response1No responseVerbal ResponseCoos or babbles5OrientedIrritable crying4ConfusedCries to pain3Inappropriate wordsMoans to pain2IncomprehensibleNone1NoneMotor ResponseSpontaneous6Obeys commandsWithdraws touch5Localizes painWithdraws pain4Withdraws painAbnormal flexion3Abnormal flexionAbnormal extension2Abnormal extensionNo response1No response Hemorrhage ControlClinical Indications:? Bleeding control of open woundsProcedure:1. Use personal protective equipment, including gloves, goggles, gown, and mask as indicated.2. Apply direct pressure to wound with clean gauze pad.3. If extremity wound, elevate above the level of the heart.4. If gauze soaks through, apply additional gauze on top of original- do not remove initial dressing.5. Once bleeding controlled, bandage dressing in place- do not rely on bandage to control bleeding.6. If unable to control bleeding with direct pressure and elevation, use pressure points. Injections-Subcutaneous, IntramuscularClinical Indications:? When medication administration is necessary and the medication must be given via the SQ or IM route or as an alternative route in selected medications.Procedure:1. Receive and confirm medication order or perform according to standing orders.2. Prepare equipment and medication expelling air from the syringe.3. Needle size Subcutaneous Injectiona. 25g 5/8 inch needle for average adultb. 25-27g ? inch needle for infant, child, elderly, or thin patientc. The most common site for subcutaneous injection is the arm. Injection volume should not exceed 1 cc.4. Needle size Intramuscular injection:a. 20-25g 1-2 inch depending on patient size.b. The possible injection sites for intramuscular injection include the arm, buttock and thigh.5. Injection volume should not exceed 1 cc for the arm and not more than 2.5 cc in the thigh or buttock.6. The thigh should be used for injections in pediatric patients and injection volume should not exceed 1 cc.7. Explain the procedure to the patient and reconfirm patient allergies.8. Expose the selected area and cleanse the injection site with alcohol.9. Insert the needle into the skin with a smooth, steady motion10. SQ: 45 degree angle IM: 90 degree angle11. Aspirate for blood. If blood is aspirated do not inject medication. Discard and begin again.12. Inject the medication.13. Withdraw the needle quickly and dispose of properly without recapping.14. Apply pressure to the site.15. Monitor the patient for the desired therapeutic effects as well as any possible side effects.16. Document the medication, dose, route, patient response and time on/with the patient care report (PCR).Orthostatic Blood Pressure Measurement Clinical Indications:? Patient situations with suspected blood / fluid loss / dehydration? Patients larger than the Broselow- Luten tapeProcedure:1. Assess the need for orthostatic vital sign measurement.2. Obtain patient’s pulse and blood pressure while supine.3. Have patient stand for two minutes.4. Obtain patient’s pulse and blood pressure while standing.5. If pulse has increased by 30 BPM or systolic blood pressure decreased by 30 mmHg, the orthostatics are considered positive.6. If patient is unable to stand, orthostatics may be taken while the patient is sitting with feet dangling.7. If positive orthostatic changes occur while sitting, DO NOT continue to the standing position.8. Patients on prolonged beta-blocker therapy will not demonstrate orthostatic vital sign changes. Provider must complete assessment and utilize clinical judgment.9. Document the time and vital signs for supine and standing positions on/with the patient care report (PCR).10. Determine appropriate treatment based on protocol. Pain Assessment and DocumentationADULTClinical Indications:? Any patient with painDefinitions:? Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. ? Pain is subjective (whatever the patient says it is).Procedure:1. Initial and ongoing assessment of pain intensity and character is accomplished through the patient’s self-report.2. Pain should be assessed and documented during initial assessment, before starting pain control treatment, and with each set of vitals.3. Pain should be assessed using the appropriate approved scale.4. Two pain scales are available: the 0 - 10 and the Wong - Baker "faces" scale.5. 0 – 10 Scale: the most familiar scale used by EMS for rating pain with patients. It is primarily for adults and is based on the patient being able to express their perception of the pain as related to numbers. Avoid coaching the patient; simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever.. Visual Analog Scale 0 1 2 3 4 5 6 7 8 9 10 No pain Worst Pain6. Wong – Baker “faces” scale: may be used with geriatrics or any patient with a language barrier. The faces correspond to numeric values from 0-10. This scale can be documented with the numeric value or the textual pain description.From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.Pulse OximetryClinical Indications:? Patients with suspected hypoxemia.Procedure:1. Turn the machine on and allow for self-tests.2. Apply probe to patient’s finger or any other digit as recommended by the device manufacturer.3. Allow machine to register saturation level.4. Record time and initial saturation percent on room air if possible on/with the patient care report (PCR).5. Verify pulse rate on machine with palpated pulse of the patient.6. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary.7. Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia.8. In general, normal saturation is SpO2 97-99%. Below 94%, suspect a respiratory compromise.9. Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the device.10. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain.11. Factors which may reduce the reliability of the pulse oximetry reading include:(a) Poor peripheral circulation (blood volume, hypotension, hypothermia)(b) Excessive pulse oximeter sensor motion(c) Fingernail polish (may be removed with acetone pad)(d) Carbon monoxide bound to hemoglobin(e) Irregular heart rhythms (atrial fibrillation, SVT, etc.)(f) JaundiceRestraintsClinical Indications:? Patients with actual or potential threat to self or others.Procedure:1. Planning:A. Request assistance from Law EnforcementB. EMS personnel are not to knowingly place themselves at risk during the process of restraining a patient.C. Obtain necessary resources to manage scene and patient.D. Assess patient for any condition that may contribute to violent behavior. Treatment for identified conditions is to be initiated according to protocol immediately after controlling the situation and patient behavior.E. Consult Medical Control as soon as possible regarding the application and use of restraints.F. Verbal de-escalation techniques are to be implemented and documented. If verbal de-escalation fails, providers may need to implement physical and or chemical restraint measures.2. Application of restraints:A. Obtaining and preparing appropriate restraints? padded leather restraints? soft restraints (i.e. posey, Velcro or seatbelt type)? any method utilized must allow for quick releaseB. Assessing the safety of the situation? Complete a visual check for potential weapons? If there is suspicion of weapon involvement request involvement of Law Enforcement prior to engaging in patient interaction.? Providers should remove any potential weapons from their person. (i.e., pens, flashlights, trauma shears etc.)C. Assigning a contact for the out of control person? Minimize the number of people speaking to the out of control person. ? Continue use of verbal de-escalationD. Designating who will direct and cue team members in the application of restraints? Assign each limb and the head to specific team members? Give the signal to go hands-on (this may be a non-verbal signal)? Supervise the application of restraints? Give the verbal signal for hands-off (RELEASE)? No team member is to release their designated limb until directed to do soE. Conduct a preliminary debriefing? Assess team members and patient for any injuries? Re-assess restraints for appropriate applicationRestraints cont’d3. Reassessment / Chemical Adjuncts:A. Following the application of physical restraints EMS personnel must assess the patient to determine the need for administration of an anxiolytic, or sedative to prevent continued forceful struggling against the restraint. Continued forceful struggling against the restraint can lead to hyperkalemia, rhabdomyolysis, or cardiac arrest.B. Chemical adjuncts to physical restraints are to be administered in accordance with patient care protocols and / or on line medical direction.C. Post restraint assessment must include hemodynamic, respiratory, and neurologic systems. Restrained extremities should be evaluated for pulse quality, capillary refill, color, nerve and motor function a minimum of every fifteen minutes.4. Documentation:A. In addition to standard information, the Medical Incident Report must document the following:i. Complete assessment of patientii. Objective description of patient behavior (competence)iii. Use and effectiveness of verbal de-escalation techniquesiv. Reason for physical restraintv. Explanation offered to the patientvi. Type of restraint used and time appliedvii. Post restraint serial extremity evaluationviii. Post evaluation of the patient’s respiratory statusix. Condition of the patient enroute and on transfer to Emergency Department Staff.5. Approved restraint devices / patient positioning:A. The following forms of restraint are not to be utilized by EMS personnel:i. “sandwiching” patients between backboards, scoop-stretchers, or mattresses, as a restraintii. restraining a patient’s hands and feet behind the patient (i.e. hog-tying)iii. Methods or other material applied in a manner that could cause respiratory, vascular, or neurological compromise, including the use of “choke holds”.iv. locking handcuffsv. hard plastic ties or any restraint device requiring a key to removeB. Patients should not be transported in the prone position. EMS personnel must ensure that the patient’s position does not compromise the patient’s respiratory, circulatory, or neurological systems, and does not preclude any necessary medical intervention to protect the patient’s airway should vomiting occur.C. Occasionally it is necessary for Law Enforcement to apply restraint devices that are not approved for EMS use in order to protect the safety of the patient and the public. As soon as the situation is controlled EMS personnel are to exchange these devices for those that are approved for EMS use. In the event that restraint exchange cannot safely occur, Law Enforcement must accompany patient during transport.Rule of NinesAdult Spinal Clearance Clinical Indication:? To determine whether it is appropriate for the paramedic to forgo full spinal immobilization i.e. rigid collar, backboard, three point restraining device and head immobilization device, in the prehospital settingProcedure:Assess for the following:1. Midline bony spinal tenderness, crepitus, or step off2. Painful cervical ROM3. Physical findings with a neurologic deficit4. Altered mental status to include substance abuse and/or loss of consciousness5. The presence of additional painful or distracting injuries6. The complaint of parasthesia or numbness7. Language barrier i.e. patient not understanding the questions asked, dementia, speaks a different language, or mentally delayed8. Children under the age of 129. Significant mechanism of injury or care provider judgmentIf any of the above findings are positive full spinal immobilization is to beImplemented. Spinal Immobilization Clinical Indications:? Need for spinal immobilization as determined by protocolProcedure:1. Gather a backboard, straps, C-collar appropriate for patient’s size, tape, and head rolls or similar device to secure the head.2. Explain the procedure to the patient.3. Place the patient in an appropriately sized C-collar while maintaining in-line stabilization of the C-spine. This stabilization, to be provided by a second rescuer, should not involve traction or tension but rather simply maintaining the head in a neutral, midline position while the first rescuer applied the collar.4. Once the collar is secure, the second rescuer should still maintain their position to ensure stabilization (the collar is helpful but will not do the job by itself.)5. Place the patient on a long spine board with the log-roll technique if the patient is supine or prone. For the patient in a vehicle or otherwise unable to be placed prone or supine, place them on a backboard by the safest method available that allows maintenance of inline spinal stability.6. Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is secured to the backboard, the second rescuer may release manual in-line stabilization.7. NOTE: Some patients, due to size or age, will not be able to be immobilized through inline stabilization with standard backboards and C-collars. Never force a patient into a non-neutral position to immobilize them. Such situations may require a second rescuer to maintain manual stabilization throughout the transport to the hospital. 8. Document the time of the procedure in the patient care report (PCR). Splinting Clinical Indications:? Immobilization of an extremity for transport, either due to suspected fracture, sprain, or injury.? Immobilization of an extremity for transport to secure medically necessary devices such as intravenous catheters.Procedure:1. Assess and document pulses, sensation, and motor function prior to placement of the splint. If no pulses are present and a fracture is suspected, consider reduction of the fracture prior to placement of the splint.2. Remove all clothing from the extremity.3. Select a site to secure the splint both proximal and distal to the area of suspected injury, or the area where the medical device will be placed.4. Do not secure the splint directly over the injury or device.5. Place the splint and secure with Velcro, straps, or bandage material (e.g., kling, kerlex, cloth bandage, etc.) depending on the splint manufacturer and design.6. Document pulses, sensation, and motor function after placement of the splint. If there has been a deterioration in any of these 3 parameters, remove the splint and reassess.7. If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, the following procedure may be followed for placement of a femoral traction splint:a. Assess neurovascular function as in #1 above.b. Place the ankle device over the ankle.c. Place the proximal end of the traction splint on the posterior side of the affected extremity, being careful to avoid placing too much pressure on genitalia or open wounds. Make certain the splint extends proximal to the suspected fracture. If the splint will not extend in such a manner, reassess possible involvement of the pelvis. d Extend the distal end of the splint at least 6 inches beyond the foot.e. Attach the ankle device to the traction crank.f. Twist until moderate resistance is met.g. Reassess alignment, pulses, sensation, and motor function. If there has been deterioration in any of these 3 parameters, release traction and reassess.8. Document the time, type of splint, and the pre and post assessment of pulse, sensation, and motor function in the patient care report (PCR). Taser Dart Removal Clinical Indication:? The darts should only be removed in the field if they do not involve the eye, face, neck, breast or groin.? Patients with retained darts in these areas should be transported to a hospital for removal by a physician.Procedure:1. Prior to removal EMS personnel must be convinced the individual/patient must be in police custody and adequately restrained. 2. Body substance isolation procedures must be taken. 3. Ensure that wires are disconnected from the gun or the wires have been cut.4. Push on the body part which the barbed dart (straight #8 fish hook) is imbedded and simultaneously pull the dart straight out.5. Apply alcohol or iodine to the puncture area and dress wound.6. Treat the dart as a “contaminated sharp”. The dart should be placed in a` biohazard sharps container and turned over to law enforcement.`7. Patient must be thoroughly assessed to determine if other medical problems or injuries are present.8. If the individual does not have any other presenting injuries/illness, they may be left in the custody/care of law enforcement.9. If transported to the hospital, follow the Patient Care Procedure regarding restraints for aggressive or violent patients.10. Detailed documentation is very important as it is likely to become evidence Temperature MeasurementClinical Indications:? Monitoring body temperature in a patient with suspected infection, hypothermia, hyperthermia, or to assist in evaluating resuscitation efforts.Procedure:1. If clinically appropriate, allow the patient to reach equilibrium with the surrounding environment. For example, the temperature of a child or infant that has been heavily bundled is often inaccurate, so “unbundle” the child for 3 to 5 minutes before obtaining temperature.2. For adult patients that are conscious, cooperative, and in no respiratory distress, an oral temperature is preferred (steps 3 to 5 below). For infants or adults that do not meet the criteria above, a rectal temperature is preferred (steps 6 to 8 below).3. To obtain an oral temperature, ensure the patient has no significant oral trauma and place the thermometer under the patient’s tongue with appropriate sterile covering.4. Have the patient seal their mouth closed around thermometer.5. If using an electric thermometer, leave the device in place until there is indication an accurate temperature has been recorded (per the “beep” or other indicator specific to the device). If using a traditional thermometer, leave it in place until there is no change in the reading for at least 30 seconds (usually 2 to 3 minutes). Proceed to step 9.6. Prior to obtaining a rectal temperature, assess whether the patient has suffered any rectal trauma by history and/or brief examination as appropriate for patient’s complaint.7. To obtain a rectal temperature, cover the thermometer with an appropriate sterile cover, apply lubricant, and insert into rectum no more than 1 to 2 cm beyond the external anal sphincter.8. Follow guidelines in step 5 above to obtain temperature.9. Record time, temperature, method (oral, rectal), and scale (C° or F°) in Patient Care Report (PCR).Thrombolytic ScreenClinical Indications:? Rapid evaluation of a patient with suspected acute stroke, acute myocardial infarction, or acute pulmonary embolus who may benefit from thrombolysis.Procedure:1. Follow the appropriate protocol for patient’s complaint to assess need for thrombolysis (e.g., Cincinnati stroke screen or other instrument for suspected stroke, 12-lead EKG for suspected myocardial infarction, etc.). If the screen is positive, proceed to step 2 below.2. By history from the patient and/or family members, obtain and record the following information:a. history of active internal bleeding?b. history of CNS neoplasm, arteriovenous (AV) malformation, or CNS aneurysm?c. history of CNS surgery in past 2 months?d. history of severe, uncontrolled hypertension (>200/130)?e. history of bleeding disorder?f. history of aortic dissection?g. history of allergy to tPA?3. Record all findings in the Patient Care Report (PCR).Venous AccessBlood DrawClinical Indications:? Collection of a patient’s blood for laboratory analysis.Procedure:1. Utilize universal precautions as per Infection control standards Page 11.2. Select vein and prep as usual.3. Select appropriate blood-drawing devices.4. Draw appropriate tubes of blood for lab testing per destination hospital protocol. Red, Blue, Green, Purple5. Assure that the blood samples are labeled with the correct information (a minimum of the patients name, along with the date and time the sample was collected.6. Deliver the blood tubes to the appropriate individual at the hospital.7. Blood draws for law enforcement can be done if it does not jeopardize the care of the patient . critically injured or sick patients).Venous AccessExternal Jugular AccessClinical Indications:? External jugular vein cannulation is indicated in a critically ill patient > 8 years of age who requires intravenous access for fluid or medication administration and in whom an extremity vein is not obtainable.? External jugular cannulation can be attempted initially in life threatening events where no obvious peripheral site is noted.Procedure:1. Place the patient in a supine head down position. This helps distend the vein and prevents air embolism.2. Turn the patient’s head toward the opposite side if no risk of cervical injury exists.3. Prep the site as per peripheral IV site.4. Align the catheter with the vein and aim toward the same side shoulder.5. “Tourniqueting” the vein lightly with one finger above the clavicle, puncture the vein midway between the angle of the jaw and the clavicle and cannulate the vein in the usual method.6. Attach the IV and secure the catheter avoiding circumferential dressing or taping.7. Document the procedure, time, and result (success) on/with the patient care report (PCR). Venous Access ExtremityClinical Indications:? Any patient where intravenous access is indicated (significant trauma or mechanism, emergent or potentially emergent medical condition).Procedure:1. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles.2. Connect IV tubing to the solution in a sterile manner. Fill the drip chamber half full and then flush the tubing bleeding all air bubbles from the line.3. Place a tourniquet around the patient’s extremity to restrict venous flow only.4. Select a vein and an appropriate gauge catheter for the vein and the patient’s condition.5. Prep the skin with an antiseptic solution.6. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the blood flash is visualized in the catheter.7. Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle into the proper container without recapping.8. Draw blood samples when appropriate.9. Remove the tourniquet and connect the IV tubing or saline lock. 10. Open the IV to assure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated. 11. Cover the site with a sterile dressing and secure the IV and tubing.12. Document the procedure, location, size of IV catheter, time and result (success) on/with the patient care report (PCR).Venous Access Intraosseous AdultClinical Indications:? Inability to obtain vascular access in a patient that requires access in an emergency mannerProcedure:1. Assemble standard intravenous access equipment as well as IO needle. If a commercial kit is being used (Sternal IO, EZ-IO, Bone gun), follow the procedure recommended by the manufacturer.2. Tibia:a. Assess for trauma, infection, decreased pulses, and decreased sensory motor function (if possible) in the lower extremity where the line is to be placed. If any of these are present, chose another site/method for access.b. Rotate the chosen leg externally to expose the medial proximal Tibia.c. Locate the tibial tuberosity. Go approximally 2cm medially toward inner leg to find a flat site. Go approximally 2cm distally toward the knee to locate penetration site.d. Prep the site with Chlorhexadrate or Betadine. If time allows, drape the site.3. Holding the I/O needle perpendicular to the site, insert it with a twisting motion until you feel decreased resistance or feel a “pop”. Stop advancing the needle.4. Remove the trochar.5. Begin infusion of IV fluids. The fluids should flow easily. Once ease of flow has been established, the line may be used just as any other IV line.6. Stabilize the IO needle.7. Record the procedure, site of insertion, size of needle, any complications, and clinical response in the patient care report (PCR).Wound CareClinical Indications:? Protection and care for open wounds prior to and during transport.Procedure:1. Use personal protective equipment, including gloves, gown, and mask as indicated.2. If active bleeding, elevate the affected area if possible and hold direct pressure. Do not rely on “compression” bandage to control bleeding. Direct pressure is much more effective.3. Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate (this may have to be avoided if bleeding was difficult to control). Consider analgesia per protocol prior to irrigation.4. Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to ensure the bandage is not too tight.5. Monitor wounds and/or dressings throughout transport for bleeding.6. Document the wound and assessment and care in the patient care report (PCR).Acetaminophen (APAP)Indications:Fever, PainADULT DoseADULT: 20mg/kg POTOXIC DOSE IS 160 MG/KGContraindications:Documented hypersensitivityPediatric Considerations:20mg/kg POLiquid solutions vary in concentration verify correct doseDo not exceed 5 doses in 24 hoursPrecautions:Use cautiously in patients with long term alcohol useMany OTC products contain APAP – Consider ToxicityAdverse Effects:HypoglycemiaAllergic reactionOnset/Duration:20-30 minute onset4-6 hour durationClassification:Antipyretic, AnalgesicAction:Analgesia, AntipyresisNotes:Caution with long term alcohol ingestionActivated Charcoal (Charcoal Slurry)Indications:Suspected overdose or accidental ingestion of drugs or chemicals. ADULT Dose:ADULT 50 grams PO/NGContraindications:ALOCDiminished or absent gag reflexCaustic, corrosive or petroleum distillate ingestionPediatric Considerations:PED 1 gm/kg PO/NGDo not use preparations containing sorbitolNG tube may be necessary for administrationPrecautions:Unpleasant taste be prepared for spitting or vomitingUse of straw may facilitate administration in adult patientAdverse Effects:VomitingAspirationOnset/Duration:Immediate onset24 hour durationClassification:Chemical absorbentAction:Inhibits gastrointestinal absorption of drugs or chemicalsNotes:Most effective if administered within 30 minutes of ingestionNG Tube may be necessary for effective administration.Adenosine (Adenocard)Indications:Supra-ventricular tachyarrhythmias (stable)ADULT Dose:6mg Rapid IVP followed with 10-20 cc NS flushRepeat dose of 12 mg q 2 minutes PRN x2>80 y/o give ? standard doseContraindications:2nd or 3rd degree heart blockSick sinus syndromeHypersensitivity to adenosinePediatric Considerations:0.1 mg/kg initialRepeat 0.2 mg/kgPrecautions:Some Asthma patients may experience bronchoconstriction.Adverse Effects:HeadacheDizzinessDyspneaChest pressureNausea/vomitingTranscient AsystoleOnset/Duration:Immediate onset10 second durationClassification:Antidysrhythmic agentEndogenous purine nucleosideAction:Slows conduction through the A-V node can interrupt the re-entry pathways through the A-V nodeNotes:Theophylline, nicotine, caffeine-may require higher dosesDipyridamole, Carbamazepine require lower dose bolusAfrin (Oxymetazoline)IndicationsPre-medication for nasal intubation, EpistaxisADULT Dose:2-3 puffs each nostril (on inhalation)Contraindications:Known hypersensitivityPediatric Considerations:Children under 12 require diluted concentrationPrecautions:Hyperthyroidism Cardiac Disease hypertension Diabetes mellitus Simultaneous use of MAOI and ephedrine may result in Hypertensive crisisAdverse Effects:Cardiovascular collapse Hypertension PalpitationsOnset/Duration:Immediate onset, 30min – 4hour durationClassification:VasoconstrictorAction:Local vasoconstriction of dilated arterioles causing reduction of blood flow and reduction of nasal congestion.Albuterol Sulfate (Proventil, Ventolin)Indications:Treatment of Bronchospasm in patients with reversible obstructive airway diseaseADULT Dose:2.5 mg in 3cc NS via nebulizer 1-2 puffs of patients OWN Metered Dose Inhaler (MDI) May initiate continuous nebulizer for persistent distress Do not exceed 15mg /hrContraindications:Known hypersensitivity, Tachycardia (relative)Pediatric Considerations2.5-10 mg as per Broselow tapePrecautions:Cardiovascular disease Hyperthyroidism Diabetes mellitusAdverse Effects:Tachycardia Hypertension Palpitations Dizziness Dysrhythmias Restlessness NauseaOnset/Duration:5 minute onset 3-4 hour durationClassification:BronchodilatorAction:Relaxes bronchial smooth muscle by stimulating beta2 receptors resulting in bronchodilationDrug: Drug InteractionsBeta Blockers: Pt may not respond as effectively to Albuterol. Sympathomiemetics: Additive effectsAMIODARONE (Cordarone?)Indications: Shock refractory ventricular fibrillation and pulseless ventricular tachycardia. Ventricular tachycardia. Wide-complex tachycardia of unknown type (regular rhythm).ADULT Dose:VF and pulseless VT: Give 300 mg IV/IO. Give additional 150 mg IV push in 3 to 5 minutes for refractory or recurrent VF/VT.VT with pulse: Give a rapid infusion of 150 mg over 10 minutes.Mix in 100 mL of D5W and infuse at 150 gtts/min (15 drop set).Contraindications:Cardiogenic shock (SBP <90).Marked sinus bradycardia.Second- or third-degree heart block.Hypersensitivity to the drug.Torsades de pointesPediatric ConsiderationsVF and pulseless VT: Give 5 mg/kg IV/IO. [No subsequent doses]VT with pulse: Give an infusion of 5 mg/kg over 20 minutes. Mix in 100 mL of D5W and infuse at 75 gtts/min (15 drop set).Slow Infusion: 1 mg/min. Mix 150 mg in 250 mL D5W and infuse at 100 gtts/min(60 drop set).Precautions:May worsen existing or precipitate new dysrhythmias, including torsades depointes and VF.Use with beta-blocking agents could increase risk of hypotension and bradycardia.Amiodarone inhibits atrioventricular conduction and decreases myocardialcontractility, increasing the risk of AV block with verapamil or diltiazem or ofhypotension with any calcium channel blocker.Use with caution in pregnancy and with nursing mothers.Adverse EffectsCNS: dizziness, headacheCV: bradycardia, cardiac conduction abnormalities, CHF, dysrhythmias, hypotension,SA node dysfunction, sinus arrestRESP: dyspnea, pulmonary inflammationOnset/DurationClassification:Pregnancy Cat. D Iodinated benzofuran derivativeTherapeutic Class: AntiarrhythmicAction:Amiodarone prolongs myocardial action potential and effective refractory period and causes noncompetitive α- and β-adrenergic inhibition. Amiodarone suppresses atrial and ventricular ectopy (PSVT, AF, ATach, VT, VF, etc.) and slows conduction through the AV node (ventricular rate control; useful in WPW). Amiodarone also causes vasodilation resulting in reduced cardiac work.Drug: Drug InteractionsAspirin (ASA, Acetylsalicylic Acid)IndicationsChest Pain with suspected MIADULT Dose:81mg X 4 tabs Chewable up to 325 mg POContraindications:Known HypersensitivityPediatric Considerations:ContraindicatedPrecautions:Toxic dose is 200-300 mg/kgAdverse Effects:Angioedema Nausea- GI upset Occult Blood loss HepatotoxicityOnset/Duration:30-60 minute onset 4-6 hour durationClassification:Antiplatelet, Analgesic, Antipyretic, Anti-inflammatoryAction:Inhibition of platelet aggregation and platelet synthesis Reduction of risk of death in patients with a history of myocardial infarction or unstable anginaNotes:Salicylate Toxicity: tinnitus, nausea, vomitingAtropine SulfateIndicationsSymptomatic bradycardia Premedication for RSI Organophosphate poisoning (OPP) Adults HR <60 Pediatrics Severe Alcohol Intoxication. ADULT Dose:Bradycardia: 0.5- 1 mg IV/IO q 3-5 min to maximum of 3 mg Organophosphate Poisoning: 2 mg IV / IO q 3-5 minutes until heart rate >60 BPM or symptoms clear.Contraindications:Non symptomatic bradycardia (Relative : Asthma, Myasthenia Gravis, narrow angle glaucoma).Pediatric Considerations:RSI 0.02 mg/kg IV/IO 0.1 mg min.dose . Contraindicated in neonates. Precautions:Use with caution in patients with suspected acute myocardial infarction (AMI) Will not be effective for Type II AV Block and new Third Degree Block with wide QRS complexes (In these patients may cause paradoxical slowing. Be prepared to pace)Adverse Effects:Tachycardia Nausea/Vomiting Increased myocardial 02 demand Dilated pupils Increased intraocular pressure PalpitationsOnset/Duration:2-5 minute onset 20 minute durationClassification:Parasympathetic blocker (Anticholinergic) Antidysrhythmic agentAction:Blocks acetylcholine receptors Decreases vagal tone resulting in increased heart rate and AV conduction Dilates bronchioles and decreases respiratory tract secretions Decreases gastrointestinal secretions and motilityAtrovent (Ipratropium Bromide)Indications:Bronchospasm due to reactive airway diseases Organophosphate poisoningADULT Dose:0.5 mg via nebulizer q 6-8 hoursContraindications:Known hypersensitivity, Pediatric Considerations0.25 mg SVNPrecautions:Should be used with caution in patients wit narrow-angle glaucoma.Adverse Effects:Anxiety Palpitations Nausea/VomitingOnset/Duration:15-30 minute onset 5-7 hour durationClassification:Anticholenergic bronchodilatorAction:Blocks acetylcholine receptors Dries respiratory tract secretions Reduces bronchospasmCalcium Chloride (CaC12)IndicationsHyperkalemia Hypermagnesemia Specific arachnid envenomation Crush Syndrome Over dose of calcium channel blockersADULT Dose:10 to 20 mg/kg slow IV / IOContraindications:VF (unless due to Hyperkalemia) Hypercalcemia Renal Calculi Pediatric Considerations:Dose: 20 mg/kg IV/IOPrecautions:Causes tissue necrosis if injected into interstitial space Precipitates with sodium bicarbonate May Increase Dig toxicity Clear IV with 20cc NS before and after administrationAdverse Effects:Bradycardia Hypotension SyncopeOnset/Duration:5 to 15 minute onset Duration is dose dependent, effects may persist for up to 4 hrsClassification:Inotropic agentAction:Couples electrical and mechanical events of the myocardium Increases myocardial irritability Increases ventricular irritabilityNotes:200mg IV prophylactic to Diltiazem admin in elderly dehydrated or drug induced hypotensionCardizem (Diltiazem)Indications:A fib A flutter PSVTADULT Dose:10-20 mg/mg IV/IO max 0.25 mg/kg repeat dose in 15 minutes at 0.35 mg/kg IV/IO over two minutes max .35mg/kgContraindications:Concomitant of IV Beta-Blockers Wide complex tachycardia of unknown etiology Sick Sinus Syndrome WPW High Degree AV Blocks Precautions:May precipitate with use of Furosemide Use cautiously in elderly patients Congestive Heart Failure Not recommended in Pediatric patientsAdverse Effects:Arrhythmias Bradycardia Hypotension Heart Failure AV block Pulmonary EdemaOnset/Duration:2 to 10 minutes onset 1 to 3 hour durationClassification:Calcium channel blockerAction:Inhibit calcium ion on passage across cell membrane Slows SA and AV node conduction velocity Decreases myocardial contractility Decreases peripheral vascular resistanceDrug: Drug InteractionsPotentiates with Beta-Blocker, Lithium, Tegretol, CyclosporinsDextrose 50% in water (D50W)IndicationsHypoglycemia Hypokalemia with concurrent insulin administration Altered level of consciousness due to suspected or confirmed hypoglycemiaADULT Dose:12.5 to 25 g IV/IO repeat dose to maximum of 50 g administer with 100 mg of ThiamineContraindications:HyperglycemiaPediatric Considerations:Dose 0.5mg/kg D25% DILUTE 50% 1:1 to D25%NEONATES- CALL MEDICAL CONTROLPrecautions:Causes tissue necrosis if injected into interstitial space May increase cerebral ischemia in CVA Caution with intracranial hemorrhageAdverse Effects:Thrombophlebitis Osmotic Diuresis Pulmonary Edema May worsen Wernicke’s Encephalopathy Onset/Duration:30-60 minute onset Duration depends on severity of Hypoglycemia Classification:Hyperglycemic agent Hypertonic solutionAction:Provide immediate source of Glucose for rapid utilization for cellular metabolismNotes:Follow with complex carbohydrate if leaving patient at homeDilaudid (Hydromorphone)Indications:Moderate to severe painADULT Dose:0.5mg IV increments total of 2mg (Caution in elderly) 1-2mg IMContraindications:Hypotension SBP <110 CNS depression Respiratory depression RR<12 Head Injury Current nausea or vomiting (prior to anti-emetics)Pediatric Considerations0.015 mg/kg IV/IMPrecautions:Caution should be used in patients who have taken other Central Nervous depressants, narcotic Analgesics, Sedative/Hypnotics, or Tricyclic antidepressantsAdverse Effects:Respiratory depression Increased sedation Headache Abdominal pain Decreased LOC Impaired Mental Status Nausea / VomitingOnset/Duration:Onset: IV – Immediate IM – 7 – 15 minutes Duration: 4-5 hoursClassification:Narcotic Analgesic, OpiateAction:Decreases sensitivity to pain, Stimulates variety of Opioid receptorsNotes:This is a strong Narcotic. Start with low does given slowly and add additional low doses as needed. 1 mg of Hydromorphone is equal to 8mg of MorphineDiphenhydramine (Benadryl)IndicationsAnaphylaxis Allergic reactions Dystonia Sedation NauseaADULT Dose:12.5 to 50 mg IV/IO/IM. 50 mg POContraindications:Known hypersensitivity Newborns Acute Asthma COPD exacerbation Relative: Narrow Angle GlaucomaPediatric ConsiderationsDOSE: 1 mg/kg IV/IO/IM/POPrecautions:Reduce dose for elderlyAdverse Effects:Seizures Sedation Thickening of Bronchial SecretionsOnset/Duration:IV administration has immediate onset, 6 to 8 hour duration . PO administration 30 minute onset, 6-8 hours durationClassification:AntihistamineAction:Prevents but does not reverse histamine mediated responses Suppresses cough reflexDrug InteractionsPotentiates CNS depressantsDopamine (Intropin)Indications:Cardiogenic shock Sepsis Vasogenic Shock Refactory Hypotension Neurogenic shock BradycardiaADULT Dose:Initial 5.0 mcg/kg/min: IVD, then titrate to effectContraindications:Tachydysrhythmias Hypovolemic shockPediatric Considerations1-20mcg/kg/min IVD Epinephrine is pressor of choice in pediatric shockPrecautions:Titrate to blood pressureAdverse Effects:Angina, Ectopy, headache, Tachydysrhythmias, VT/VF, Increased Myocardial Ischemia, AMI, HypertensionOnset/Duration:Less than 5 minute onset Less than 10 minute durationClassification:SympathomimeticAction:Stimulates Alpha, Beta, and Dopamine receptors, depending on dose Increases cardiac output and systemic arterial pressure Dilates vessels to brain, heart and kidneys. Increases heart rateEpinephrine Hydrochloride (Adrenaline)IndicationsCardiopulmonary Arrest: Anaphylaxis Ventricular Fibrillation Status Asthmaticus Pulseless Ventricular Tachycardia Profound refractory Hypotension Asystole Pulseless electrical activityADULT Dose:Cardiopulmonary Arrest: 1mg 1:10,000 q 3 to 5 minutes IV/IO Anaphylaxis: 0.1-0.3 mg of 1:1000 IM q 10 to 20 minutes X 2 Status Asthmaticus: 0.3 mg of 1:1000 IM q 20 minutes X 2 Profound refractory hypotension: 2-10 mcg/min IV infusion Mix one milligram of 1:1000 Epinephrine in 250 cc Normal Saline for concentration of 4mcg/ccPediatric Considerations:Dose 0.01 mg/kg 1:1000 SQ/IV/IO max 0.3 mg Nebulized for respiratory emergencies see Pediatric ProtocolsPrecautions:Use caution when given IV in Anaphylactic Shock as Myocardial Ischemia and or Cardiac Arrest may occurAdverse Effects:Hypertension, Tachycardia, Increased Myocardial oxygen demandOnset/Duration:Onset: Immediate if given IVP / 5-10 minutes SQ/IM Duration: 3-5 minutes IVP / 20 minutes SQ/IMClassification:Sympathomimetic agent (Catecholamine)Action:Beta effect is more profound than Alpha effectNotes:Epinephrine is the pressor of choice in the case of Pediatric Shock states. Dopamine may be ineffective1 mg Epinephrine 1:1000 in 250 cc = 4 mcg/cc Use 60gtt tubingMcg/ min246810Administer30 gtt/min60 gtt/min90 gtt/min120 gtt/min150 gtt/minEtomidate (Amidate)Indications:Induce sedation to facilitate intubation. CardioversionADULT Dose:0.1-0.3 mg/kg IV over 15-30 seconds this dosing also applies to children over 10.Contraindications:Hypersensitivity PregnancyPediatric ConsiderationsDo not use in children under 10 years oldPrecautions:Do not re-dose with Etomidate. Long term use can cause decreased Corticosteroid productionAdverse Effects:Myoclonic skeletal muscle movement, Apnea, Hyperventilation, Laryngospasm, Dysrhythmias, nausea, vomiting, eye movement, hiccups, snoring, seizuresOnset/Duration:Onset is 15-20 seconds. Duration is 3-5 minutes Classification:Hypnotic, non sedative, non narcotic, non analgesicAction:Ultra short acting, nonbarbituate hypnotic. Produces rapid induction of anesthesia with minimal cardiorespiratory effects. Rapidly distributed following IV injection/ rapidly metabolized and excreted. (Note extremely short duration)Notes:MUST Use sedative (Ativan/Versed) for intubation maintenance.Wt in lbs100110120130140150160170180190200Wt in kg4550545964687377828691Dose in mg13 mg15 mg16 mg18 mg19 mg20 mg22 mg23 mg25 mg26 mg27 mgWt in lbs210220230240250260270280290300Wt in kg95100104109113118122127132136Dose in mg28 mg30 mg31 mg33 mg34 mg35 mg37 mg38 mg40 mg41 mgFentanyl (Sublimaze)Indications:AnalgesiaPulmonary EdemaAcute MIADULT Dose:25-50 mcg IV/IO/IMContraindications:Known hypersensitivityPediatric Considerations:DOSE: 1-2 mcg/kg IV/IMPrecautions:Head injuriesCOPDALOCHypotensionAdverse Effects:CNS depression, Resp. depression, Hallucinations, Hypotension, Hypertension, Arrhythmias, Nausea/Vomiting, Constipation, Chest wall rigidityOnset/Duration:Onset- 1-2 min IV, 7-15min IM Duration: ? - 1hr IV, 1-2-hr IMClassification:Opioid Agonist/Narcotic AnalgesicAction:Binds to Opiate receptors as an agonist to alter patients’ perception of painful stimuli.Notes:CNS and Resp. depressant effects are similar to Morphine. Drug has little hypnotic activity and rarely causes histamine release.Furosemide (Lasix)Indications:Pulmonary EdemaADULT Dose:40mg-80mg (or double patient’s daily dose up to 100mg) slowly *can be dosed at 0.5-1.0 mg/kgContraindications:Dehydration/ Hypovolemia, Hypokalemia, Hepatic comaPediatric Considerations:2 mg/kgPrecautions:Patients using Potassium depleting steroids, HX of SLE, HX of Hepatic Cirrhosis, increased risk of Hypokalemia in patients taking Digoxin, Dehydration or PneumoniaAdverse Effects:Hypotension, Electrolyte imbalance, Transient hearing lossOnset/Duration:Onset: 5 minutes for preload reduction, 30 minutes for diuresis Duration: ~2 hoursClassification:Non-Potassium sparing loop diureticAction:Inhibits Sodium and Chloride re-absorption in the proximal loop of henle promoting excretion of sodium, water, chloride, and potassium. Also reduces Cardiac preload by increasing venous capacitance.GlucagonIndications:Hypoglycemia, Beta-blocker OD, Calcium channel blocker OD, Symptoms of Esophageal obstructionADULT Dose:Hypoglycemia – 1.0mg IM Ca++ and Beta-blocker OD – 3-5mg IV/IM/INContraindications:None in emergency settingPediatric Considerations:Dose: 0.1mg/kg up to 1mg IMPrecautions:Do not dilute with Saline solutions, will form a precipitateAdverse Effects:Nausea & VomitingHyperglycemiaHypersensitivity ReactionsOnset/Duration:Onset is 5-20 minutes, peak effect at 30 minutes. Duration is 1-1.5 hoursClassification:Polypeptide hormoneAction:Accelerates liver glycogenolysis and inhibits glycogen synthetase resulting in blood glucose elevation. Stimulates hepatic gluconeogenesis and causes an Inotropic Myocardial effect. Relaxes GI smooth muscleNotes:Reconstitute powdered solution with supplied dilutent only IF given IV, flush line with D-5% instead of NS solutionGlucose Oral (Glucose Paste)Indications:Hypoglycemia in conscious patient that is able to swallowADULT Dose:One tube PO – between cheek and gumContraindications:Unconsciousness, Inability to swallow, hyperglycemiaPediatric Considerations:One tube POPrecautions:Not tasty, watch for spittingAdverse Effects:Choking if not properly administeredClassification:CarbohydrateAction:Rapidly metabolized source of calories in patients with inadequate oral intake.Notes:Perform Glucose check before and after administration of Glucose. Follow with complex carbohydrate if leaving patient at homeHydroxocobalamin (Cyanokit?)Generic Name:Trade name:Hydroxocobalamin (hye-drox-oh-koe-bal’–amin)Cyanokit?Chemical Class:Therapeutic Class:Vitamin B complexHematinic; vitaminActions:Cyanide is an extremely toxic poison. In the absence of rapid and adequate treatment, exposure to a high dose of cyanide can result in death within minutes due to inhibition of cytochrome oxidase resulting in arrest of cellular respiration. Specifically, cyanide binds rapidly with cytochrome a3, a component of the cytochrome c oxidase complex in mitochondria. Inhibition of cytochrome a3 prevents the cell from using oxygen and forces anaerobic metabolism, resulting in lactate production, cellular hypoxia and metabolic acidosis. The action of Cyanokit? in the treatment of cyanide poisoning is based on its ability to bind cyanide ions to form cyanocobalamin, which is then secreted in the urine.Pharmacokinetics:N/AIndications:Known or suspected cyanide poisoningContraindications:Hypersensitivity to hydroxocbalamibn or cyanocobalaminPrecautions:Pregnancy Cat. CAllergic reactions may include anaphylaxis, chest tightness, edema, urticaria, pruritus, dyspnea and rash.Hypertension Side Effects:CNS: headacheCV: Increased blood pressureGI: Transient chromoaturia (abnormal coloration of the urine), nauseaSKIN: Erythemia, rash, injection site reactionAdministration:Adult: Give 5 g IV infused over 15minutes. If signs and symptoms persist, a repeat dose can be administered (Medical Control). The infusion rate for second dose is usually between 15 minutes and 2 hours.Pediatric: Give 70 mg/kg, up to 5 g IV infused over 15 minutes. If signs and symptoms persist, a repeat dose can be administered (Medical Control). The infusion rat for second dose is usually between 15 minutes and 2 hours.Supply:Each 2.5 g vial needs to be reconstituted with 100 mL of normal saline, rocked or inverted repeatedly not shaken. Total volume prior to administration is 200 mL and contains 5 g of drug.Notes:The drug substance is the hydroxylated active form of vitamin B12.Cyanide poisoning may result from inhalation, ingestion, or dermal exposure to various cyanide-containing compounds, including smoke from closed-space fires. The presence and extent of cyanide poisoning are often initially unknown.There is no widely available, rapid, confirmatory cyanide blood test. Treatment decisions must be made on the basis of clinical history and signs and symptoms of cyanide intoxication. If clinical suspicion of cyanide poisoning is high. Cyanokit? should be administered without delay.Incompatible with diazepam, dobutamine, dopamine, fentanyl, nitroglycerin, pentobarbital, propofol, thiopental, blood products, sodium, thiosulfate, sodium nitrite and ascorbic acid. Use separate IV lines.Lidocaine (Xylocaine)Indications:First line antiarrythmic in pregnancy; symptomatic PVC’s; VT/VF; RSI with suspected closed head injuries; VT with pulse.ADULT Dose:VF/VT – 1.5mg/kg IV/IO q 5-10 minutes Max 3 mg/kg VT w/pulse– 1 -1.5mg/kg IV/IO, then 0.5-0.75mg/kg q 5-10 minutes up to 3mg/kg Drip- 2-4 mg/min following bolus/conversion RSI- 1-1.5 mg/kg IV/IOContraindications:High degree Heart blocks WPW Strokes-Adams Syndrome SVT Hypotension BradycardiaPediatric Considerations:VF/Pulseless VT- 1mg/kg IV/IO bolus then 20-50mcg/kg/min, repeat bolus dose if infusion initiated >15 minutes after initial bolus RSI- 1-2 mmg/kg IV/IOPrecautions:Caution in use with patients >70 y/o or with Liver or Renal disease, CHF, Resp Depression, Shock. Reduce maintenance infusion by 50%Adverse Effects:Seizures, Slurred Speech, Altered Mental StatusOnset/Duration:Onset- 45-90 seconds Duration: 10-20 minutesClassification:Amide Derivative, AntiarrythmicAction:As an Antiarrhythmic, it suppresses automaticity and shortens the effective refractory period and action potential duration of His-Purkinje fibers an suppresses spontaneous Ventricular Depolarization during Diastole by altering Sodium permeability through cellular fast channel membranes. The drug acts preferentially on diseased or Ischemic Myocardial tissue, exerting its effect on the conduction system by inhibiting re-entry mechanisms and halts Ventricular ArrhythmiasDrip – mix 1G/250ml D5W using 60gtt set4mg//ml:1mg2mg3mg4mgMcg/min:15gtt30gtt45gtt60gttLorazepam (Ativan)Indications:Seizures Anxiety Sedation Intubation maintenanceADULT Dose:1 – 2 mg IV/IN/IM May repeat PRNContraindications:Narrow angle Glaucoma, pregnancyPediatric Considerations:0.1 mg/kg IV/IO/IMPrecautions:Caution in use with patients with Renal or Hepatic impairment. Increased CNS depression in patients intoxicated or on other depressant type drugs.Adverse Effects:Orthostatic Hypotension, drowsiness, Tachycardia, Respiratory, Confusion, DepressionOnset/Duration:Onset 1-5 minutes IV, 15-30 minutes IM; Duration 12-24 hoursClassification:Benzodiazepine HypnoticAction:CNS depressant via facilitation of inhibitory neurotransmitter gamma-amiobutyric acid (GABA) at Benzodiazepine receptor sites in the ascending reticular activating system. Effects include muscle relaxation, Anticonvulsant activity and emotional behavior anxiolytic effects.Magnesium Sulfate (MgSo4)Indications:Eclamptic seizures, Torsade’s de Pointes, Refractory VF/VT, Refractory BronchospasmADULT Dose: ADULT: TdP/VF/VT -2g IVP Eclamptic SZ – 4-6 gram IVP (10 grams IM) Breathing difficulty/RAD -2g/100cc IV over 5-20 minutesContraindications:Renal diseaseHeart BlockHypermagnesemiaPrecautions:Caution should be used in patients receiving Digitalis as it may cause severe Hypotension or Cardiac Arrest. Calcium Chloride should be readily available as an antidote if respiratory depression results from treatment.Adverse Effects:Hypotension, Respiratory Depression, Bradycardia, Dysrhythmias, Cardiac Arrest, CNS depression, flushing, sweatingOnset/Duration:1-5 minute / approximately 30 minutesClassification:Electrolyte, Anticonvulsant, AntidysrhythmicAction:Decreases Acetylcholine at neuromuscular junction (motor end plate), which is responsible for anticonvulsant properties; reduces SA node impulse formation an prolongs conduction time in the Myocardium; Attracts and retains water in the intestinal lumen which distends the bowel to promote mass movement and relieve constipationDrug: Drug interactionPotentiates Neuromuscular blockade produced by nondepolarizing paralytics (rocuronium/Zemuron, Vecuronium/Norcuron)Methylprednisolone (Solu-Medrol)Indications:Allergic reaction; Anaphylaxis; Upper Airway Burns; Reactive Airway Disease; COPD ExacerbationsADULT Dose:All Adult indications 125 mg IV / IO / IMContraindications:Preterm Infants Newborn Systemic Fungal InfectionsPediatric Considerations:2mg/kg IV / IO / IMPrecautions:Use with caution in patients with G.I. Bleeding, Diabetes Mellitus and Severe Infection.Adverse Effects:Alkalosis, CHF, Headaches, Hypertension, Hypokalemia, Seizures, Nausea and VomitingOnset/Duration:Onset: 20 minutes- 2 hours Duration: 18-36 hoursClassification:CorticosteroidGlucocorticoid steroidAnti-InflammatoryAction:Decreases inflammation by depressing migration of Polymophonuclear Leukocytes and activity of Endogenous Mediators of inflammation. Potentiates Vascular smooth muscle relaxation by Beta Adrenergic agonistsNotes:Hypoglycemic responses to insulin and oral hypoglycemic agents may be blunted. Potassium depleting agents may potentiate hypokalemia induced by corticosteroids.Midazolam (Versed)Indications:RSI induction Seizure Chemical restraintADULT Dose:RSI – 2.5-10mg IV/IO over 2 minutes Chemical restraint – 2.5-5mg IM/IV/IN over 2 minutes, repeat PRN for restraint Seizure – 2.5-5mg IV/IM/IO/INContraindications:Hypersensitivity, OD of alcohol or other CNS depressants; depressed vital signs / hypoperfusion, acute narrow angle glaucoma; PregnancyPediatric Considerations:6 months to 5 years of age: Initial dose 0.05 to 0.1 mg/kg. A total dose up to 0.6 mg/kg 6 to 12 years of age: Initial dose 0.025 to 0.05 mg/kg; total dose up to 0.4 mg/kg may be needed to reach the desired endpoint but usually does not exceed 10 mg total.Precautions:Use caution in patients with Renal impairment, history of COPD; may wish to double the IV dose when administering IMAdverse Effects:Respiratory depression or Arrest, Hypotension, Bradycardia, HA, N/V, pain at injection site, hiccupsOnset/Duration:IV/ IO: 1-3 minutes IM: approximately 10-20 minutes Duration of action is dose dependentClassification:BenzodiazepineCNS depressant Anticonvulsant Amnestic Muscle relaxantAction:Potentiation of gamma aminobutyric acid (GABA) by binding to specific Benzodiazepine receptors in the CNS; may act on limbic system and on the reticular formationNotes:Sedative effect potentiated by barbiturates, alcohol and narcoticsMorphineIndications:Pain management, Pulmonary edema, Procedural sedation, Analgesia, Acute Myocardial InfarctionADULT Dose:2-4 mg IV/IN/IM titrated, 1-3 mg q 2 minutes to 20 mg maxContraindications:Head injuryExacerbated COPD Depressed Respiratory drive Hypotension ALOCPediatric Considerations:0.1 mg/kg IV/IM/IOPrecautions:Patients with Acute Bronchial Asthma, Chronic Pulmonary diseases, Severe Respiratory depression, and Pulmonary edema induced by chemical irritants.Adverse Effects:Respiratory depression, Hypotension, ALOC, Nausea and VomitingOnset/Duration:IV immediate onset, peak effect 20 minutes IM/SQ 15-30 minutes, peak effect 30-60 minutes Duration 2-7 hoursClassification:Narcotic analgesicAction:Narcotic agonist with activity at U-receptors (supraspinal analgesia, Euphoria, Respiratory and physical depression), K-receptors (sedation and myosis), and Delta-receptors (dysphonia, hallucinations, respiratory and vasomotor stimulation)Notes:Naloxone and respiratory equipment should be immediately accessible.Naloxone (Narcan)Indications:Suspected or Known Narcotic overdose Altered level of consciousnessADULT Dose:IM,SQ,SVN, IV/IO .04-2mgContraindications:None in the emergent settingPediatric ConsiderationsDose: 0.1 mg/kg Max dose 2 mg Use caution in newbornsPrecautions:Rapid reversal of narcotic effects may lead to combative behavior and vomiting. May not reverse hypotension. For patients with chronic pain issues administer 0.4 mg increments until respirations improveAdverse Effects:Hypertension Nausea Vomiting Tremors DysrhythmiasOnset/Duration:Immediate, 0-3 minutes / up to 30 minutesClassification:Narcotic AntagonistAction:Competitively binds with Opiate receptor sites in the CNSNitroglycerine (Nitrostat)Indications:ACS Acute Angina MI CHF with Pulmonary EdemaADULT Dose: 0.4MG SL Every 3-5minutes as long as the Systolic blood pressure remains above 100mmHg and patient is symptomatic. If becomes asymptomatic, apply 1 inch of 2% ointment topically , systolic BP needs to stay above 100 mmHgContraindications:SPB <100 mm/Hg Intracranial bleeding/head trauma Within 24 hours of erectile dysfunction or Pulmonary hypertension medication Sildenafil (Viagra/Revation) or Vardenafil (Levitra) Within 48 hours of erectile dysfunction medication Tadalafil (Cialis)Precautions:Will cause severe loss of blood pressure if administered to a patient experiencing an Inferior MIAdverse Effects:Hypotension HA, Syncope Reflex Tachycardia Skin flushingOnset/Duration:Immediate, 0-3 minutes / up to 30 minutesClassification:NitrateAction:Causes relaxation of the vascular smooth muscle via stimulation of intracellular cyclic guanosine monophosphate production. This results in decreased preload, afterload, blood pressure, left ventricular workload and Myocardial oxygen demand. Relaxes esophageal smooth muscleNotes: Aspirin may increase nitrate serum concentrations; marked symptomatic hypotension may occur with co-administration of calcium channel blockers or beta-blockers (dose adjustment of either agent may be necessary) Oxytocin (Pitocin)Indications:Control of postpartum hemorrhageADULT Dose:10 units IM; then mix 20 units in 1000cc NS administered IV at 50-1000cc/hr to control postpartum hemorrhageContraindications:Hypersensitivity Toxemia of pregnancy Undelivered placenta Undelivered babyPrecautions:Status post cervical or uterine surgery, uterine sepsis, primipara after age 35Adverse Effects:HTN Subarachnoid hemorrhage Anxiety Dysrhythmias Tetany Uterine ruptureHyponatremiaOnset/Duration:IV: 1 minute IM: 3-7 minutes IV: 30 minute with half-life of 12-17 minute IM: 60 minute with half-life of 12-17 minuteClassification:HormoneAction:A synthetic water-soluble protein pharmacologically identical to the naturally occurring oxytocin secreted by the posterior pituitary. Directly produces phasic uterine contractions characteristic of normal labor and delivery and to treat uterine atony.Notes:Additive effects with other Vasopressors and Edphedra, Amphetamine or Methamphetamines resulting in severe Hypertension; Rule out multiple fetuces.Promethazine (Phenergan)Indications:Nausea / vomiting Analgesic potentiationADULT Dose:12.5-25 mg slow IV/IO/deep IM (if≥60 y/o 12.5 mg IV/IO/IM) Start at 12.5 mg and titrate dose to desired effect Must be dilutedContraindications:Documented hypersensitivity, Comatose patients, Debilitated patients (signs of dehydration and weakness) Glaucoma, Known sulfa allergy, Concomitant CNS depressant use/administration , NeonatesPrecautions:Avoid SQ administration, Give Slowly – rapid administration can cause vein irritation, phlebitis and sclerosis. Avoid concomitant use with Epinephrine as it may result in further hypotension. Watch for signs/symptoms of excessive sedation. Dystonic reaction (treat with Diphenhydramine)Adverse Effects:May reduce seizure threshold in heatstroke patients. Drowsiness, Sedation, ALOC, Allergic Reaction, Dysrhythmia, Nausea and Vomiting, Hyperexcitability, Dystonic (extrapyramidal) reaction and hypertension. Use in children may cause hallucinations, convulsions and sudden death.Onset/Duration:Onset: IV, 5 minutes IM, 20 minutes Duration: 4-6 hoursClassification:Anti-emeticPhenothiazineAntihistamine H? receptor site.Action:Blocks cholinergic receptors in the vomiting enter, which mediate nausea and vomiting; competes with histamine for the H? receptor site.Notes:In case of Dystonic reaction, treat with Diphenhydramine. Promethazine decreases the effects of Anticoagulation therapy. Rocuronium (Zemuron)Indications:Need for aggressive airway control and maintenance using RSIADULT Dose:0.6-1.2 mg/kg IVContraindications:Muscular disordersKnown hypersensitivityPediatric Considerations0.6 mg/kg IVPrecautions:Not recommended for RSI in Caesarean patients or those over 65 years of age.Adverse Effects:Hypotension Altered Mental status Increases pulmonary resistanceOnset/DurationOnset: 60-70 seconds Duration: 20+ minutesClassificationNondepolarizing neuromuscular blockerActionNeuromuscular blockade (Paralysis)NotesAirway control equipment must be readily available. Intubation conditions expected in 1-2 minutes after injection. Consider lower doses in extremely debilitated patients.Sodium Bicarbonate (NaHCO?)Indications:Metabolic acidosis 2? Cardiac Arrest, Cyclic antidepressant, OD, hyperkalemiaADULT Dose:8.4% - 1mEq/kg IVPediatric Considerations4.2% - 1 mEq/kg IV/IOPrecautions:Do not administer in the same IV with Calcium Chloride. Prepare to ventilate patient.Adverse Effects:Metabolic Alkalosis Electrolyte imbalanceFluid overloadOnset/DurationImmediate if IV, onset is less than 15 minutes Duration: 1-2 hoursClassificationAlkalizing agentActionAgent that dissociates to provide bicarbonate ion to buffer hydrogen ions in order to raise the pH level to reverse acidosis. It has also been found beneficial in the event of drug overdose in order to force urine alkalization/diuresis, membrane stabilization of cardiac cells as well, and electrolyte balance restorationNotesMost catecholamines and vasopressors (Dopamine, Epinephrine) can be deactivated by alkaline solutions like Sodium bicarbonate. When administered with Calcium Chloride, a precipitate may form that will clog the IV line.Succinylcholine (Anectine)Indications:An adjunct to general anesthesia, to facilitate tracheal intubation, and to provide skeletal muscle relaxation.ADULT Dose:Pediatric Dose:1.5 mg/kg IV; 1-2 mg/kg IV1-2 mg/kg IVContraindications:HyperkalemiaPrecautions:Caution should be observed if succinylcholine is administered to patients during the acute phase of injury following major burns, multiple trauma, extensive denervation of skeletal muscle or upper motor neuron.Adverse Effects:Respiratory depression Apnea Anaphylaxis Hypertension Hypotension Renal Failure Hyperkalemia Increased intraocular pressure Dysrhythmias Malignant hyperthermiaOnset/DurationOnset: 1 minute Duration: 4-6 minutesClassificationDepolorizing neuromuscular blocking agentActionShort-acting depolarizing-type, skeletal muscle relaxantNotesShould not be mixed with alkaline solutionsThiamine (Betalin, Biamine, Vitamin B1)Indications:Coma and seizures of unknown origin especially if alcohol use is suspected. Concurrent use with D50 for patients with history of alcohol abuse. Beriberi, delirium tremens, malnutrition or thiamin deficiency, suspected Wernicke or Koraskoff Syndrome & severe CHFADULT Dose:100 mg IM/IV (slow)Contraindications:Known hypersensitivityAdverse Effects:Anaphylaxis (rare), nausea, vomiting, hypotension (from rapid administration or excessive dose) & anxiety/agitationOnset/DurationOnset: rapidDuration: dependent upon degree of deficiencyClassificationOnset: 1 minute Duration: 4-6 minutesActionAllows and is required for normal metabolism of glucose. Combines with ATP to form thiamine pyrophosphate coenzyme, a necessary component for carbohydrate metabolism. Provides the appropriate thiamine levels to allow glucose to be utilized in sufficient amounts, thus reversing cellular hypoglycemia secondary to thiamine deficiency.NotesBe alert for allergic reactions.Thiamine has been shown to be useful in severe CHF.Vasopressin (Pitressin)Indications:VT/VF arrested statesADULT Dose:40 Units IV/IO one time dose. Follow up with the administration of Epi q5 minutes in the presence of cardiac arrestContraindications:Chronic Nephritis, none in the setting of cardiac arrestPrecautions:This drug should not be used in patients with vascular disease, especially disease of the coronary arteries, except with extreme caution. May produce water intoxication. The early signs of drowsiness, listlessness, and headaches should be recognized to prevent terminal coma and convulsions.Adverse Effects:Moderate to severe skeletal weakness, which may require artificial respiration. Malignant hyperthermiaOnset/DurationOnset unknown Duration: 2 to 8 hoursClassificationPosterior pituitary antidiuretic hormoneActionProduces vascular smooth muscle contraction and decreased urinary flow rateVecuronium (Norcuron)Indications:Paralysis to facilitatae intubationAdult Dose:Pediatric Dose:0.1mg/kg IV/IO0.1-0.2mg/kg IV/IOContraindications:Newborn infants Myasthenia gravisPrecautions:Patient must be sedatedAdverse Effects:ApneaOnset/DurationOnset 1-2 minutes Duration 30 minutesClassificationNondepolarizing neuromuscular blocking agentActionPrevents acetylcholine from binding to receptors on the motor end plate, thus blocking depolarization.Zofran (Ondansetron)Indications:Nausea and vomitingADULT Dose:4mg / 2ml Slow IV or IMContraindications:HypersensitivityLiver disease (reduce dose)Pediatric Considerations0.15 mg/kg IV/IM Recommended for use in children greater than 2 years of agePrecautions:Maintain lower dose with Amiodarone; Maintain lower dose with liver diseaseAdverse Effects:Rare hypersensitivityFatigue PyrexiaDizzinessHeadacheconstipation Urinary retention.Onset/DurationRapid onset; Duration 5 hoursClassificationAntiemeticActionSelective serotonin blocking agent NotesMay precipitate with Sodium bicarbonateDrug ReferenceEquivalents: 1kg – 2.2 lb 1 gm = 1000 mg 1kg – 1000 gm 1 L = 1000 ml 1ml = 60 mcgtts (micro tubing) 1 ml = 10, 15, 20 gtts (macro tubing) 1 ml and 1 cc are interchangeableConversions: MULTIPLY to convert a larger unit into a smaller unit using the above table. DIVIDE to convert a smaller unit into a larger unit using the above table.Dosage Calculations: To calculate the amount of drug to be drawn up or administered, use the following formula: WHAT (type and amount of drug ordered) Multiplied by the QUANTITY (volume of fluid in the container) Divided by MINUTES (time of the infusion) = Number of drops/minute to the solution. . WHAT x QUANITY = Amount to be HAVE administered IV Rate: To calculate the flow rate of an IV in gtts per minute use the following formula: VOLUME (the amount of fluid to be infused) Multiplied by the DRIP FACTOR (Number of drops per milliliter) Divided by MINUTES (time of the infusion) = Number of drops/minute to the solution. VOLUME x DRIP FACTOR = Number of drops/minute MINTUES to the solution Air Ambulance TransportsAn air ambulance will be activated based on the Washington State Trauma Triage Proceduresby the on scene EMS provider or Incident Commander. Whenever possible, providers willcontact Medical Control prior to activating an air ambulance. The decision process as to whento mobilize an air ambulance should take into consideration: site resuscitation, stabilizationcapabilities and ground transport time. Dispatch may assist in contacting an air ambulanceservice for activation as soon as the need for air transport is identified.Every attempt should be made to stabilize the patient prior to transport, including IV, airway,chest decompression or stabilization, control of external hemorrhage, and spineimmobilization. Transfer of care to air ambulance personnel will optimally occur at designatedlanding sites. Deviation from designated landing sites should be briefly discussed withMedical rmation to have available regarding airlift transport:? Map coordinates - township, range and section? Location of nearest landing zone? Capability to transport to landing zone? How landing zone is marked? Any obstructions near landing zone? Relevant weather informationPhysician Present at the SceneThe prehospital care provider functions under the direction of the on-duty Base Stationphysician. With Base Station permission, a physician on scene may participate in thecare of a patient at the scene of any emergency in one of the following ways:1. Take total responsibility for management of the patient(s). If so mustaccompany the patient(s) to the hospital. The physician on scene must supplyproof of being a MD or DO prior to initiation of any patient care direction ortreatment.2. Offer assistance in caring for the patient(s), allowing the prehospital careprovider to remain under the control of the Base Station Physician and withinthe prehospital provider’s scope of practice.In all cases, the Base Station Physician must be contacted to specifically delegateauthority to any on-scene physician. Access to communication with the Base Stationshould be provided to any on-scene physician on request. Notation of Physician’sidentification and directive from base station must be documented on the MedicalIncident Report.Emergency at a Physician’s officeAt a private Physician’s office, the individual physician maintains the responsibility forthe treatment and management decisions for the patient. During transport, treatmentrendered by the prehospital provider must remain within the provider’s scope ofpractice.Medical Incident Reports (MIR)A copy of ECG tracing MUST be attached to all copies of the MIR when any dysrhythmia isencountered in the field.A copy of the MIR must be left at the receiving medical facility, unless the EMS unit is toned out to another emergency. Then the MIR must be dropped off or faxed to the medical facility <24 hours.The prehospital contact report is to include:a. Unit identificationb. Age and sex of patientc. Severityd. Chief complainte. Relevant medical historyf. Vital signsg. Treatment given, and response to treatmenth. ETAi. Request for additional information or treatmentLaw Enforcement Assists1. BLOOD DRAW – A patient’s blood may be drawn by IV Certified providers upon request from on scene law enforcement, only if it does not interfere with patient care.2. TASER? REMOVAL – Taser? barbed darts may be removed from the patient upon Law Enforcement request only when the eye, face, neck, breast or groin are not involved. If in custody the individual must be adequately restrain by law enforcement for the protection of EMS Personnel. The patient must be thoroughly assessd for other injuries or medical emergencies. If the patient does not have any other presenting injuries/illness, they may be left in the custody/care of law enforcement. Document in detail on MIR. Law Enforcement must sign refusal of transport.Ten Critical Steps for Handling Possible Bioterrorism Events1 – Maintain anindex of suspicionIn an otherwise healthy population, some associations are very suggestive, especially when seen in clusters, high numbers, or unusual presentations“Clustered” Symptoms Potential BioagentsHemoptysisPlagueFlaccid ParalysisBotulismPurpuraViral Hemorrhagic Fevers (VHF)Wide mediastinumAnthraxCentripetal rashSmallpox2 – Protectyourself and yourpatients.Use appropriate personal protection equipment (PPE).Prophylaxis; vaccines, if available; or antibiotics, if risks are known3 – Adequatelyassess the patient.Review and assess the patient’s history. Also, ask:? Are others ill?? Were there any unusual events?? Was there an uncontrolled food source or otherenvironmental factor?? Was there vector exposure?? Has the patient been traveling?? What is the patient’s immunization record?Perform a physical examination with special attention to the respiratory system, nervous system skin condition and hematologic and vascular status.4 – Decontaminateas appropriate.Do not use bleach on exposed people. Soap, water andshampoo are perfectly adequate for all biological and most chemical agents. Chemically contaminated clothes should be removed and discarded safely.Biologically contaminated clothes can be laundered with soap, water and perhaps, bleach.5 – Establish adiagnosis.Think clinically and epidemiologically; always send specimens for culture.Symptom (individuals)Possible DiagnosisPulmonaryTularemia, plague, staphenterotoxin B (SEB)NeuromuscularBotulism, Venezuelan equine encephalitis (VEE)Bleeding/purpuraVHF, ricin, plague (late)Flu-like symptomsVariesImmediate Symptoms (largenumbers)Possible DiagnosisPulmonarySEB, mustard, Lewisite,phosgene, cyanideNeurologicNerve gases, cyanideDelayed Symptoms (largenumbers)Possible DiagnosisPulmonaryBiologic agents, mustard,phosgeneNeurologicBotulism, VEE, otherencephalitis6 – Render prompttreatmentA irway, B reathing, C irculation.7 – Provide good infection control.? Gown, gloves, mask and hand washing, and eyewear ifnecessary, are sufficient.? Recommended isolation precautions for biologic agentsinclude: Standard Precautions – for all individuals/patients Contact Precautions – Viral Hemorrhagic Fevers Droplet Precautions – Pheumonic Plague and Tularemia Airborne Precautions - Smallpox8 – Alert the properauthorities.CALL FIRST: Your local law enforcement agency; call either911 or your local phone number for law enforcement.CALL SECOND: Your area FBI officeWestern WA: 206-622-0460Eastern WA: 509-747-5196After hours statewide in WA: 206-622-0460CALL THIRD: Your local emergency management agency, orif unavailable, the WA state EM Duty Officer at:1-800-258-59909 – Assist in theepidemiologicinvestigations.Steps in an epidemiologic investigation so as to determine whomay be at risk? Count cases;? Relate to the at-risk population;? Make comparisons;? Develop hypotheses;? Test hypotheses;? Make inferences;? Conduct studies;? Interpret and evaluate.10 – Know and spread this information. Medical SpanishInitial questioningIs there someone with you who speaks English??Hay alguien con usted que hable ingles?Ah-ee ahl-gee-ehn hohn oss-tehd keh ah-bleh enn-glehs?I speak a little Spanish. Please answer yes or no to the following questions.Hablo un poco de espa?ol. Por favor conteste si o no a las siguientes preguntas.Ah-bloh oon pohr-fah-borg kokn-tehs-the see oh noh ah lahs see-gee-ehn-tehs preh-goon tahs.Speak slowly, please.Hable despacia, por favor.Ah-bleh dehs-pah-see-oh, pohr fah-bohr.What is your name?When did the problem start??Cómo se llama??Cuándo empezó el problema?Koh-moh she yah-mah? Kwahn-doh ehm-peh-soh ehl prog-bleh-mah?How old are you?What medicine do you take??Cuántos a?os tiene??Qué medicina torna?Kwahn-tohs ah-nyohs tee-eh-neh?Keh meh-dee-see-nah toh-mah?Numbers1. uno11. once21. vientiuno2. dos12. doce22. vientidós3. tres13. trece23. veintritrés4. cuatro14. catorce24. veinticuatro5. cinco15. quince25. veinticinco6. seis16. dieciséis26. veintiséis7. siete17. diecisiete27. veintisiete8. ocho18. dieciocho28. veintiocho9. neueve19. diecinueve29. veintineuve10. diez20. viente30. treintaDays of the weekLunes: MondayViernes: FridayMartes: Tuesday Sábado: SaturdayMiércoles: Wednesday Domingo: SundayJueves: ThursdayCommon Medical Questions/TermsHow do you feel?Don’t move?Cómo se siente?No se meuvaKoh-moh she see-ehn-the?Noh she mweh-bahWhat is the problem?We are going to give you an IV?Cuál es el problema?Vamos a ponerie suero intravenosoKwahl ehs ehl proh-bleh-mah? Bah-mohs ah poh-nehr-leg soo-eh-roh enn-trahbeh-nohsohHave you had this problem before?Do you have a fever??Ha tenido este problema antes??Tiene fiebre?Ah the-nee-doh ehs-the proh-bleh-mah ahn-tehs?Tee-eh-neh fee-eh-breh?Do you have nausea or vomiting?Where is the pain??Tiene nausea o vómito??Dónde tiene el delor?Tee-eh-neh nah-oo-she-ah oh boh-meh-toh Dohn-deh tee-en-neh ehl doh-lohr?Where does it hurt?Show me?Donde le duele?Ensé?emeDohn-deh leh dweh-leh?Ehn-she-nyeh-meh.When?How??Cuándo??Cómo?Kwahn-doh?Koh-moh?For how long?Why??Por cuánto tiempo??Por qué?Pohr kwahn-toh tee-ehm-poh?Pohr keh?Relax, pleaseCalm downPor favor, relájeseCálmesePohr fah-bohr, reh-lah-heh-she.Kahl-meh-sahHigh Blood Pressure?Diabetes?Alta presion de la sangre?Diabetes?Ahl-tah preh-see-ohn deh lah sahn-greh?Dee-ah-beh-tehsAsthma?Epilepsy?Asma?Epilepsia?Ahs-mah?Eh-pee-lep-see-ah?Heart disease?Stomach ulcers?Ehfermedad del corazón?Ulceras del estomago?Ehn-fehr-meh-dad dehl koh-rah-sohn? Ool-she-rahs dehl ehs-toh-mah-goh?Do you take medicine??Tomas usted medicina?Toh-mah oos-tehd lah meh-dee-see-nah?Painpain start?Where did the pain start??Cuándo empezó el dolor??Donde empezó el dolor?Kwahn-doh ehm-peh-soh ehl doh-lohr?Dohn-deh ehm-peh-soh ehl doh-lohr?Does the pain travel to another place?How long does the pain last??Le viaja el dolor a otro lugar??Cuánto tiempo le dura el dolor?Leh vee-ah-hah ehl doh-lohr ah oh-troh loo-gahr? Kwahn-toh tee-ehm-poh leg doo-rah ehl doh-lohrIs it severe?Does it ache??Es severo??Es adolorido?Ehs she-beh-roh?Ehs ah-doh-loh-ree-doh?Is it like pressure?Is the pain the same since it started??Es opresivo??Es el dolor igual desde que empezó?Ehs oh-preh-see-boh?Ehs ehl doh-lor ee-gwahl dehs-deh keh ehmChest PainPain in the chest??Dolor del Pecho?Doh=lohr dehl peh-choh?Point to where the pain is, please.Apunte dónde tiene el dolor, por favor.Ah-poon-the dohn-deh tee-eh-neh ehl doh-lohr.Does the pain travel to your left shoulder (arm)??Le viaja el dolor al hombre (brazo) izquierdo?Leh bee-ah-hah ehl doh-lohr ahl ohm-broh (brahsoh)ees-kee-her-doh?Is it piercing??Es punzante?Ehs poon-sahn-the?OB / GYNAre you having contractions??Tiene contracciones?Tee-eh-neh kohn-track-see-ohn-ehs?(Don’t) push.(No) Empuje.(Noh) Ehm-poo-hehHow many minutes do the contractions last??Cuántos minutes le duran las contracciones?Kwahn-tohs mee-noo-tohs leh doo-rahn lahs kohntrahk-see-ohn-ehs?MNEMONIC’sPatient Assessment:Newborn Assessment:Medical:A: Airway A: Appearance M: MorphineB: Breathing P: Pulse Rate O: OxygenC: Circulation G: Grimace (facial actions) N: NitratesD: Disability A: Activity A: AspirinHistory:E: Expose R: Respirations S: Signs and symptoms P: Progression of symptomsA: Allergies A: Associated chest painM: Medications S: Sputum productions, speech,P: Pertinent past medical word sentences history T: Temperature, tirednessL: Last oral intake M: Medications the patient isE: Events leading to injury or currently taking illness E: Exercise/Exertion normally toleratedD: Diagnosis (previous)Trauma Assessment:Trauma:Scene safety V: Vitals T : Tracks, Tags, TattoosSpinal Stabilization O: Oxygen I : InstabilityLOC M: Monitor C : CrepitusAirway I : IV/Information S : ScarsBreathing T: Transport decisionOxygen H: HistoryCirculation A: AllergiesArterial Bleeds M: MedicationsBare the BodyTrauma or Pain Questions:Trauma:O: Onset D: DeformitiesP: Provocation, progression C: ContusionsQ: Quality, pain type? A: AbrasionsR: Radiation P: PuncturesS: SeverityT: Time, duration B: Burns T: Tenderness L: Lacerations S: SwellingCauses of Pulseless electrical Activity (PEA) – The “5” H’s and “5” T’s:H: Hypovolemia T: Tablets (drug OD, accidents)H: Hypoxia T: Tamponade, cardiacH: Hydrogen ion – acidosis T: Tension PneumothoraxH: Hyper / Hypokalemia T: Thrombosis, Coronary (ACS)H: Hypothermia T: Thrombosis, pulmonary (embolism)Altered Mental Status (ALOC):A: Alcohol, Drugs T: TraumaE: Endocrine (glands) I: InfectionI: Insulin, Infection P: PyschiatricO: Overdose S: ShockU: Uremia (20 kidney insufficiency)Triage Charting:A: Alert S: SubjectiveP: Responsive to Verbal O: ObjectiveV: Responsive to Pain A: AssessmentU: Unresponsive P: PlanSTATE OF WASHINGTONPREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDUREPurposeThe purpose of the Triage Procedure is to ensure that major trauma patients are transported to the most appropriate hospital facility. This procedure has been developed by the Prehospital Technical Advisory Committee (TAC) endorsed by the Governor’s EMS and Trauma Care Steering Committee, and in accordance with RCW 70.168 and WAC 246-976 adopted by the Department of Health (DOH).The procedure is described in the schematic with narrative. Its purpose is to provide the Prehospital provider with quick identification of a major trauma victim. If the patient is a major trauma patient, that patient or patients must be taken to the highest level trauma facility within 30 minutes transport time, by either ground or air. To determine whether an injury is major trauma, the Prehospital provider shall conduct the patient assessment process according to the trauma triage procedures.Explanation of Process Any certified EMS and Trauma person can identify a major trauma patient and activate the trauma system. This may include requesting more advanced Prehospital services or aero-medical evacuation.The first step (1) is to assess the vital signs and level of consciousness. The words “Altered mental status” mean anyone with an altered neurologic exam ranging from completely unconscious, to someone who responds to painful stimuli only, or a verbal response which is confused, or an abnormal motor response.The “and/or” conditions in Step 1 mean that any one of the entities listed in Step 1 can activate the trauma system.Also, the asterisk (*) means that if the airway is in jeopardy and the on-scene person cannot effectively manage the airway, the patient should be taken to the nearest medical facility or consider meeting up with an ALS unit. These factors are true regardless of the assessment of other vital signs and level of consciousness."Respect for ones patients is the highest duty of civil life. “The second step (2) is to assess the anatomy of injury. The specific injuries noted require activation of the trauma system. Even in the assessment of normal vital signs or normal levels of consciousness, the presence of any of the specific anatomical injuries does require activation of the trauma system.Please note that steps 1 and 2 also require notifying Medical Control. The third step (3) for the Prehospital provider is to assess the biomechanics of the injury and address other risk factors. The conditions identified are reasons for the provider to contact and consult with Medical Control regarding the need to activate the system. They do not automatically require system activation by the Prehospital provider.Other risk factors, coupled with a “gut feeling” of severe injury, means that Medical Control should be consulted and consideration given to transporting the patient to the nearest trauma facility.Please note that certain burn patients (in addition to those listed in Step 2) should be considered for immediate transport or referral to a burn center/unit.Patient Care ProceduresTo the right of the attached schematic you will find the words “according to DOH-approved regional patient care procedures.” These procedures are developed by the regional EMS and Trauma council in conjunction with local councils. They are intended to further define how the system is to operate. They identify the level of medical care personnel who participate in the system, their roles in the system, and participation of hospital facilities in the system. They also address the issue of inter-hospital transfer, by transfer agreements for identification, and transfer of critical care patients.In summary, the Prehospital Trauma Triage Procedure and the Regional Patient Care Procedures are intended to work in a “hand in glove” fashion to effectively address EMS and Trauma patient care needs. By functioning in this manner, these two instruments can effectively reduce morbidity and mortality.If you have any questions on the use of either instrument, you should bring them to the attention of your local or regional EMS and Trauma council.STATE OF WASHINGTONPREHOSPITAL TRAUMA TRIAGE (DESTINATION) PROCEDURESEFFECTIVE DATE 1/2011● Prehospital triage is based on the following 3 steps: Steps 1 and 2 require Prehospital EMS personnel to notify medical control and activate the Trauma System. Activation of the Trauma System in Step 3 is determined by medical control** STEP 1ASSESS VITAL SIGNS & LEVEL OF CONSCIOUSNESS●Systolic BP <90*●HR >120* °for pediatric (<15y) pts. use BP<90 or capillary refill >2sec. °for pediatric (<15y) pts. use HR <60 or >120Any of the above vital signs associated with signs and symptoms of shockand/or●Respiratory Rate <10 >29 associated with evidence of distressand/or●Altered mental status Take patient to the highest level trauma center within 30 minutes transport time via ground or air transport according to DOH approved regional patient are procedures YES **If Prehospital personnel are unable to effectively manage airway, consider rendezvous with ALS or intermediate stop at nearest facility capable of immediate definitive airway management.NOSTEP 2ASSESS ANATOMY OF INJURY●Penetrating injury of head, neck, torso, groin; OR●Combination of burns ≥20% or involving face or airway; OR●Amputation above wrist or ankle; OR●Spinal cord injury; OR●Flail chest; OR●Two or more obvious proximal long bone fractures.NO Take patient to the highest level trauma center within 30 minutes transport time via ground or air transport according to DOH approved regional patient care procedures. STEP 3ASSESS BIOMECHANICS OF INJURY AND OTHER RISK FACTORS●Death of same care occupant; OR●Ejection of patient from enclosed vehicle; OR●Falls ≥20 feet; OR●High energy transfer situation Rollover Motorcycle, ATV, bicycle accident Extrication time of >20 minutes●Extremes of age <15 >60 ●Hostile environment (extremes of heat or cold)●Medical illness (such as COPD, CHF, renal failure, etc)●Second/third trimester pregnancy●Gut feeling of medicCONTACT MEDICAL CONTROL FOR DESTINATION DECISIONYESYESNONOTRANSPORT PATIENT PER REGIONAL PATIENT CARE PROCEDURES PROVIDENCE CENTRALIA HOSPITALEMERGENCY DEPARTMENT TRAUMA ACTIVATION CRITERIAFULL TRAUMA ACTIVATIONConfirmed SBP <90 at any time in adults (or children > 10 years old)Age Specific hypotension for children up to 10 years of age Term neonates (0-28 days) <60 mm HgInfants (1-12 months)<70 mm HgChildren (1-10 yrs. old)<80 mm HgRespiratory compromise or obstruction0? sats <90% or Adult RR < 10 or > 29GCS <9 with mechanism attributed to traumaPenetrating injury to the head, neck, torso, groinTrauma full ArrestMODIFIED TRAUMA TEAM ACTIVATIONSignificant MOIConcern for potential multisystem involvementPregnancy > 24 weeks with significant traumaAmputation above the wrist or ankleSuspected spinal cord injury with paralysisElectrocutions, near drowning, or strangulationsBurns with ≥ 20% TBSATwo or more obvious long bone fracturesSuspected pelvic fxSuspected flail chestFall > 20 ft. (3x the body length of children up to 15 yrs. old)Ejection from an enclosed vehicleExtrication time > 20 min.Suspected occult life threatening injury (consider “Co-Morbid” and “High Energy Factors”; upgrade to a MTT as you see fit)State of WashingtonPrehospital Cardiac Triage Destination ProcedureWhy triage cardiac patients?The faster a patient having a heart attack or who’s been resuscitated gets treatment, the less likely he or she will die or be permanently disabled. Patients with unstable angina and non-ST elevation acute coronary syndromes (UA/NSTE) are included in the triage procedure because they often need immediate specialized cardiac care. This triage procedure is intended to be part of a coordinated regional system of care that includes dispatch, EMS, and both Level I and Level II Cardiac Hospitals.How do I use the Cardiac Triage Destination Procedure?A. Assess applicability for triage – If a patient is post cardiac arrest with ROSC, or is over 21 and has any of the symptoms listed, the triage tool is applicable to the patient. Go to the “Assess Immediate Criteria” box NOTE: Women, diabetics, and geriatric patients often have symptoms other than chest pain/discomfort so review all symptoms with the patient.B. Assess Immediate criteria – If the patient meets any one of these criteria, he or she is very likely experiencing a heart attack or other heart emergency needing immediate specialized cardiac care. Go to “Assess Transport Time and Determine Destination” box. If the patient does not meet immediate criteria, or you can’t do an ECG, go to the “Assess High Risk Criteria” box.C. Assess high risk criteria – If, in addition to meeting criteria in box 1, the patient meets four or more of these high risk criteria, he or she is considered high risk for a heart attack or other heart emergency needing immediate specialized cardiac care. These criteria are based on the TIMI risk assessment for unstable angina/non-STEMI. If the patient does not meet the high risk criteria in this box, but you believe the patient is having an acute coronary event based on presentation and history, consult with medical control to determine appropriate destination. High risk criteria definitions: 3 or more CAD (coronary artery disease) risk factors:Age ≥ 55: epidemiological data for WA show that incidence of heart attack increases at this ageFamily history: father or brother with heart disease before 55, or mother or sister before 65High blood pressure: ≥140/90, or patient/family report, or patient on blood pressure medicationHigh cholesterol: patient/family report or patient on cholesterol medicationDiabetes: patient/family report Current smoker: patient/family report. Aspirin use in last 7 days: any aspirin use in last 7 days. ≥2 anginal events in last 24 hours: 2 or more episodes of symptoms described in box 1 of the triage tool, including the current event. Known coronary disease: history of angina, heart attack, cardiac arrest, congestive heart failure, balloon angioplasty, stent, or bypass surgery. ST deviation ≥ 0.5 mm (if available): ST depression ≥ 1 mm for more than 20 minutes places these patients in the STEMI treatment category. Elevated cardiac markers (if available): CK-MB or Troponin I in the “high probability” range of the device use. Only definitely positive results should be used in triage decisions.D. Determine destination – The general guidelines is to take a patient meeting the triage criteria directly to a Level I Cardiac Hospital within reasonable transport times. For BLS, this is generally within 30 minutes transport time, and for ALS, generally 60 minutes transport time. See below for further guidance. Regional patient care procedures and county operating procedures may provide additional guidance.E. Inform the hospital en route so staff can activate the cath lab and call in staff if necessary.What if a Level I Cardiac Hospital is just a little farther down the road than a Level II?You can make slight changes to the 30/60 minute timeframe. The benefits of opening an artery faster at a Level I can outweigh the extra transport time. To determine whether to transport beyond the 30 to 60 minutes, figure the difference in transport time between the Level I Cardiac hospital and the Level II Cardiac hospital. For BLS, if the difference is more than 30 minutes, go to the Level II Cardiac Hospital. For ALS, if the difference is more than 60 minutes, go to the Level II Cardiac hospital. BLS examples: A) Minutes to Level I minus minutes to Level II = 29: go to Level I B) Minutes to Level I minus minutes to Level II = 35: go to Level II ALS examples: A) Minutes to Level I minus minutes to Level II = 45: go to Level I B) Minutes to Level I minus minutes to Level II = 68: go to Level IINOTE: We recommend ALS use a fibrinolytic checklist to determine if a patient is ineligible for fibrinolysis. If ineligible, transport to closest Level I hospital even if it’s greater than 60 minutes or rendezvous with air transport. What if there are two or more Level I or II facilities to choose from? f there are two or more of the same level facilities to choose from within the transport times, patient preference, insurance coverage, physician practice patterns, and local rotation agreements may be considered in destination decision.State of WashingtonPrehospital Cardiac Triage Destination ProcedureAssess Applicability for Triage Post cardiac arrest with ROSC -OR- ≥21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease:Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back.Pain or discomfort in 1 or both arms, neck, jaws, shoulders or back.Shortness of breath with or without chest discomfort.Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain.Other symptoms may include sweating, nausea vomiting, and lightheadedness.Note: Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.NoTransport per regional patient care proceduresAssess High Risk CriteriaIn addition to symptoms in Box 1,Pt. has 4 or more of the following: Age ≥ 55 3 or more CAD risk factors:family historyhigh blood pressurehigh cholesteroldiabetescurrent smoker Aspirin use in last 7 days ≥2 anginal events in last 24 Hours, including current episode Known coronary disease ST deviation ≥ 0.5 (if available) Elevated cardiac markers . (if available) NOIf EMS personnelStill suspect an acute coronary event, contact medical control for destination. If not, transport per regional patient care procedures. Assess Immediate Criteria Post cardiac arrest with return of spontaneous circulation Hypotension or pulmonary edema EKG positive for STEMI (if available)NO Yes If ALS has not been dispatched, upgrade if available. Unstable patients (life threatening arrhythmias, severe respiratory distress, shock) unresponsive to EMS treatment should be taken to the closest hospital Yes Yes Assess Transport Time and Determine Destination by Level of Prehospital CareBLS/ILSALS Level I Cardiac Hospital w/in 60 MinutesLevel I Cardiac Hospital w/in 30 MinutesGo to Level I Cardiac hospital and alert destination hospital en route ASAPLevel II Cardiac Hospital 30Minutes closer than Level I?Level II Cardiac Hospital 60Minutes closer than Level I? Yes Go to Level I Cardiac hospital and alert destination hospital en route ASAP Go to closest Level II Cardiac Hospital and alert destination hospital en route ASAP Yes*Slight modifications to the transport times may be made in county operating procedures. See page 2. Consider ALS and air transport for all transport greater than 30 minutes.If there are two or more Level I facilities to choose from within the transport timeframe, patient preference, insurance coverage, physician practice patterns, and local rotation agreements maybe considered in determining destination. This applies if there are two ro more Level II facilities to choose from.State of WashingtonPrehospital Stroke Triage Destination ProcedurePurposeThe purpose of the Stroke Triage and Destination Procedure is to help you identify stroke patients in the field so you can take them to the most appropriate hospital. Like trauma, stroke treatment is time-critical the sooner a patient is treated, the better their chances of survival. Fast treatment can mean less disability, too. For strokes caused by a blood clot in the brain (ischemic), clot-busting medication must be administered within 4-5 hours from the time they first have symptoms. For bleeding strokes (hemorrhagic), time is also critical. As an emergency responder, you play a crucial role in getting patients to treatment in time.Stroke Assessment – F.A.S.T.The F.A.S.T. assessment tool (also known as the Cincinnati Prehospital Stroke Scale + Time) is a simple but pretty accurate way to tell if someone might be having a stroke. It’s easy to remember: Facial droop, Arm drift, Speech, + Time. If face, arms, or speech is abnormal, it’s likely your patient is having a stroke. You should immediately transport the patient to a stroke center. Regional patient care procedures and county operating procedures may provide additional guidance. Alert the hospital on the way. Transport should not be delayed for IV and EKG monitoring.TESTNORMALABNORMALFacial droop: Ask the patient to show his or her teeth or smile. Both sides of the face move equally.One side of the face does not move as well as the otherArm drift: Ask the patient to close his or her eyes and extend both arms straight out for 10 seconds. The palms should be up, thumbs pointing out.Both arms move the same or both arms do not move at allOne arm drifts down, or one arm does not move at all.Speech: Ask the patient to repeat a simple phrase such as “Firefighters are my friends.”The patient says it correctly, with no slurringThe patient slurs, says the wrong words, or is unable to speakTime: Ask the patient, family or bystanders the last time the patient was seen normal.Stroke warning signs:● Sudden numbness or weakness of the face, arm or leg, especially on one side of the body● Sudden confusion, trouble speaking or understanding● Sudden trouble seeing in one or both eyes● Sudden, severe headache with no known causeEncourage family to go to the hospital to provide medical history, or obtain contact information for a person who can provide medical history.Report to ED: Possible IV t-PA contraindications: symptoms onset more than 180 minutes ● head trauma or seizure at onset ● recent surgery, hemorrhage, or heart attack ● any history of intracranial hemorrhage ● minor or resolving stroke ● sustained BP> 185/110, but EMS do not treat!State of WashingtonPrehospital Stroke Triage Destination ProcedureAssess Applicability for TriageAssess Applicability for TriageReport from patient or bystander of one or more sudden:□ Numbness or weakness of the face, arm or leg, especially on one side of the body□ Confusion, trouble speaking or understanding□ Trouble walking, dizziness, loss of balance or coordination□ Severe headache with no known causeTransport per regionalpatient care proceduresNOPerform F.A.S.T. Assessment□ Face: unilateral facial droop?□ Arms: unilateral drift or weakness?□ Speech: abnormal or slurred?□ Time last normal (determine time patient last known normal)Yes to any one sign (Face, Arms, Speech) = YESNo to all three signs = NO YESTransport per regionalpatient care proceduresNO*If unable to manage airway, consider rendezvous with ALS or intermediate stop at nearest facility capable of definitive airway management.If stroke center is not available within transport times by ground, consider air transport of contact medical control for destination decision.If there are two or more facilities to choose from within the transport timeframe, patient preference, insurance, physician practice patterns, and local rotation agreements may be considered.Determine Destination*Estimate time patient last normal to arrival at stroke center emergency department YES Transport patient to the nearest highest level 1, 2, or 3 stroke center within 30 minutes transport time per regional patient care procedures.patient care procedures≤3.5 hrsTransport patient to the nearest: □ Level 1 stroke center within 60 minutes transport time or□ Level 2 stroke center with intra-arterial inter-ventional capability within 60 minutes transport time. ≤3.5 hrs to ≤ 6 hrs> 6 hrs or unknownTransport patient to level 1, 2, or 3 stroke center within 30 minutes transport time per regional patient care procedures and patient/family preference.patient care procedures Limit scene time and alert destination hospital PRE-HOSPITAL PROVIDER CONDUCTLewis County EMS Providers must maintain the highest standard of professional conduct. Competent medical care must be provided with compassion and dignity for all person regardless of nationality,race, creed, religion, sex or status.Providers must refuse to participate in unethical activities and/or activities which may impair professional judgment and the ability to act competently.Matters of disagreement between Prehospital providers regarding patient care must be handled professionally without alarming anyone on the scene. Base Station contact will be made for immediate direction. Providers should not threaten, degrade, insult or verbally abuse each other.Patient Confidentially will be maintained at all times in compliance with health Insurance Portability and Accountability Act (HIPPA) of 1996.INFECTION CONTROL STANDARDSInfection Control Standards assume that all contact with blood, other bodily fluids and potentially infectious materials is infectious.The standards of use of Universal Precautions / Body Substance Isolation, which includes safe work practices, correct use of engineering controls and personal protective equipment is mandated by WISHA, and must be adhered to.EMS Providers must protect themselves at all times from “reasonably anticipated potential for exposure”. The following is a list of mandated items: Gloves, Masks, Face Shields, Safety Glasses, High Efficiency Particulate Air (HEPA) Filters, Resuscitation Equipment, and Protective Clothing.All known or possible chemical or infectious exposures must be reported to appropriate personnel as soon as possible after the exposure.PATIENT REFUSAL OF MEDICAL EVALUATION1. ConsentThe patient has responsibility to consent to or refuse treatment. If the patient is unable to do so, a responsible relative or guardian has this right. If waiting to obtain lawful consent from the authorized person would present a serious risk of death, serious impairment of health, or would prolong severe pain or suffering to the patient, treatment may be undertaken to avoid these risks without consent. In no event should legal consent procedures be allowed to delay immediately required treatment The patient must be eighteen years of age or emancipated to legally refuse treatment.If the patient is under age, consent should be from a natural parent, adopted parent, or legal guardian only2. Mental competenceA person is mentally competent if:1. Capable of understanding the nature and consequence of the proposed treatment.2. Sufficient emotional control, judgment, and discretion to manage their own affairs are present.A person is not mentally competent if he/she has impaired cerebral perfusion, presents in shock, is postictal, or under the influence of drugs or alcohol.Base Station contact with the Base physician is necessary for all patients refusing transport.Nurses may speak for the Base Station physician if the physician is unable to come to the telephone. The nurse must give the Prehospital care provider the name of the Base physician who is directing the nurse H?) ................
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