Protocol

Jackson County Emergency Medical Services Written Physician’s Authorization and Medical Protocol For Basic and Advanced Life Support Squads Effective January 1, 2013

Authorization The following Written Physician’s Authorization and Medical Protocol has been authorized by the Jackson County Medical Services for use on runs handled by JCEMS squads, in keeping with recognized state and national standards for the rendering of pre-hospital emergency care. Any routine treatment not specifically referred to in this document which is a normal part of the delivery of emergency medical services as described in the Ohio Revised Code shall be accomplished according to the current standards of the National Course Curriculum (US DOT) for EMTs.

Medical Director Dr. Jason Reaves, M.D.

General Guidelines The authority to perform procedures under the scope of this protocol applies only to Ohio certified employees responding to emergency situations being handled by JCEMS. All procedures assigned to EMT, Advanced EMT, and Paramedics refer to personnel holding a valid Ohio certification in the appropriate category and employed by JCEMS to function in such capacity . Students enrolled in EMS education programs contracted with JCEMS may perform as specified in the contracts.

All procedures assigned to EMT, Advanced EMT, and Paramedic are within the scope of these classifications as defined in the Ohio Revised Code.

Any deviation from the following Written Physician’s Authorization and Medical Protocol is to occur only upon the direct order of a physician licensed to practice in the State of Ohio.

(See “Statement on Control of the Emergency Scene” page 10) While verbal direction by the receiving hospital (TF) Emergency Department is encouraged, the decision to request such assistance is at the discretion of the responding unit, based on the patient’s condition and the circumstances of the run. In all cases, the receiving hospital’s Emergency Department is to be notified as soon as possible of the patient’s pending arrival, the patient’s condition and all pre-hospital care given. Orders regarding the patient’s care must be directly transmitted by a physician or a designated registered nurse, as required by state law. In the event that a squad requests medical advisement and the physician or designated registered nurse is not available, JCEMS personnel are directed to proceed with all the indicated protocols.

A written record of all pertinent patient information and pre-hospital care of all patients is to be kept by JCEMS and a copy is to be left at the treatment facility. This record is to be signed by the JCEMS personnel responsible for providing the patient care.

Whenever a question arises as to whether a patient requires transport, the Emergency Department of the hospital to which the patient would be transported should be contacted and advised of the patient’s condition. If the physician on duty authorizes that the patient not be transported, this must be fully recorded and documented. This applies to all patients with medical or trauma conditions, but is essentially relevant to minor patients regardless of how obvious the patient’s illness or injury Early transport is to be considered a primary responsibility of every crew. The majority of treatments authorized in this protocol should be accomplished while enroute to the TF whenever possible. If a Basic or Intermediate unit believes further ALS intervention is indicated, the decision to wait at site for paramedic back-up or proceed

toward the TF should be based on whether the ETA of the paramedic unit is less than the patient’s ETA to the TF. In most cases, the best course is to begin transport and meet the ALS unit enroute.

Basic airway equipment (at least a pocket mask with one-way valve) and procedure gloves are to be carried with every crew member whenever away from the vehicle. When responding on emergency runs the full crash kit is always to accompany the first-in crew member. Oxygen, suction device and monitor/defibrillator should also be taken in initially whenever the nature of the call indicates a possible cardiac, respiratory or unconscious victim, or if the patient is located some distance from the vehicle (i.e. upstairs apartment, etc.).

Before administration of any medication, possible interactions with agents recently taken by the patient must be ruled out. Check the Interaction Appendix at the end of the protocol for specifics regarding each agent.

General Guidelines for the Prevention of Communicable Diseases A. B. C. D. E. F. G. H. I.

J. K.

Full details are described in JCEMS EXPOSURE CONTROL PLAN posted at stations Treat all blood and body fluids as infectious.

Use gloves whenever treating emergency patients.

Use face and eye protection for intubation, needle and surgical criocothyrotomies.

Use gowns and suits, masks and eye protection for any procedures that could involve extensive splashing of blood or body fluids. (OB deliveries, traumatic injuries, etc.)

Use pocket masks, resuscitation bags, or other ventilation devices to resuscitate a patient to minimize exposure that may occur during mouth-to-mouth resuscitation. These devices should be immediately available to ensure there is no delay in care.

Use masks whenever a patient presents with cough, skin rash and/or documented or perceived fever. Use HEPA or N-95 mask if acute TB is diagnosed or suspected.

Wash your hands thoroughly after removing your gloves and immediately after contact with blood or body fluids. Dispose of gloves in a red bio-hazard bag after patient contact.

Disposable needles and syringes are to be used exclusively. Do not recap, bend, or cut needles. Place sharps in special containers immediately after use. Handle needles and other sharps with extreme care to avoid injury.

Follow system procedures for sterilization, disinfection, housekeeping and waste disposal. Use the appropriate protective equipment when cleaning areas soiled with body fluids or blood. Place linens contaminated with blood or body fluids in isolation bags. Contaminated disposables should be placed in the specially designated bags to prevent contamination of other workers.

Blood spills should be cleaned up immediately by thorough scrubbing of the contaminated surface and use of a designated disinfectant solution.

Protect yourself from on-the-job cuts and scratches by using appropriate protective gloves, etc. during extrication procedures. If a needle-stick injury or cut/scratch should occur, cleanse the wound immediately with an iodine (Betadine®) pad. Flush eyes or mucous membranes with water or saline.

File an incident report anytime that an injury occurs on a run, regardless of how minor the injury seems.

Report all accidental needle sticks to HQ immediately and present to E.D. Remove personal clothing that becomes soaked with a patient’s blood or body fluids as soon as possible and shower immediately. Document on an incident report if any such exposure occurs. Protect those who could become contaminated at scene by assuring that items are disposed of before leaving site.

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JCEMS Requirements for PPE Activity Bleeding control with spurting blood Bleeding control with minimal bleeding Emergency Childbirth Drawing of blood samples/ performing glucometer reading Starting an IV Endotracheal Intubation, Needle Chricothyrotomy or Chest Decompression Oral/ Nasal/ Endotracheal Suctioning Manual Clearing of Airway Administration of aerosolized treatments Handling/ cleaning contaminated instruments or equipment Caring for patients with fever, rash, or productive cough or immunocompromised patients Hands-on patient contact including taking care of vital signs, etc.

Giving an IM, Sub-q, or IV injection to a patient Routine cleaning of the ambulance, cot and equipment after a call Cleaning of the ambulance, cot and equipment following a call on which blood or body fluids, parts have been spilled or splattered Activities associated with victim treatment or extrication at scenes where broken glass, twisted metal or other objects may tear clothing or risk abrasions or lacerations to personnel

Yes Yes

Disposable Coveralls Or Gowns Yes No

Yes

No

No

No

No

Yes

No

No

No

No

Yes

No

No

No

No

Yes Yes Yes

No No No At least plastic apron

Yes Yes Yes

Yes Yes No

No No No

Yes

Yes

No

Yes

Yes

Yes

No

No

Yes

No

No

No

No

Yes

No

No

No

No

Yes

No

No

No

No

Yes

Yes

Yes

Yes

No

Yes under extrication gloves

No

Yes

Yes

Yes

Disposable Gloves

Yes

Yes No

Protective Eyewear ** Yes No

Light Rescue Gear No No No

Disposable Mask*

Activities requiring high visibility (such as at night or highway and roadway scenes, etc.)

No

No

No

No

Scenes where falling debris may be present

No

No

No

No

* **

at least helmet & coat or reflective vest as appropriate at least helmet

HEPA or N-95 if tuberculosis confirmed or suspected Face shield are appropriate for protection from spattering. If patient has fever, rash, or productive cough must use surgical type mask.

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Statement on Control of the Emergency Scene In keeping with position papers drafted by both the Ohio State Medical Association and the Ohio Chapter of the American College of Emergency Physicians, the following Medical Directive is issued: “Control of the emergency scene should be the responsibility of the individual who is most highly skilled in providing emergency stabilization and transport.” Specifically, this means that the Paramedic’s judgment takes precedence over both the Advanced EMT and EMT. The Advanced EMT takes precedence over the EMT. When any squad under the direction of JCEMS is requested and dispatched to the scene of an emergency, a doctor-patient relationship has been established between the patient and the physicians responsible for the administration of the JCEMS protocol. This relationship exists with the Paramedic, Advanced EMT or EMT acting as the intermediary of those physicians. This responsibility may be relinquished only if: A. On-line direction with the treatment facility is utilized.

B. The patient is in the immediate care of a physician, as in a doctor’s office, nursing home, or other facility where the physician is physically present; C. A physician known to the emergency personnel, or providing acceptable credentials attesting to licensure, is present at the scene and agrees to accept responsibility for the patient.

The fully licensed physician who wishes to assume control of the medical care of the patient must agree to the following: A. Sign all orders given; B. Recognize the EMT, Advanced EMT and Paramedic can function only within the scope of his/her training and statutory authority; C. Any order given beyond the training and/or authority of the EMT, Advanced EMT, or Paramedic requires the physician to be responsible for assuring adequate supervision of the medical care provided during treatment and transport. This means the physician will accompany the patient to the hospital unless it is a multiple casualty incident or disaster situation and the physician deems it necessary to stay at the scene; D. Agree to communicate with the base hospital physician as soon as feasible. In the case where the physician arrives at the scene after Paramedic personnel, if the base physician does not relinquish control, the Paramedic follows the orders of the base physician.

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Guidelines for Accessing Air Transport Whereas the arrival of a JCEMS unit at the site of any patient injury/illness initiates a doctor-patient relationship between the physicians responsible for the administration of protocol and the victim, and recognizing the importance of rapid delivery of traumatic injury patients to a definitive care setting, the following guidelines will govern the transfer of care from a JCEMS unit to any medical air transport service: A. If the dispatcher on duty or scene commander recognizes the nature of the incoming emergency call to be of such magnitude or the remote location of a suspected major trauma victim to be such that aeromedical transport may be indicated, the service with the closest response to the site may be accessed through the JCEMS dispatcher center.

B. Upon arrival at site, the crew shall perform a rapid trauma assessment and begin supportive victim care C. Personnel at the site should rapidly prepare the patient for transport. If the air unit has not yet arrived, the in-charge paramedic shall ascertain the ETA of the responding air unit. Generally, unless arrival of the air transport unit is imminent (5 minutes or less) patients should be transported to the most appropriate treatment facility. However, the paramedic must consider the best course of action that causes the patient to arrive at the appropriate facility in the least amount of time. The immediate goal is to deliver the patient to a facility where definitive care can be provided. The in-charge paramedic must immediately determine if waiting for the air unit to arrive or transporting the patient by squad will achieve this goal.

D. Should an air transportation unit and a JCEMS unit both be at an emergency site, a physician-patient relationship is established with the first arriving unit.

E. When the emergency situation is a multiple casualty incident in which the number of injured victims exceeds the number of available ground units in which they can be transported, the EMD or EMS Scene Commander may request air transport automatically.

F. JCEMS dispatch center will notify and alert the area fire department to set up a landing zone (or standby if a designated LZ is utilized). The dispatcher should notify the responding aeromedical service of the unit and frequency with which to communicate about the LZ, as well as the JCEMS scene commander and unit for patient information.

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START (Simple Triage And Rapid Treatment)

Identify and direct all ambulatory patients to designated Green area for secondary triage and treatment. Begin assessment of nonambulatory patients as you come to them. Proceed as below:

RESPIRATION S NO

NO Deceased

Under 30/min

YES

PERFUSION

Over 30/min

Position Airway

MINOR

Cap refill > 2 sec

Immediate

Control Bleeding

YES

Immediate

Immediate

Failure to follow simple commands Immediate

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Cap refill < 2 sec.

MENTAL STATUS Can follow simple commands Delayed

The Jump START Field Pediatric Multicasualty Triage System

(Patients aged 1- 8 years) (Simple Triage And Rapid Treatment)

Identify and direct all ambulatory patients to designated Green area for secondary triage and treatment. Begin assessment of nonambulatory patients as you come to them. Proceed as below:

Spontaneous respirations?

YES

NO

Check resp. rate

Open airway Spontaneous respirations?

YES

MINOR

< 15/min or > 40/min or irregular

NO Peripheral pulse?

15 - 40/ min, regular Peripheral pulse?

NO IMMEDIATE

IMMEDIATE

NO

YES

DECEASED

Perform 15 sec.

Mouth to Mask Ventilations

IMMEDIA TE

YES Check mental status (AVPU)

Spontaneous respirations?

YES IMMEDIATE

P (inappropriate) U

NO DECEASED

IMMEDIATE

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A V P (appropriate) DELAY ED

1. The following drugs may be administered on interfacilty emergency transfers if specific orders regarding route, dosage and time intervals are signed by the transferring physician: Carried on vehicles:

Not on Vehicles, but

Oxygen 0.9% Sodium Chloride Adenosine (Adenocard®) Albuterol (Proventil®) Aspirin Atropine Sulfate Dextrose 50%

allowable on Transfers: Activated Charcoal Bronkosol Calcium Chloride Calcium Gluconate Dexamethasone (Decadron®) Duoneb Isoproterenol (Isuprel®) Magnesium Sulfate Propranolol (Inderal®) Syrup of Ipecac Verapamil

Diphenhydramine (Benadryl®) Epinephrine (Adrenalin®) Furosemide (Lasix®) Glucagon Intropin (Dopamine®) Ipratropium bromide (Atrovent®) Lidocaine HCl (Xylocaine®) Lorazapam (Ativan ®) Morphine Sulfate Naloxone (Narcan®) Nitroglycerin tablets Ondansetron (Zofran®) Sodium Bicarbonate (optional) Succinylcholine Thiamine

The following additional IV drips may be taken, if specific parameter for titration are authorized on transfer sheet.: Additional non-medicated crystalline IV solutions Heparin Mannitol (Osmitrol ) Nitroglycerin Norepinephrine (Levophed) Oxytocin (Pitocin) Potassium Chloride Procainamide (Pronestyl) Volume Expanders, (i.e. Plasmanate or Gluconate)

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General Guidelines for Documentation Clear and concise documentation of all events including scene assessment, patient assessment, treatment, and transportation should be made in every patient encounter. For every patient contact, the following must be documented at a minimum: 1. A clear history of the present illness including chief complaint, time of onset, associated complaints, pertinent negatives, mechanism of injury, etc.

2. A complete physical assessment including pupil assessment, breath sounds, motor function, abdominal exam, extremity exam, etc.

3. An exact level of consciousness using the AVPU Method.

4. At least one complete set of vital signs (pulse, respirations, and an auscultated blood pressure). These vital signs should be repeated and documented after every drug administration. A reason must be documented for a complete lack of vital signs.

5. For drug administration, you must document the dosage of the drug, route of the drug, time of administration, and response to the drug.

6. A complete listing of treatments performed in chronological order. Any response to those treatment should also be listed.

7. For patients with an extremity injury, neurovascular status must be noted before and after immobilization.

8. For patients with spinal immobilization, document motor function before and after spinal immobilization.

9. For IV administration, the size of the IV catheter, placement of the IV, number of attempts, type of fluid, and flow rate.

10. All ECG Code summaries must be attached to the trip ticket for every patient placed on the cardiac monitor. Any significant rhythm changes should be documented. For cardiac arrest patients, the initial strip, ending strip, pre and post defibrillation strips, pacing attempts, etc should be attached to upper right hand corner of trip ticket. The patientâ&#x20AC;&#x2122;s name and run number should be documented on the strip.

11. For intubations, centimeter mark at the teeth, methods to confirm placement, size of ET tube, number of attempts.

12. Any orders requested whether approved or denied should be documented clearly.

13. Reading of Medical Miranda point by point and documenting on patient care report.

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Criteria for Initiation of Resuscitative Efforts The following is criteria regarding the decision to attempt resuscitation in the field. In all situations where a patient is apneic and/or pulseless, resuscitative efforts are to be initiated unless signs and symptoms are incompatible with life.

The paramedic should be aware of the following facts: 1. The person in V-fib, PEA, or asystole can potentially be resuscitated.

2. The â&#x20AC;&#x153;time downâ&#x20AC;? is an inaccurate parameter of resuscitation, as the patient could have been in bradycardia or simply unconscious for all of that time, yet still profusing blood to the brain.

3. Pupil size and response to light can be inaccurate as medications taken orally or intraocularly can affect them. Additionally, children and hypothermic patients may have fixed and dilated pupils from anoxia and yet be resuscitated without neurological deficit

Resuscitation need not be attempted in the field in cases of: A. Rigormortis B. Dependent lividity.

C. Decapitation D. Decomposition E. Incineration F. Visual massive trauma to the brain and heart incompatible with life.

Place the cardiac monitor on the patient to confirm asystole in at least two leads.

Attach code summary to run report.

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Do Not Resuscitate Orders and Living Wills JCEMS accepts the State of Ohio approved DNR Comfort Care and DNR comfort Care-Arrest forms.

JCEMS also accepts a valid living will which has been acted upon by two physicians who concur the patient is terminal or permanently unconscious.

The living will supersedes any conflicting power of attorney for health care or DNRCC or DNRCCA order.

If there is no physical evidence of any of these documents at the scene, then proceed with resuscitative efforts.

The State of Ohio Do Not Resuscitate Order Approved by the Ohio Department of Health Identification Patients can be either DNR Comfort Care patients or DNR Comfort Care-Arrest patients. The difference is that for a DNR Comfort Care patient, the State of Ohio DNR Protocol is activated immediately when a DNR order is issued or when a living will requesting no CPR becomes effective, but for a DNR Comfort Care--Arrest patient, the protocol is activated only when the patient experiences a cardiac arrest or a respiratory arrest. Be careful to check the patients DNR identification to determine which applies.

A DNR Comfort Care or DNR Comfort Care-Arrest patient’s status is confirmed when the patient has one of the following: 1. A DNR Comfort Care card or form completed for the patient.

2. A completed State of Ohio living will (declaration) form that states that the patient does not want CPR (in the case of a patient who has been determined by two doctors to be in a terminal or permanently unconscious state).

3. A DNR Comfort Care necklace or bracelet bearing the DNR Comfort Care official logo.

4. A DNR order signed by the patient’s attending physician or, when authorized by section 2133.211 of the Ohio Revised Code, a certified nurse practioner (CNP) or clinical nurse specialist (CNS).

5. A verbal DNR order is issued by the patient’s attending physician, CNP, or CNS. Copies of these items are sufficient.

EMS workers are not required to search a person to see if they have DNR identification.

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If an EMS or other health care worker discovers one of these items in the possession of a patient, the worker must make a reasonable effort to identify DNR patients in appropriate circumstances. Examples of ways to verify identity are: The patient or a family member, care giver, or friend gives the patient’s name.

The health care worker knows the patient personally.

Institution identification band.

Driver’s license, passport, or other picture ID. If you cannot verify the identity of a patient with DNR identification after reasonable efforts, you must follow this protocol.

Verification of identity is not required for patients or residents of health care facilities when a DNR order is present on the person’s chart.

EMS personnel who receive a verbal DNR order from a doctor or CNP/CNS must verify the identity of the person issuing the order. Some examples of verification are: Personal knowledge of the doctor/CNP/CNS. List of practitioners with other identifying information such as addresses.

A return telephone call to verify information provided.

Activation When this protocol is activated for a given DNR Comfort Care patient, it depends on whether the patient is a DNR Comfort Care patient or a DNR Comfort Care-Arrest patient. If a DNR - Comfort Care patient, this protocol is activated when the DNR order is issued. For a DNR Comfort Care-Arrest patient, the protocol is activated when the patient experiences a cardiac arrest or a respiratory arrest.

“Cardiac arrest” means absence of a palpable pulse.

“Respiratory arrest” means absence of spontaneous respirations or presence of agonal breathing.

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Actions For patients for whom the DNR Comfort Care protocol is activated, you: Will: Suction the airways Administer oxygen Position for comfort Splint or immobilize Control bleeding Provide pain medication Provide emotional support Contact other appropriate health care providers such as hospice, home health, attending physicians/CNP/CNS Will Not: Administer chest compressions Insert artificial airway Administer resuscitative drugs Defibrillate or Cardiovert Provide respiratory assistance (other than that listed above) Initiate resuscitative IV Initiate cardiac monitoring If you have responded to an emergency situation by initiating any of the “will not” actions prior to confirming that the DNR Comfort Care Protocol must be activated, discontinue them when you activate the protocol. You may continue respiratory assistance, IV medication, etc., that have been part of the patient’s ongoing course of treatment for any underlying disease.

Interaction with the Patient, Family and Bystanders The patient always may request resuscitation even if he or she is a DNR Comfort Care patient and this protocol has been activated. The request for resuscitation amounts to a revocation of DNR Comfort Care status.

If family or bystanders request or demand resuscitation for a person for whom the DNR Comfort Care Protocol has been activated, do not proceed with resuscitation. Provide comfort measures as outlined above and try to help family understand the dying process and the patient’s choice not to be resuscitated.

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Documentation EMS or other health care personnel who implement the DNR Protocol for a DNR Comfort Care patient should document in their records, in accordance with the policy of their agency of facility: The item that identified the person as DNR Comfort Care (as listed in the Identification portion of this protocol) The method of verifying the person’s identity, if any was found through reasonable efforts.

Whether the person was a DNR Comfort Care or DNR Comfort Care - Arrest patient.

The actions taken to implement the DNR Protocol.

When a DNR Order is Current A DNR order for a patient of a health care facility shall be considered current in accordance with the facility’s policy. A DNR order for a patient outside a health care facility shall be considered current unless discontinued by the patient’s attending physician/CNP/CNS, or revoked by the patient. EMS personnel are not required to research whether a DNR order that appears to be active has been discontinued.

“Do Not Resuscitate Orders” 1. A valid living will which has already been acted upon by two physicians who concur the patient is terminal or permanently unconscious supercedes any conflicting power of attorney for health care or DNRCC or DNRCC-Arrest order. (These patients would most often be in care facilities or receiving hospice care.) If there is no evidence of the two physicians having acted on the living will, then proceed with resuscitation efforts.

2. A valid durable power of attorney for health care (MUST specifically say for healthcare, as opposed to a generic power of attorney for business purposes) overrides a conflicting DNRCC or DNRCC-Arrest order.

3. If anyone other than the patient indicates any of these forms has been initiated, but the form is not physically present, PROCEED WITH RESUSCITATIVE EFFORTS. If a valid form is then produced, cease all efforts just as listed under the “will not” section of the DNRCC.

16

Patient Refusal of Treatment and/or Transport A legally and mentally competent patient, (18) eighteen or older can refuse treatment and/or transportation at any time during patient contact with JCEMS crews. To be determined to be mentally competent, generally the patient must be alert to person, place, and time. The patient must be able to understand the consequences of not accepting medical treatment and/or transport for their condition. In order for a patient to refuse treatment and/or transport, two events must occur: You must first insure there are no life or limb threatening injuries or illnesses that would place the patient’s life in jeopardy if left untreated.

You must give the patient enough information about the decision they are making so that there is an Informed Consent. You must be satisfied that the patient has understood the risks and options concerning their decision.

Procedure: 1. Assess the patient’s mental status and legal capacity.

2.

Advise the patient of his/her medical condition and proposed treatment.

3.

Avoid the use of confusing medical terminology.

4.

Make the sure the patient’s refusal is knowing and voluntary.

5.

If the patient is hesitant, try to talk him/her into care.

6.

Repeat the offer for care and/or transport several times.

7.

If it’s the patient’s wishes not to accept treatment and/or transport, have the Refusal form signed and witnessed by one crew member and a third party; preferably a law enforcement officer.

8.

Document the entire event in the narrative including that the patient was made aware of the consequences of not accepting care and/or transportation.

9.

Reading of Medical Miranda point by point and documenting on patient care report.

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MEDICAL MIRANDA In order for a patient to refuse treatment and/or transport, events must occur to protect both the patient and yourself.

1. You must first insure that there are no life or limb threatening injuries or illnesses that would place the patient’s life in jeopardy.

2. You must give the patient enough information about the decision they are making so that there is an informed consent. You must be satisfied that the patient has understood the risks and options concerning their decision You must read The Medical Miranda verbatim as follows: “You are refusing medical treatment and/or transport. Your health and safety are our primary concern, Please remember the following 1. Our evaluation and/or treatment is not a substitute for medical evaluation and treatment by a doctor.

We advise you to see a doctor or go to a hospital emergency department.

2. Your condition may not seem as bad as it actually is. Without treatment, your condition or problem could become worse.

3. If you change your mind or your condition becomes worse please call do not hesitate to call us back, by Calling 911. We will do our best to help you.

4. Don’t wait! When medical treatment is needed, it’s usually better to get it right away.

------- SPECIAL CONDITIONS ------5. Your condition has been discussed with a doctor at the hospital by radio or telephone and the advise given to you has been issued or approved by the doctor.

6. FOR MINORS: Instruct the patient’s legal guardian that in this situation they are acting on behalf of the patient and they understand the above information regarding refusal of treatment or transport, and accept responsibility for the patient.”

You must document in the Patient Care Report that the Medical Miranda was read as required by the Protocol.

Provider-initiated refusals should be limited to true non-emergency situations. When not treating and/or transporting an individual, who in your opinion is neither ill nor injured, contact medical control and advise the physician of the situation and to whether to treat and/or transport the individual.

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Protocol for Initiation of Intravenous Fluid Therapy (Advanced EMT or Paramedic) General Guideline:

A. No more than two IV attempts are to be made unless the patient is in critical condition or the transportation time is excessive.

B. IV’s on multiple trauma patients are to be started enroute to the TF unless prolonged extrication is required.

C. Prep the site with an approved site prep.

D. Obtain blood samples from all patients on whom IV therapy is initiated, (Generally, 3 red-topped, 1 lavender-topped and 1 blue-topped tube, but if the squad is aware that the receiving TF has a specific preference, this may be honored.) Do not pull blood up into a syringe and inject into the blood tube, as this may jeopardize analysis. All of the tubes should be adequately labeled with the patient’s name, the date and time the blood was drawn and the name of the person who drew the blood. Samples should then be placed immediately into an impervious bio-hazard bag. Retain two of the red-topped tubes for followup studies should an accidental exposure to blood or other body fluids occur during the run. If no exposure occurs, leave all the tubes with the hospital.

E. Preservation of the IV site should not be compromised in an effort to obtain the blood samples. A redtopped tube will provide the most useful information for the TF. F. On all IV’s, indicate on a piece of tape near the insertion site the date and time of the IV initiation, the catheter size, JCEMS, and the name of the person starting the IV. Also record this information on the trip ticket. Mark the IV bags at the TF to indicate the amount of fluid given and record this information on the trip ticket.

G. The Intermediate EMT or Paramedic may, at his or her discretion, initiate a saline lock in place of a keep open IV drip on patients determined on assessment to not be in need of fluid therapy.

H. Twin-caths® may be initiated at the discretion of the Advanced EMT or Paramedic if it is believed an emergent cardiac or CVA patient may be a candidate for fibrolytic therapy.

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Adult / Pediatric IO Procedure (Advanced EMT or Paramedic0 An adult IO should only be attempted by the paramedic after 2 unsuccessful peripheral IV attempts Procedure 1. Select needle size based on patient’s weight.

2. 3 – 39 Kg – use 15mm needle set 3. 40+ Kg with normal amount of tissue in the lower leg – use 25mm needle set.

4. 40+ Kg with excessive tissue in lower leg – use 45mm needle set.

5. BIS 6. Insert 1 cm medical to the tuberosity on the flat, broad portion of the tibia.

7. Clean the site with alcohol and/or Betadine.

8. Ensure the 25mm 15 gauge needle set is attached securely to the driver 9. Remove the needles safety cap.

10. Insert the needle at a 90 degree angle stabilizing the leg with your free hand.

11. Insert the catheter through the bone cortex by applying gentle downward pressure while depressing the trigger.

12. When a sudden give is felt or the flange touches the skin release the trigger.

13. Remove the driver and stylet.

14. Ensure that the catheter is standing at a 90 degree angle.

15. Attach the EZ Connect extension set to the catheter.

16. Aspirate for a small amount of blood and flush the catheter with 10ml of normal saline.

17. Administer 50mg of Lidocaine 2% for adult patient.

18. Administer 10mg of Lidocaine 2% for pediatric patient 19. Administer fluids and medications as indicated.

20. Apply dressing and secure.

21. attach an arm band to the patient with the date and time of insertion written on the arm band.

Precautions To remove the EZ-IO discontinue fluids/medications and attach a small sterile syringe and rotate clockwise while applying traction to the catheter.

The site should be monitored for infiltration/extravation.

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Specific Guidelines for IV Therapy for Adult Conditions: Anaphylaxis - (Acute Allergic Reaction) 0.9% Sodium Chloride at a rate necessary to maintain a systolic BP of 100 mmHg. Cardiopulmonary - (Any patient with a suspected MI, respiratory distress or significant dysrhythmia) - 0.9% Sodium Chloride at a keep open rate (25cc/hr.) Use a minidrip setup and monitor the drip rate closely to avoid circulatory overload.

Cerebral and Spinal Cord Injuries - .9% Sodium Chloride at a keep open rate (25 cc/hr.) If the systolic BP is below 70 mmHg, treat for shock. (Isolated head injuries rarely cause shock. If the patient is in shock it is usually from some other injury.) Do not push the systolic BP over 90-96 mmHg (a higher BP may increase intracranial pressure and worsen the injury.)

CVA or TIA - 0.9% Sodium Chloride at a keep open rate (25 cc/hr.)

Dehydration - 0.9% Sodium Chloride at a keep open rate. Watch for early signs of shock and titrate the rate to maintain a systolic BP of 100 mmHg. Diabetics - Fluid indications in diabetic patients experiencing problems other than specific diabetic reactions are the same as for any other patient.

Drug Overdose - 0.9% Sodium Chloride with the rate titrated to maintain a systolic BP of 100 mmHg. Fluid Challenge Bolus- 20 ml/kg Hypoglycemic Reactions - 0.9% Sodium Chloride at a keep open rate (25 cc/hr) Hypothermia - 5% Dextrose in Normal Saline (D5NS) (EMT-P) or Normal Saline (EMT-I) with an initial fluid bolus of 250 ml, then at a keep open rate. (D5NS is made by wasting 100 ml of NS from a liter bag and replacing it with two 50 ml amps of 50% Dextrose) ( See â&#x20AC;&#x153;Protocol for Initiation of Intravenous Fluid Therapy,â&#x20AC;?

General Guidelines. (EMT-P) Renal Dialysis - 0.9% Sodium Chloride at a keep open rate (25 cc/hr). Do not start the IV in the extremity that contains the dialysis fistula. This site should also be avoided when taking blood pressures.

Shock - 0.9% Sodium Chloride. Start and run at a rate sufficient to maintain a systolic BP of 90-100 mmHg. Stop bleeding as trained. Use a 14 gauge or 16 gauge needle if at all possible since the patient may require blood transfusions at the T.F. Severe trauma cases may require two IV sites simultaneously.

Trauma- Fluid therapy with 0.9% Sodium Chloride is indicated in trauma cases involving: 1. Severe burns (See Protocols for Trauma Care) 2. Hip or femur fractures 3. Severe bleeding from any source 4. Symptoms of shock with no obvious signs of injury 5. A mechanism of injury indicating potential for patient deterioration Set the fluid flow rate sufficient to maintain a systolic BP of 90 - 100 mmHg. Severe trauma cases may require two IV/IO sites simultaneously. Large bore catheters (14 - 16 ga.) should be used if possible.

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Unconscious Patients - For all patients unconscious prior to squad arrival (including seizure patients) check the patient’s blood sugar level and begin an IV of 0.9% Sodium Chloride. (See “Protocol for Medical Emergencies,” Hypoglycemic reactions)

Specific Guidelines for Airway Management 1. Utilize Basic Life Support procedures appropriate to the emergency.

A. Head-tilt/chin lift B. Modified Jaw Thrust C. Heimlich Maneuver 2. Maintain airway as necessary A. Oral pharyngeal Airway B. Nasal Pharyngeal Airway C. Suction 3. Endotracheal Intubation remains the definitive airway A. Oral Intubation (Advanced EMT and Paramedic) B. Nasal Intubation.

(Paramedic Only) C. Inline intubation (Paramedic Only) D. Digital Intubation.

(Paramedic Only) E. King Airway shall be used after two unsuccessful attempts at intubation.

If patient is in Cardiac Arrest and no Paramedic is on site use the King Airway ( EMT and Advanced EMT).

Verify tube placement using at least two of the following methods: A. B. C. D. E. F.

ETCo2.

Capnography.

Chest rise.

Condensation in the tube.

Absence of breath sounds in the abdomen.

Direct visualization of tube through the cords.

A Bougie type airway assist device may be used for difficult and/or traumatic intubations (EMT-P) .

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Conscious Intubation INDICATIONS: The need for airway control in a conscious patient or one with an intact gag reflex who cannot be passively ventilated and/or oxygenated.

ABSOLUTE CONTRAINDICATIONS:

Children 13 years of age OR weigh less than 100 pounds.

Patients with a known hypersensitivity to Versed or Succinylcholine.

PROCEDURE: 1. Explain to the patient the need for the procedure if possible.

2. Assemble necessary equipment (IV, Suction, BVM, ET tubes, laryngoscope, syringes, King Airway, end tidal CO2 monitor, pulse oximetry).

3. Position patient in the sniffing position using in-line stabilization 4. Place Patient on Cardiac monitor.

5. If not done already, initiate IV of 0.9 % normal saline.

6. Start pre-oxygenation with a BVM and 100% oxygen. If the patient can breathe on their own, use a nonrebreather at 12 L/min for 2 to 3 minutes. Continuously monitoring pulse oximetry.

7. Administer Versed (Midazolam) 2 mg IVP over 30 – 60 seconds 8. Once Versed has taken effect (1 –2 minutes).

9. Administer Succinylcholine 0.5 – 1.0 mg/kg IVP. 10. Intubate the patient.

11. Ensure proper placement of the ET tube.

12. If the patient becomes agitated after the intubation, administer 2 mg Ativan IVP (Dilute with equal amount of 0.9 % Sodium Chloride.). Additional doses may be approved through medical control. (EMT-P) 13. Document procedure.

14. Apply filterline capnography to end of ET tube for continuous ETCo2 monitoring.

Have Flumazenil (Romazicon) 0.2 mg on hand if need to reverse the effects of the Versed.

If copious amount of oral secretions noted, you may administer 0.5mg of Atropine if heart rate is under 130 bpm.

If possibility of Trauma or Head Injury you may administer Lidocaine 1.0 – 1.5 mg/kg IVP.

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Surgical Cricothyrotomy (Only to be used as a last resort!)

Definition: This is a surgical procedure to secure a definitive airway in that patient who cannot be intubated for various reasons. This is the last option to be utilized in the ventilatory management of a patient.

INDICATIONS: A person in respiratory distress whose airway cannot be secured by intubation.

Situations in which standard endotrachial intubation cannot be performed because of massive orotracheal trauma, complete upper airway obstruction precluding intubation.

Any situation in which orotracheal intubation is unsuccessful and without this procedure, hypoxic insult to the patient is inevitable.

ABSOLUTE CONTRAINDICATIONS: Known laryngeal trauma.

Children under 13 years of age.

PROCEDURE: 1. Patient should be in the supine position 2. Palpate the cricothyroid membrane 3. Prep the site with Iodine (Betadine速) followed by an alcohol pad. (If the patient is allergic to iodine, use only alcohol pads.)

4. Holding the neck structures taut between the thumb and index finger, make a vertical incision with a 10# scalpel about 1.0 to 2.0 cm in length over the membrane in the midline, exposing the cricothyroid membrane.

5. Make a stab through the membrane and insert your finger through the incision into the trachea to hold the incision open for the tracheostomy tube.

6. Pass a tracheostomy tube through the incision and inflate the cuff. Attach the BVM and ventilate the patient using the end tidal CO2 monitor and pulse oximtery device. Suction as necessary.

7. Document procedure.

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Protocol for Medical Emergencies Altered Mental Status - Changes in a patient’s mental status may be a reflection of cardiac dysrhythmias, COPD, CVA, drug ingestion, heat related illness, hyper/hypoglycemia, hypertension, hypothermia, hypoxia, psychiatric problems, seizures or trauma. The history and physical exam will give clues to help narrow the differential diagnosis, but you must consider all possibilities.

A. Open the airway. Assist breathing as necessary. Apply oxygen and titrate oxygen therapy to a pulse oximeter level to at least 95%. If there are signs of respiratory distress, proceed with the Respiratory Distress Protocol. (EMT, Advanced EMT, Paramedic).

B. Obtain vital signs, and a SAMPLE history. (EMT, Advanced EMT, Paramedic) C. Attach the cardiac monitor and treat any dysrhythmias according to the appropriate algorithms.

(EMT-P) Advanced EMT may interpet cardiac monitor.

D. Draw blood samples (Advanced EMT, Paramedic) E. Test the patient’s blood with a glucometer.(EMT, Advanced EMT, Paramedic) If the blood sugar is less than 60 proceed with the Hypoglycemia Protocol. (EMT-P) F. Establish an IV of 0.9% Sodium Chloride at a keep open rate (25cc/hr).

(Advanced EMT, Paramedic) G. Maintain a systolic BP of at least 100 mmHg. Recheck the blood pressure often.

H. Proceed with other protocols as indicated, based on the history and physical findings.

I. Transport to the receiving hospital.

Anaphylaxis - (Acute Allergic Reaction) Open the airway. Assist breathing as necessary. Apply oxygen and titrate to a pulse oximeter level of at least 95%.

(EMT, Advanced EMT, Paramedic) Attach Cardiac Monitor.

Administer Epinephrine (Adrenalin®) 0.3 cc of 1:1,000 solution Sub-Q. (Advanced EMT, Paramedic) Basic EMT units may assist a patient who has a prescribed auto injector to administer, if the patient requires help.

Initiate an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr). If systolic is less than 100 mmHg, treat according to the Shock Protocol.

Administer Diphenhydramine (Benadryl®) 50 mg. IV bolus. (or IM if unable to start on IV) (Advanced EMT, Paramedic)

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May repeat epinephrine once in five minutes if necessary at same dosage. (Advanced EMT, Paramedic) If the patient is in severe respiratory distress administer 125 mg of Solu-Medrol IVP (Paramedic).

When airway is not compromised Benadrly 50 mg IV bolus may be administered. Advanced EMT, Paramedic) Acute Asthmatic Attack A. Open the airway. Assist breathing as necessary. Apply oxygen and titrate oxygen therapy to a pulse oximeter level of at least 95%.

B. Attach Cardiac Monitor.

C. Obtain a SAMPLE history especially regarding the use of bronchodilating medications.

D. Draw blood samples (Advanced EMT, Paramedic) E. If there are no contraindications, administer Albuterol (Proventil®, Ventolin®) 2.5 mg by nebulized mist. The oxygen flow should be set high enough to produce a continuous mist from the mouthpiece. Assist the patient and teach the patient to breathe the mist in while inhaling deeply on the mouthpiece, and to exhale through the nose. Observe for any side effects. The treatment is complete when the nebulizer no longer mists. If the patient has already taken an albuterol treatment prior to squad arrival without relief or an albuterol treatment is administered by the paramedic and the patient’s condition has not improved, a 500 mcg unit dose of ipratropium bromide (Atrovent®) may be administered by nebulized mist. Additional treatments of albuterol and or ipratropium bromide may be given with permission from the TF. (Advanced EMT, Paramedic) F. OR If the patient is not exchanging sufficiently to use the aerosol and is cyanotic and in severe respiratory distress, administer epinephrine (Adrenalin®) 0.3 cc of 1:1,000 solution Sub-Q (EMT-P) In patients for whom epinephrine may not be the drug of choice, (i.e. the elderly or patients with chronic cardiovascular disease) contact the T.F. for additional orders. (Advanced EMT, Paramedic) (EMT units may assist a patient who has a prescribed measured dose inhaler to use it in accordance with directions, if approved by T.F. (they may not administer nebulized mist as listed above) G. Initiate an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr). If the systolic BP is less than 100 mmHg, treat according to the Shock Protocol.

(Advanced EMT, Paramedic) H. If respiratory distress continues administer Solu-Medrol 125mg IVP ( Paramedic).

I. Asses patient for possible use of CPAP.

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Chronic Obstructive Pulmonary Disease (as presenting problem) A..Asses the patients respirations and observe for signs of acute respiratory distress.

B. If moderate shortness of breath is present, apply 2 LPM via Nasal Cannula only if pulse oximeter reading is below 92%. Observe the patients response. If the patient is already on home O2 leave it in place. (EMT, Advanced EMT, Paramedic).

C. D. Ascertain the patients immediate medication history and obtain blood samples. If no contraindications administer DuoNeb via nebulized mist. (Advanced EMT, Paramedic).

E. If signs of acute distress (nasal flaring, tracheal tugging, intercostal retractions, use of accessory muscles or cyanosis) are present, do not withhold full O2 supplementation. Administer 10-12 lpm by nonrebreather mask. Be ready to assist respirations if necessary (EMT, Advanced EMT, Paramedic).

F. If respiratory distress continues administer Solu-Medrol 125mg IVP (Paramedic).

G. In the COPD patient being treated for a suspected MI, shock, or any other critical problem affecting blood flow, if the pulse oximetry reading is 92% or below, O2 flow rate should be at the same rate as specified for patients without COPD having the same problems. (EMT, Advanced EMT, Paramedic).

H. Asses patient for possible use of CPAP.

Behavioral Emergencies A patient may be exhibiting bizarre and endangering activities that would make him/her a danger to him/her, the crew, and the general public. Also a patient may be experiencing a psychological emergency and their mental and/or emotional condition is impacting his/her overall health.

A. Do not approach the patient if immediate safety risk to crew is possible.

B. Request Law Enforcement to the scene to assist with patient control.

C. Assess for treatable cause(s) of the behavioral problem and treat per protocol.

D. Gently restrain the patient as a last resort to protect the safety of the patient and EMS crew.

E. Utilize appropriate airway management F. Initiate IV of 0.9 NS at 25 cc/hr if possible. Maintain a systolic BP 100 mmHg (Advanced EMT, Paramedic)

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G. Draw blood samples. (Advanced EMT, Paramedic) H. Check blood glucose level. (EMT, Advanced EMT, Paramedic) I. Cardiac Monitor if possible (Advanced EMT, Paramedic) J. If patient continues to exhibit exceptional behaviors and/or cannot be mentally or emotionally consoled consider administering 2 mg of Lorazepam (Ativan®) IVP (Dilute with equal amount of 0.9 % Sodium Chloride.). May be repeated once in 10 - 15 minutes if needed. Additional doses must be approved through medical control. (Advanced EMT, Paramedic) K. If an IV cannot be established on the patient, administer 2 mg Lorazepam (Ativan®) IM. (Dorsal Gluteal (Buttock) (Advanced EMT, Paramedic)

Cardiac Emergencies A. Open the airway. Assist breathing as necessary. Apply oxygen to maintain a pulse oximetry of 95%.

B. Obtain vital signs (including apical and radial pulses over a full minute) and a SAMPLE history.

C. Place chest electrodes in the Lead II position for constant monitoring and assess the cardiac rhythm. Document rhythm frequently and mark the run number, the patient’s name and the time on the recording paper if not automatically done. (The monitor/defibrillator should be taken to the patient, not the patient taken to the monitor) Obtain 12 lead EKG on all potential cardiac patients and transmit to receiving facilities if the EKG monitor is equipped.

D. Consider whether the patient may be a possible candidate for fibrinolytic therapy (TPA or Streptokinase.) This therapy may be indicated if: 1. The history indicates this is most likely the patient’s first heart attack 2. The patient does not have an active bleeding disorder If so:

1. It is imperative that there should not be excessive attempts at IV sticks.

2. If the first attempt is unsuccessful, and the patient is stable, contact the TF and report the situation to determine if additional attempts are indicated.

3. Immediate transport is essential. Do not delay at site.

E. Establish an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) Use a minidrop setup.( Advanced EMT, Paramedic) At the discretion of the Advanced EMT or Paramedic if a Twincath® device may be utilized if fibrinolytic therapy is likely.

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F. Administer Nitroglycerin 0.4 mg ( 1 tablet ) for suspected cardiac pain. This may be repeated every 5 minutes, up to a total of 3 doses, until pain subsides. Monitor the BP after each dose to ensure that it does not drop dramatically. (Advanced EMT, Paramedic) G. If the pain is severe and the patient is not hypotensive, administer Morphine Sulfate 5 mg IV over a one minute period. Morphine Sulfate 5 mg may be repeated once in 10 minutes to a total of 10 mg or patient becomes pain free. (Paramedic) H. If the history and physical exam suggests that the patient is having a myocardial infarction/heart attack, and if there are no contraindications (allergies, bleeding ulcers, etc.) administer 324 mg of aspirin (4 – 81 mg chewable aspirin). Have the patient chew and swallow. Administer Aspirin even if the patient has already taken Aspirin that day. (Advanced EMT, Paramedic) I. Patients with automatic internal cardiac defibrillators (AICD) are treated as any other cardiac patient. Firing of the internal unit may occur and can be felt by the rescuer as a slight tingling sensation, but no harm can occur. Glove usage will tend to decrease this sensation.

J. Obtain a 12 lead EKG on all potential cardiac patients.

12 lead EKG shall be transmitted to receiving facilities if the EKG monitor is equipped.

When an Inferior wall MI is noted, a RV4 should be performed to ensure that the right ventricle has not been affected. This should be done prior to administration of Nitroglycerin. If right ventricle involvement is noted the receiving facility shall be contacted as soon as possible for further orders.

Treat the following complications; Acute Congestive Heart Failure (Pulmonary Edema) a. Keep the patient in the sitting position b. Administer Furosemide (Lasix®) 40 mg IV (do not administer the Lasix® any faster than 20 mg/min). (may be given IM if unable to start IV) (Paramedic) c. If the patient is currently prescribed Furosemide, adminisiter 80 mg IV under the same guidelines. d. Nitroglycerin 0.4 mg tablet may be administered once, if patient is not hypotensive. e. Contact the TF for permission to administer Morphine Sulfate, (Paramedic) Observe for respiratory depression, if administered.

Recheck vital signs frequently. f. Access the patient for possible use of CPAP.

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Continuous Positive Airway Pressure (CPAP) Indication Any adult patient who is in respiratory distress with signs and symptoms consistent with Asthma, COPD, Pulmonary edema and CHF. Patient needs to be awake and able to follow commands.

Patient has the ability to maintain an open airway.

Patient has a respiratory rate greater than 25 bpm.

Patient has a SPO2 of less than 92%.

Patient is using the accessory muscles during respirations.

Contraindications Patient is in respiratory arrest or is apneic.

Patient is suspected of having a pneuothroax or chest trauma.

Patient has a tracheostomy.

Patient is actively vomiting or has an active upper GI bleed.

Procedure Explain the procedure to the patient.

Ensure adequate O2 supply to the ventilation device per manufactures instructions.

Place patient on continuous pulse oximetry.

Place patient on cardiac monitor if not yet done.

Place delivery device over patients mouth and nose.

Secure mask with provided straps.

System is set to deliver 7.5cm of PEEP. Check for air leaks.

Monitor and document vital signs every 5 minutes.

If patient showing signs of CHF or Hypertension administer 0.4mg Nitro (1 tab).

Continue to monitor patient and readjust mask as needed.

If respiratory status deteriorates, remove device and apply intermittent positive pressure ventilation via BVM as needed.

CPAP therapy needs to be continuous and should not be removed unless the patient can not tolerate the Mask or experiences respiratory arrest or begins to vomit.

Special Notes Do not remove CPAP until hospital therapy is ready to be placed on the patient Watch for gastric distention.

Due to changes in cardiac preload and afterload during CPAP therapy, a complete set of vital signs must Be obtained every 5 minutes.

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Cardiac Arrest - (A pulseless, apneic patient) In all cases of cardiac arrest, consider the underlying cause(s) and possible treatments: Hypoxia Hypothermia Hydrogen Ion Tamponade, cardiac Tension Pneumothorax

Hypovolemia Hyop/hyperkalemia Toxins Thrombosis (coronary or pulmonary)

Trauma (hypovolemia, increased ICP)

BLS Vehicles -

Initiate Automatic External Defibrillation Protocol immediately. Do not delay initiation to call for back-up or apply other measures if AED is immediately available. Apply CPR with supplemental high-flow oxygen.

Secure airway utilizing the King Airway. Call for back-up. If ALS backup is several minutes away, transport immediately upon arrival of a third employee at site and proceed to TF. Meet ALS back-up enroute to TF , if possible. Continue sequencing of shocks and CPR enroute, according to algorithm.

(EMT-B, EMT-I, EMT-P)

ALS Vehicles -

Follow protocol algorithm for specific rhythm displayed

Cardiogenic Shock - (A patient who has a suspected MI and has progressed to visible signs of shock, i.e., increased heart rate, decreased BP, pallor, cyanosis, diaphoresis, pallor, diaphoresis, mental status changes.)

Initiate Dopamine (Intropin速) drip at 5 mcg/kg/minute (Paramedic) Utilize pre-mixed Dopamine 1600 mcg/ml for drip.

Initiate drip rate of 15 minidrops per minute (5 mcg/kg assuming a 80 kg patient) Titrate the rate to maintain systolic BP of 90-100 mmHg Check and record BP every 5 minutes. (EMT, Advanced EMT, Paramedic) tiate drip at a rate of 5 minidrops/min (1.9 mcg/kg assuming a 70 kg pt)

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Dysrhythmias - Treat per the algorithms (Paramedic) See appendix A for adult algorithms.

Advanced EMT may provide cardiac strip interpretation but MAY NOT administer cardiac medications.

Bolus Drugs

Adenosine must be given IV with a rapid bolus (over 1to 2 seconds) followed by a 10 â&#x20AC;&#x201C; 20 cc rapid bolus of .9% normal saline. The usual dose is 6 mg for first dose with subsequent doses of 12 mg to a total dose of 30 mg.

Atropine may be given IV/IO or via an ET tube.* The usual dose is 0.5 - 1.0 mg (5-10 ml) Epinephrine may be given IV/IO or via an ET tube.* The usual dose is 0.5 - 1.0 mg (5-10 ml 1:10,000 solution) Lidocaine may be given IV/IO or via an ET tube. * The usual dose is 1 - 1.5 mg/kg for the first dose with subsequent doses of 0.5 - 0.75 mg/kg. The maximum total dose is 3 mg/kg. In patients over 70 years of age, or patients with impaired hepatic blood flow (MI, CHF, or shock), all dosages except the first dose should be reduced by 50%. Do not administer with heart blocks or with heart rate less than 60 bpm.

IV should be the first choice for medication administration.

If 2 unsucssesful IV attempts occur an IO should be established.

Endotracheal dosages can be utilized if an IV/IO can not be established. * Endotracheal dosages should be 2 - 2.5 times greater than IV dosages, and are facilitated by diluting into10cc of Normal Saline, delivery through a catheter beyond the tip of the ET tube, and stopping of chest compressions while the dosage is delivered in a quick burst with several successive insufflations with the BVM to facilitate dispersion. Lidocaine, Epinephrine, Atropine, and Narcan can all be given via ET tube.

Continuous Infusions (drips) Epinephrine for continuous infusion is prepared by adding 2 ml of 1:1,000 epinephrine to 500 ml of 0.9% Sodium Chloride. The usual starting dose is 2 mcg/min (30 minidrops/min) which is then titrated to achieve a heart rate over 60.

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Lidocaine for continuous infusion comes pre-mixed 0.4% (400 mg/100ml) or can be made by adding 1 gm of 20% Lidocaine to 250 ml of 0.9% Sodium Chloride. Base drip rates on number of boluses needed to control rhythm.

15 minidrops/min.=1mg/minute 30 minidrops/min.=2mg/minute 45 minidrops/min=3mg/minute 60 minidrops/min=4mg/minute Dopamine for continuous infusion comes pre-mixed 1600 mcg/ml or can be made by adding 800 mg of Dopamine to 500 ml 0.9% Sodium Chloride {1600 mcg/ml}. The usual starting dose is 5 mcg/kg/minute. Assuming a 80 kg patient: 15 minidrops/min=5 mcg/kg/minute 30 minidrops/min=10 mcg/kg/minute 45 minidrops/min=15 mcg/kg/minute 60 minidrops/min=60 mcg/kg/minute In cardiac arrest situations, all resuscitative attempts, including CPR and ALS procedures, are to be continued while enroute to the TF unless the patient revives or is pronounced dead by an authorized physician at the site. (see â&#x20AC;&#x153;Statement on Control of the Emergency Sceneâ&#x20AC;?)

Transcutaneous Pacing (TCP)

(Paramedic)

Technique: Consider sedation with 2 mg Versed IV/IO Place pacing electrodes in place per the manufactures instructions Turn the pacer on Set the demand rate to approx. 60 minute. This rte can be adjusted up or down (based on patient clinical response) once pacing is established Set the current milliamperes (mA) output 2 mA above the dose at which consistent capture is observed.

Percautions: TCP is contraindicated in severe hypothermia and is not recommended for asystole.

Do not assess the carotid pulse to confirm mechanical capture; electrical stimulation causes muscular jerking that may mimic the carotid pulse.

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CVA - Cerebrovascular Accident - If suspected Stroke - immediate assessment should be performed using the Cincinnati A. Pre-Hospital Stroke Scale.

Facial Droop (have patient show teeth or smile) Normal - both sides of the face move equally Abnormal - one side of the face does not move as well as the other side Arm Drift (patient closes eyes and holds both arms straight out for 10 seconds) Normal - both arms move the same or both arms do not move at all Abnormal - one arm does not move or one arm drifts down compared with the other Abnormal Speech (have the patient say “you can’t teach an old dog new tricks.”

Normal - patient uses correct words with no slurring Abnormal - patient slurs words, uses the wrong words or is unable to speak.

Interpretation If any one of these three signs are abnormal, the probability of a stroke is 72%.

B. Open the airway. Assist breathing as necessary. If pulse oximeter reading is 95% or below, apply oxygen C. Obtain vital signs and a SAMPLE history.

D. Attach cardiac monitor and observe rhythm. (Advanced EMT, Paramedic) E. Withdraw blood samples and check the blood sugar. (Advanced EMT, Paramedic) F. Test the patient’s blood with a glucometer. (EMT, Advanced EMT, Paramedic) If the blood sugar is less than 60, proceed with the Hypoglycemia Protocol. (Advanced EMT, Paramedic) G. Establish a saline lock or IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) (Advanced EMT, Paramedic)

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Heat Exhaustion (The body’s response to salt and water loss occurring in persons losing fluid in a hot environment. Patients are sweating profusely with a normal temperature, have GI upset, headache, possible syncope. Altered mental status not present. If the mental status is altered, go to the Heat Stroke Protocol.)

A. Remove patient to a cool environment.

B. Since salt and fluid replacement is therapeutic, consider oral solutions, (i.e.

Gatorade®) if they are available and the patient is not complaining of nausea.

C. Consider an IV of 0.9% Sodium Chloride if the patient is nauseated, vomiting or hypotensive. Initiate an IV at a keep open rate (25 cc/hr) and titrate the rate to maintain a systolic BP of 100 mmHg. (Advanced EMT, Paramedic) Heat Stroke (A severe disturbance in the body’s heat regulating mechanism resulting in the loss of the ability to control temperature. The onset is sudden with the body temperature rising precipitously; reaching as high as 106◦ F. Mental status alterations are usually present.)

Assure an adequate airway and administer high flow oxygen.

Remove the patient to a cool environment. Begin active cooling. (remove clothing, irrigate the skin, fan the patient) Establish an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) and titrate the rate to maintain the systolic BP of 100 mmHg. (Advanced EMT, Paramedic) Connect the cardiac monitor and treat any dysrhythmias according to the appropriate algorithms (Paramedic) Transport to the TF expediently Consider iced towels or cold packs to the neck, groin, and the axilla.

Avoid causing the patient to shiver. Monitor the vital signs every 5 - 10 minutes Hypertension ( A systolic BP greater than 240 or a diastolic BP greater than 140 ) A.

Complete the primary and secondary survey with special attention to the onset of symptoms, the neurological status and any focal neurological deficits.)

B. Initiate oxygen therapy based on the protocol for any other underlying conditions. ) C. Establish an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) (Advanced EMT, Paramedic) D. Connect the cardiac monitor and treat any dysrhythmias according to the appropriate algorithms (Paramedic)

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E. Administer up to three (3) Nitroglycerin tablets sublingual five minutes apart, monitoring the blood pressure between doses to maintain a systolic blood pressure above 100. (Advanced EMT, Paramedic) F. Record the blood pressure every 5 minutes while enroute to the TF (EMT, Advanced EMT, Paramedic) Hypoglycemic Reaction (A known diabetic who is unconscious or exhibiting bizarre behavior) A.

Maintain the airway and give additional life support as needed.

B.

Make a venipuncture and draw blood samples. (Advanced EMT, Paramedic) Test the blood with a glucometer (EMT, Advanced EMT, Paramedic)

C.

Establish an IV of 0.9% Sodium Chloride at a keep open rate. (25 cc/hr) (Advanced EMT, Paramedic)

D.

If the glucometer reading is below 60, then administer 25 grams of 50% Dextrose IV bolus. (Advanced EMT, Paramedic) If the patient is likely to be an alcoholic or is likely to be anorexic or on strict dietary restrictions, administer 100 mg of Thiamine IV bolus prior to giving 50% Dextrose. (Paramedic)

E.

If the blood sugar reading is below 60 and an IV cannot be established, administer 100 mg of Thiamine IM, if indicated above. (Paramedic) If the patient is conscious, administer oral instant glucose or sugar in any form acceptable to patient. If the patient is unconscious, Glucagon 1 mg (1 unit) may be administered IM or Sub-q. (Advanced EMT, Paramedic) If a Basic squad, turn the patientâ&#x20AC;&#x2122;s head to one side and administer instant glucose along the inside of the cheek.

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Hypothermia Algorithm Initial therapy for all patients Remove wet garments Protect against heat loss and wind chill (use blankets and insulating equipment) Maintain horizontal position Avoid rough movement and excess activity Monitor core temperature Monitor cardiac rhythm Assess responsiveness, breathing and pulse Pulse and breathing present________________________ Pulse or breathing absent What is core temperature?

Mild Hypothermia - 94◦ to 97◦ F Passive rewarming Active external rewarming

Start CPR Defibrillate VF/pulseless VT up to a maximum of 3 shocks (200 J, 300 J, 360 J) Attempt, confirm, secure airway, ventilate with warm, humid oxygen Establish IV access Infuse warmed D5NS 1

Moderate Hypothermia - 86◦ to 94◦ F Passive rewarming Active external rewarming

What is core temperature? < 86◦F ____________> 86◦F

Severe Hypothermia - < 86◦ F Active internal rewarming

Continue CPR Withhold IV medication Limit shocks for VF/VT to maximum of 3 Continue CPR Transport to hospital Give IV medication as indicated Active Internal Rewarming _____________ Repeat defibrillation Warm IV fluid for VF/VT as core Warm humid oxygen temperature rises 1.Initiate an IV of warmed D5 Normal Saline (waste 100 ml from a liter bag of Normal Saline and replace it with two 50 ml amps of D50W.) (Advanced EMT, Paramedic) or 0.9% Sodium Chloride (Advanced EMT, Paramedic). Administer a 250 ml bolus then decreased the rate to a keep open rate (25 cc/hr) Consider the need for Thiamine therapy.

Footnote:

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A non-invasive oral or axillary temperature should be obtained and documented for all conscious patients. Patients with a decreased level of consciousness or responsiveness that exhibit signs and symptoms of mild to severe hypothermia, Frostbite A. B. C. D.

Avoid unnecessary manipulation of frostbitten tissue.

Frozen tissue should be rewarmed totally and as quickly as possible Do not thaw tissue if there is a possibility of it re-freezing.

Transport frostbitten patients as early as possible

Nausea and Vomiting

For continuous nausea and vomiting without a decrease level of consciousness, head trauma, or drug overdose.

A. Use appropriate airway management.

B. Place patient on cardiac monitor (Advanced EMT, Paramedic) C. Initiate IV of 0.9 NS at 25cc/hr (Advanced EMT, Paramedic) D. If signs of dehydration are present, administer a 20cc/kg 0.9 % Sodium Chloride fluid bolus. (Advanced EMT, Paramedic) (Dilute equal amount of 0.9 % Sodium Chloride.

E. Administer 4 mg of Zofran IV/ IM (Paramedic)

Pain Management - Pain is based on the patientâ&#x20AC;&#x2122;s complaint, not the subjective opinion of the EMT. However, use discretion with suspected pain medication abusers.

Use the pneumonic O P Q R S T (O - onset, P - provocation, Q - quality, R - radiation, S severity [pain scale], T - time of onset) during the assessment of pain.(EMT-B, EMT-I, EMT-P) All patients are to be evaluated using the pain scale (0-10 with zero meaning no pain and ten meaning the worst pain ever experienced) prior to and following administration of Morphine Sulfate.

Indications (Adult Patients Only)

Acute burns - second and/or third degree Kidney Stone(s) - patient has previous history of kidney stone(s) and the current presentation mimics previous episode(s) Orthopedic Injuries - patient presents with an obvious or suspected acute- isolated fracture or dislocation

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Contraindications:

Do not administer Morphine Sulfate if: the systolic blood pressure is less than 100 mmHg the patient presents with a headache or head trauma the patient presents with multiple systems trauma the chest pain is not cardiac in nature the patient has taken other medications the patient has been drinking alcohol

Dosage A. Initiate an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) (Advanced EMT, Paramedic) B. Attach cardiac monitor (Advanced EMT, Paramedic) C. Administer Morphine Sulfate 2 mg IV over a one minute period. (Paramedic) D. Morphine Sulfate may be titrated in 2 mg increments every 3 - 5 minutes up to a total of 10 mg or patient becomes pain free. (Paramedic) NOTE:

1. Vital signs and pain scale must be assessed prior to and after each dose of Morphine Sulfate as noted above.

2. For nausea and vomiting associated with the Morphine Sulfate administration of 4 mg of Zofran IV/ IM may be considered.

(Paramedic)

Toxicity of Morphine Sulfate If the patient experiences respiratory depression or apnea following Morphine Sulfate administration: Assist ventilations using a bag-valve-mask with high flow oxygen at a rate of 12 20 ventilations per minute.

Administer Narcan® (naloxone hydrochloride) 0.4 mg IV bolus (Advanced EMT, Paramedic) If the patients respiratory status does not improve, Narcan® 0.4 mg may be repeated every 2 to 3 minutes until the patients condition improves or a total of 2 mg has been administered (Advanced EMT, Paramedic) Caution If the patient is on narcotic medications on a daily basis (whether prescribed or illegal) and following administration of Morphine Sulfate the patient develops respiratory depression or arrest, be careful in administering Narcan®. Consider withholding Narcan® and support ventilations with a BVM or endotracheal intubation. Narcan® can precipitate violent reactions with chronic narcotic users.

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.

Pre-Term Labor (before 36 weeks) Initiate IV of 0.9% Sodium Chloride and administer 1000 ml wide open, if no indication of hypertension, pre-eclampsia or obvious edema. (Advanced EMT, PAramedic)

Respiratory Distress (nasal flaring, tracheal tugging, intercostals retraction, use of accessory muscles or cyanosis) A.

Assure an open airway. Apply pulse oximeter for continuous monitoring. Initiate oxygen therapy to maintain a pulse oximeter rate of 95%. Be ready to assist breathing as necessary. (EMT, Advanced EMT, Paramedic)

B.

Auscultate the lungs and obtain a SAMPLE history. If the underlying cause is apparent (anaphylaxis, CHF, etc.) treat according to specific protocol.

(Paramedic)

C.

Initiate an IV infusion of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) (Advanced EMT, Paramedic)

D.

If there are no contraindications, administer Albuterol (Proventil®, Ventolin® 2.5mg by nebulized mist. The oxygen flow should be set high enough to produce a continuous mist from the mouthpiece. Assist the patient and teach the patient to breathe the mist in while inhaling deeply on the mouthpiece, and to exhale through the nose. Observe for any side effects. The treatment is complete when the nebulizer no longer mists. If no change in the patient’s condition administer Ipratropium Bromide (Atrovent®) 500 mcg per nebulized mist. Additional treatments of Albuterol and or Ipratropium Bromide may be given with permission from the TF. (Advanced EMT, Paramedic) OR If the patient is not exchanging sufficiently to use the aerosol and is cyanotic and in severe respiratory distress, administer Epinephrine (Adrenalin®) 0.3 cc of 1:1,000 solution sub-Q.(Advanced EMT, Paramedic)

E.

If inhalation of hazardous substances is a possible cause, notify the TF of the causative agent so the TF can consider consultation with the Poison Control Center. (EMT, Advanced EMT, Paramedic)

F.

If the patient becomes unconscious and the gag reflexes are absent, insert an ET tube unless contraindicated. (Advanced EMT, Paramedic) If necessary, nasal intubation or conscious intubation can be utilized. (Paramedic) Nasal intubation can be accomplished by lubricating the ET tube with lidocaine gel and utilizing a BAAM whistle tip device. Conscious intubation can be accomplished by administering Versed (Midazolam) 2mg and Succinylcholine 0.5-1.0 mg/kg can be used. (Paramedic) If the upper airway is obstructed and unable to be cleared by any other maneuver, and only as the very last resort, perform a surgical cricothyrotomy. (Paramedic)

40

Seizure Activity (Convulsions) Protect the patient from injury. (EMT, Advanced EMT, Paramedic) Maintain an open airway. Insert an oropharyngeal airway. Do not force if the teeth are clamped shut. A nasopharyngeal airway may be used. (EMT, Advanced EMT, Paramedic) Apply oxygen and maintain SpO2 at 95 % (EMT, Advanced EMT, Paramedic) If present when the seizure begins, note and record the body area in which the activity begins.(EMT, Advanced EMT, Paramedic) Obtain a SAMPLE history.

Perform venipuncture, draw blood samples and obtain blood glucose reading. (Advanced EMT, Paramedic) If the reading is 60 or less, treat according to the Hypoglycemia Protocol. In a patient who is unconscious (or was unconscious prior to squad arrival), initiate an IV of 0.9% Sodium Chloride at a keep open rate (25 cc/hr) If signs of shock are present, run the IV at a rate to maintain a systolic BP of 100 mmHg. Consider the need for Thiamine therapy.

If status epilepticus (continuous, uncontrolled convulsions or no period of consciousness between convulsions) occur, administer Lorazepam (AtivanÂŽ) 4 mg IV bolus over 1-2 minutes (Dilute with equal amount of 0.9 % Sodium Chloride.). Can be repeated once in 10-15 minutes. Observe respirations and be ready to assist with breathing, Contact the TF as soon as possible. (Advanced EMT, Paramedic) If an IV cannot be initiated, administer Lorazepam 4 mg IM. (Advanced EMT, Paramedic) Can be repeated once in 10-15 minutes. Repeat doses through the approval of Medical Control.

Suspected Drug Overdose Maintain an open Airway.

Utilize airway adjuncts as indicated. (EMT-B, EMT-I, EMT-P) Insert an ET tube if the airway reflexes are absent.

Obtain blood samples. (EMT-I, EMT-P) Initiate an IV of 0.9% Sodium Chloride and run at a keep open rate (25 cc/hr).

Test the patientâ&#x20AC;&#x2122;s blood with a glucometer, If the sugar is 60 or less, proceed with the Hypoglycemia Protocol. (Paramedic) Maintain a systolic BP of at least 100 mmHg. Recheck the blood pressure often.

Obtain any bottles, syringes, etc. containing drugs possibly taken; take these to the TF with the patient.

Contact the TF for consultation regarding specific therapy. Do not spend time trying to contact the Poison Control Center. The TF will consult Poison Control as needed.

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All Unconscious Patients A. Maintain an open airway (use the jaw thrust technique if neck trauma is suspected).

1. Utilize airway adjuncts as indicated. (EMT, Advanced EMT, Paramedic) 2. Check pulse oximeter reading. Apply oxygen to maintain a pulse oximeter reading of at least 95%, except if the patient has a known history of severe COPD, apply oxygen at 2 L/minute via nasal cannula only if pulse oximeter reads 92% or below, and be prepared to assist breathing. (EMT, Advance EMT, Paramedic) 3. If airway reflexes are absent, insert an ET tube (Advanced EMT, Paramedic), with appropriate C-spine immobilization (if indicated).

4. If the respiratory rate slows and/or the effort becomes shallow, intubate the patient, with appropriate C-spine immobilization (if indicated) (Paramedic), and assist breathing.

B. Immobilize the C-spine if patient has fallen from the standing position, or if there is any suspicion of injury to the head or neck. (EMT, Advanced EMT, Paramedic) C. Initiate monitoring of the cardiac rhythm. (Advanced EMT, Paramedic) D. Make a venipuncture and obtain blood samples. (Advanced EMT, Paramedic) E. Initiate an IV of 0.9% Sodium Chloride and run at a keep open rate (25 cc/hr.)

F. Test the patientâ&#x20AC;&#x2122;s blood glucose. (EMT, Advanced EMT, Paramedic) If the blood sugar is less than 60, proceed with the Hypoglycemia Protocol. (Paramedic) G. If the patient is likely to be an alcoholic or is likely to be anorexic or on strict dietary restrictions, administer 100 mg Thiamine IV. If no IV is established, administer 100 mg Thiamine IM.(Paramedic) H. Alcoholism should be suspected in patients where bystanders or family members divulge a history of alcoholism, where there is the presence of jaundice or spider veins, or where there is physical evidence that the patient has been consuming alcohol.

I. Maintain a systolic BP of 100 mmHg. Recheck the blood pressure often.

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General Guidelines for Trauma Care ( EMT, Advanced EMT, Paramedic ) A.

The on scene time should not exceed 10 minutes unless additional time is necessary for extrication and/or additional extenuating circumstances.

B.

Airway management with cervical spine immobilization is the first priority.

C.

High flow oxygen should be delivered by non-rebreather mask, BVM, ET tube, or King Airway when appropriate.

D.

Control blood loss.

E.

Advise receiving facility of the patient’s status and treatment as soon as possible.

F.

While enroute establish two IV’s of 0.9% Sodium Chloride with large bore needles (14 - 16 gauge if possible) For a trauma arrest, treat the cause after transport begins. Only tension pneumothorax ( needle decompression) (advanced EMT, Paramedic) and hypovolemia should be treated on scene before transport.

G.

External blood loss amount should be estimated and noted.

H.

Capillary refill is a general indicator of shock. Be aware that body and weather temperature extremes may affect capillary refill times.

I.

Blood pressure decrease is virtually always a late sign of shock. Use pulse location for a rapid estimation of the patient’s blood pressure (Radial-approx. 80 mmHg systolic; Carotid-approx. 60 mmHg systolic.)

J.

Cold IV fluids must be warmed. Hot packs attached to the fluid bags and wrapped around the IV tubing will warm fluids to some extent.

K.

Transport should not be delayed in any case of severe trauma.

L.

Walking patients whose mechanism of injury indicates need for immobilization should be secured to a backboard while in the standing position.

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Protocol for Trauma Care Assessment is the key skill in pre-hospital trauma care. Rapid examination of the patient to recognize life-threatening and potentially life-threatening injuries is essential.

I.

II.

Scene Survey - (EMT, Advanced EMT, Paramedic) A.

Note any possible hazards to the crew, the patient and/or bystanders (do not enter an area that you determine unsafe.) Request additional agencies as needed. (i.e. PD, FD, electric company)

B.

Note the mechanism of injury and the number of victims.

C.

If the situation necessitates use of bio-hazard protection gear, it must be donned prior to entering the scene or coming into contact with the patient.

Primary Assessment - Do not proceed in the assessment until the current step is appropriately managed and maintained. (EMT, Advanced EMT, Paramedic) A.

Open the airway while applying manual, in-line cervical stabilization and assess the level of consciousness using the AVPU scale.

B.

If the airway is compromised perform any necessary techniques (e.g.: suctioning, manual jaw thrust maneuver, etc.) to open and maintain it.

C.

Assess the quality of breathing.

D.

If the rate or depth is abnormal, expose the neck and chest to visualize any potential cause(s) and treat accordingly (e.g.: decompress a tension pneumothorax using the second or third intercostal space at the mid-clavicular line approach, stabilize a flail segment, occlude sucking chest wound, etc.)

E.

If indicated apply oxygen and maintain SpO2 of 95 %

F.

Check the circulation by palpating the radial and carotid pulses simultaneously.

G.

Control hemorrhage using direct pressure, elevation, cold application, digital pressure and as a last resort, tourniquet.

H.

Check the skin noting temperature, color, moisture, and capillary refill.

I.

Establish the patientâ&#x20AC;&#x2122;s responsiveness if not already done. (This may be performed anytime during the assessment.)

A : Alert V : Verbal Stimuli P : Pain Stimuli U : Unresponsive

If life threatening injuries exist: (difficulty with ventilation, circulation or a decreased level of consciousness)

44

III.

PREPARE TO TRANSPORT: 1. Apply a cervical collar (after checking the neck for distended veins, the position of the trachea, etc.) and continue manual, in-line cervical stabilization. If unable to apply a cervical collar, maintain stabilization and use a blanket roll and head immobilizer to secure the patient to a backboard. Manual stabilization must be maintained.

2. If the patient is still in a vehicle, perform a rapid extrication.

3. Rotate the patient as a unit onto a long backboard. Pad the board to the patient to utilize it as a full body splint.

4. If indicated and not already done, perform in-line endotracheal intubation with close attention to in-line cervical stabilization. (Paramedic) 5. If in-line intubation is not feasible and the airway is still compromised, and all other options have been attempted and failed, initiate a surgical cricothrotomy only as a last resort in airway management. (Paramedic) 6. While enroute to the TF, prepare and initiate 2 large bore needles (14-16 gauge preferred) IV’s of 0.9% Sodium Chloride and obtain blood samples. Run the IVs at a rate to maintain a systolic BP of 90-100 mmHg. (Advanced EMT, Paramedic) 7. Reassess the ABC’s frequently.

8. Complete the full secondary survey if the patient’s condition allows.

IV.

If no life threatening injuries exist: Complete the full secondary survey, and the normal splinting, immobilization, and extrication procedures as indicated.

The application of a cervical collar is always indicated by the mechanism of injury, not necessarily by a specific patient complaint or neurologic deficit.

The application of cervical collars always requires the immobilization of the patient to a back board with additional head/neck stabilization. This allows the patient to be turned to the side, without injury to the spine, to help clear the airway.

If a “load and go” situation is found in the secondary assessment (distended abdomen, pelvic instability, etc.) immediately prepare the patient for transport and finish the assessment enroute.

45

V.

IMMOBILIZATION A.

If a life threatening injury is detected during the primary survey, do not immobilize individual injuries other than the cervical spine. Utilize a backboard, cervical collar and cervical immobilization device (CID) as a “body splint.”

B.

If no life threatening injury is found, or if life threatening injuries have been corrected and transport time permits, immobilization should be instituted utilizing the following principles: 1. Always perform a pulse, motor, and sensory check both prior to and after immobilization. Document all findings.

2. Any painful injury of the soft tissue or the musculoskeletal system should be immobilized until evaluated at the TF regardless of the presence or absence of an obvious deformity.

3. Immobilization should be done in the midline position unless a joint is involved, there is severe pain, or resistance is encountered. In these situations splint the injury in the position in which it is found.

4. Splinting should always include the joint above and the joint below the fracture site.

5. Board, ladder or other rigid splints should be padded. Pillow splints may be useful in immobilizing unusually angulated fractures or joint injuries where the limb cannot be straightened.

6. Traction splints should be used only for fractures to the shaft of the femur. Do not pull protruding bone ends back into the wound if the fracture is open. Do not use a traction splint for hip fractures or lower leg fractures.

7. A SAM® Sling should be utilized on all suspected pelvic fractures.

VII.

WOUND CARE A. Control bleeding by direct pressure. Elevation and cold application may also be utilized. If severe bleeding continues use digital pressure. A tourniquet should be a last resort.

B. Do not replace protruding organs into the wound. Cover them with a sterile dressing and keep them moist with saline.

C. Do not remove impaled objects. Stabilize them with bulky dressings. (Exception: penetrating objects into the facial cheek and the airway is compromised or the penetrating object is in the chest and CPR can not be performed without it’s removal.)

46

D. Brush loose foreign matter away from the wound with 4x4s, or use forceps to avoid cutting yourself. Do not pick out debris or particles imbedded in the wound. Skin flaps may be folded back to a normal position. If it is necessary to rinse dirt from wound, use a sterile saline solution.

E. Sterile Normal Saline solution should be used as the routine irrigating solution for all injuries (wounds, eyes, etc.)

F. Apply a sterile dressing to the wound and bandage it in place. (If there is a likelihood that CSF is mixed with blood, or if the wound is on the head or neck, apply the bandages loosely unless pressure is necessary to control arterial bleeding.) Leave fingers and toes visible whenever possible so that capillary refill can be checked.

G. Cover open pneumothorax with an Asherman Seal H. Recheck distal pulse; note the skin color, temperature, and any swelling.

Document all findings. Adjust the bandages and immobilization as necessary.

VIII.

HEAD INJURIES A.

Assess the ABC’s and stabilize the C-spine.

B.

Document the level of consciousness (LOC): Alert, Verbal, Painful, Unresponsive (AVPU), and orientation to person, place and time.

C.

Check the pupils.

D.

Check voluntary muscle control, (hand grip, extremity movement, etc.) and sensory function (pain and touch.)

E.

In the presence of any abnormal functions, particularly, Cushing’s Reflex, Herniation Syndrome, (unequal pupils) posturing, and/or abnormal breathing patterns, perform the following: 1. Administer high flow oxygen via NRM (if not already established.)

2. Hyperventilate adult patient 20/minute with 100% oxygen by bag-valve-device.

3. Establish an IV of 0.9% Sodium Chloride at a keep open rate. (25 cc/hr.) If the systolic BP is below 70 mmHg, treat for shock. (Isolated head injuries rarely cause shock. If the patient is in shock it is usually from some other injury.) Do not push the systolic BP over 90-96 mmHg. (Higher BP may increase the intracranial pressure and worsen the injury.) (Advanced EMT, Paramedic).

4. Transport with the head slightly elevated. (Use a backboard with a cervical collar in place) 5. Continue to reassess the ABC’s and LOC every 5-10 minutes.

6. Document all findings.

47

IX.

BURNS A. Know and utilize the appropriate safety/protection methods for flame, chemical, electrical, radiation, and inhalation burns. Do not attempt a rescue beyond the constraints of policy and training. (EMT, Advanced EMT, Paramedic) B. Assess the ABC’s (with cervical spinal immobilization if indicated.)

C. Stop the burning process: Remove contact with the agent unless the agent is adherent to the patient’s skin (e.g. hot tar). Remove all clothing. Brush off particulate matter. (EMT, Advanced EMT, Paramedic) D. For flame/electrical burns, cool the injury with sterile saline for 1 minute only.

Do not create hypothermia. (EMT, Advanced EMT, Paramedic) E. For chemicals burns, brush off powders (if not contraindicated by the HAZMAT policy.) If the agents are not water reactive, flush them with copious amounts of water or Normal Saline. Wear protective covering.

F. Assess the degree and extent of burns utilizing the rule of nines. The patient’s palm is approximately 1% of the total body surface area. This can be used to estimate the size of smaller burns.

G. Classify burns based on percentage of total body surface area and degree of burn: Minor <15% 2◦ in adults. <10% 2◦ in children. <2% 3◦ in anyone.

Moderate 15-25% 10-20% 2-10%

Critical >25% 2◦ in adults. >20% 2◦ in children. >10% 3◦ in anyone.

All electrical burns.

All inhalation injuries.

All burns with other associated injuries.

All high risk patients (elderly adults, small Children or anyone in poor health).

2◦ in adults 2◦ in children 3◦ in anyone.

H. Contact the TF for instructions regarding wet or dry dressings. Always use sterile dressings or sterile burn sheets (EMT, Advanced EMT, Paramedic) I. If unable to contact the TF, use dry dressing except for small areas of the hands or feet, which may be immersed in cool saline or wrapped in cool, moist sterile towels (EMT, Advanced EMT, Paramedic) J. Initiate high flow oxygen via NRM if any smoke inhalation is suspected. Treat respiratory distress according to established protocols. (EMT, Advanced EMT, Paramedic) K. If the patient is unconscious, intubate early to avoid possible tracheal occlusion by laryngeal edema. (Paramedic) L. Attach the cardiac monitor and treat dysrhythmias accordingly. (Paramedic) 48

M. Protect the burned areas. (EMT, Advanced EMT, Paramedic) 1.

2.

3.

4.

Do not break blisters.

Remove all restrictive clothing and jewelry.

Do not remove any adherent materials.

Do not apply any antiseptics, ointments, etc.

N. For moderate or critical burns, initiate an IV of 0.9% Sodium Chloride. Run at an hourly rate equal to the patientâ&#x20AC;&#x2122;s body weight (in kg) times the percentage of burn surface area divided by 8. (eg. A 70 kg patient with a 9 % total body surface area burn would have an IV rate of 70x9/8=630/8=80 cc/hr.) (Advanced EMT, Paramedic) X.

AMPUTATED PARTS (limbs, soft tissue, skin flaps, etc.)

A.

Perform the primary survey and treat any life threatening injuries.

B.

If the transport time is short, wrap the part in a sterile (or at least clean) towel or sheet and transport the part to the TF dry.

C.

If the transport time is prolonged: 1. Rinse the parts with Normal Saline.

2. Wrap the parts in sterile gauze dampened with Normal Saline.

3. Place the wrapped parts in a plastic bag.

4. Place the bag on a cold pack (or crushed ice, if available) for transport.

5. Never freeze the parts.

6. Never allow the parts to come in direct contact with the ice.

7. Never float the parts in solution, except teeth, which should be floated in normal saline.

8. Never use antiseptics or other solutions on the parts.

D.

Incomplete amputations should be splinted in the position found. Control hemorrhage in the usual manner.

E.

Never let the preparation of an amputated part distract you from the care of the patient.

49

XI.

NEAR-DROWNING (Respiratory or cardiac arrest under water.)

A.

Resuscitate all cold water victims with less than one hour submersion.

B.

Resuscitate all warm water victims with less than 30 minutes submersion.

C.

Resuscitate all victims with unknown time of submersion regardless of water temperature. (unless rigor mortis or other obvious signs of death are apparent.)

D.

Stabilize the neck and spine (even prior to removal from the water if it can be done safely.)

Begin rescue breathing in the water if possible. (EMT, Advanced EMT, Paramedic)

E.

Maintain an open airway (use the jaw thrust technique if neck trauma is suspected.)

1. Utilize airway adjuncts as indicated. (EMT, Advanced EMT, Paramedic) 2. Insert an ET tube, with appropriate C-spine immobilization, if airway reflexes are absent. (Paramedic)

F.

Apply oxygen and maintain SpO2 of 95 %. Assist with breathing as needed.

G.

Begin cardiac compressions if no pulse is present.

H.

Use Heimlich maneuver only if the airway is blocked.

I.

Manually decompress a distended stomach with gentle hand pressure only if the abdominal distention interferes with airway exchange. Be certain that patient is turned to the side to avoid additional insult to the airway. (EMT, Advanced EMT, Paramedic)

J.

Strip off all cold, wet garments. Keep the patient warm.

K.

Connect the patient to the cardiac monitor. Treat any dysrhythmias according to the corresponding algorithm, unless patient is hypothermic, then follow Hypothermia Protocol. (Paramedic)

L.

Initiate an IV of 0.9% Sodium Chloride solution at a keep open rate (25 cc/hr.)

(Use D5NS if the patient is hypothermic. Titrate the IV rate to maintain a systolic BP of 100 mmHg. (Advanced EMT, Paramedic). Consider the need for Thiamine therapy. (Paramedic)

50

XII.

BITES AND STINGS (EMT, Advanced EMT, Paramedic) A. Assure an adequate airway. Apply high flow oxygen via NRM and be ready to assist ventilations as needed B. Watch for anaphylaxis or shock. Treat according to the corresponding protocol.

C. Identify the cause of the injury (snake, insect, etc.) and bring it to the TF if possible.

D. Get a S.A.M.P.L.E. history including the amount of time since bite/sting.

Signs/Symptoms Allergies Medicines Past medical history Last oral intake Events surrounding the injury E. Assess the wound noting its location and appearance. Be certain to note the patientâ&#x20AC;&#x2122;s pulse, skin, pulmonary, cardiac, and neurological status.

F. Contact the TF for specific orders. (The TF will contact the Poison Control Center as indicated. This saves valuable time for the squad.)

G. Keep the patient at rest, and allow the patient to have nothing by mouth (NPO.) H. Recheck vital signs every 5 minutes.

I. Apply a constricting band proximal to the snake bite or insect sting if it is on an extremity. Recheck this often to be sure distal pulse remains palpable.

J. Do not apply a cold pack to a snake bite or a possible poisonous spider bite. Cold may increase the chance of tissue necrosis. Cool compress or a Sting EaseÂŽ swab may be applied to insect stings to ease pain.

51

XIII.

POISONING (EMT-B, EMT-I, EMT-P) A.

HYDROCARBONS INGESTION 1. Do not induce vomiting.

2. Administer high flow oxygen if the patient is in respiratory distress or wheezing.

3. Contact the TF for specific orders. (The TF will contact the Poison Control Center as indicated. This saves valuable time for the squad.)

B.

INSECTICIDES (Organophosphate and Carbamate) 1. Administer high flow oxygen via NRM (except do not give oxygen to victims of paraquat poisoning) if the patient is in respiratory distress or wheezing.

2. If there is skin exposure, have patient, if able, remove all clothing and shower at the scene. If needed have the Haz-mat Response or Fire Department in protective gear assist them. JCEMS personnel should put on disposable, protective coveralls to prevent trace amounts of substance which may be left after field decontamination of the patient from coming in contract with skin or clothing.

3. Contact the TF for specific orders. (The TF will contact the Poison Control Center as indicated. This saves valuable time for the squad.)

4. Be sure to advise TF early that a patient who has been field 5. decontaminated is coming in, so they can institute their procedures to avoid cross-contamination.

C.

ACID/ALKALI INGESTION 1. Do not induce vomiting.

2. Administer high flow oxygen via NRM if the patient is in respiratory distress or wheezing.

3. Contact the TF for specific orders. (The TF will contact the Poison Control Center as indicated. This saves valuable time for the squad.)

4. Do not give the patient any oral fluids (NPO.)

D.

CARBON MONOXIDE INHALATION 1. Administer high flow oxygen via NRM. 2. Contact the TF for specific orders. (The TF will contact the Poison Control Center as indicated. This will save valuable time for the squad.

3. Remember: pulse oximetry reading may be normal, since the Carbon Monoxide displaces oxygen and saturates the hemoglobin.

52

Protocol for the Treatment and Transport of Minors Below the Age of Eighteen Definition:

A minor is a person less than 18 years of age.

A minor not requiring parental consent is a person who: >Is married >Is emancipated by marriage or enters military service.

(Pregnancy and childbirth out of wedlock does not constitute emancipation in Ohio)

Refusal of Medical Assistance (RMA) An individual who is legally a minor cannot give effective legal/informed consent to treatment and therefore, conversely, cannot legally refuse treatment.

Legal Representative A person who is granted custody or conservatorship of another person by a court of law. (A law Enforcement Officer does not qualify as a Legal Representative) Consent: A. Voluntary Consent- Treatment or transportation of a minor child shall be with the consent of the parent of legal representative.

B. Involuntary Consent- In the absence of a parent or legal representative, emergency treatment and/or transport of a minor may be initiated without consent “Whenever a question arises as to whether a patient requires transport, the Emergency Department of the hospital to which the patient would be transported should be contacted and advised of the patient’s condition. If the physician on duty authorizes that the patient NOT be transported, this must be fully recorded and documented.”

If the physician authorizes you not to transport, the patient should be released into the custody of: 1. Law Enforcement 2. A responsible adult at the scene (i.e. school bus driver, grandparent, pastor, neighbor, etc.)

3. Designated Care-giver Complete documentation including the physician’s name, how the physician was accessed, etc. must be noted on the run report.

53

When communications fail or are unavailable, the minor patient is to be transported.

Under no circumstances will a JCEMS’ squad delay transport while awaiting the arrival of a parent or legal representative for refusal purposes. If the physician states that the patient(s) should be transported, then the patient should be treated and transport started within the normal on-scene time limit of 20 minutes. Parents and legal representatives can be delayed enroute, delaying the care that may be required for children and minors. (Just as we don’t wait at scene for helicopters, we don’t wait at scene for parents) Under no circumstances will a JCEMS’ squad, while enroute to a treatment facility; discontinue transport because of being flagged over by a parent or legal representative. Transport should continue, and the parent or legal representative can meet the squad at the treatment facility where they can decide to allow their child to be treated or to withdraw consent for treatment.

Under no circumstances will a JCEMS squad or a JCEMS dispatcher accept a “phone refusal”.

There is no way to determine whether the person on the telephone is the actual parent or legal representative, and further, the parent or legal representative is not “on-scene” and able to see the extent of injury or illness. The parent or legal representative should be told which hospital their child is being transported to and encouraged to meet the squad at that facility.

OTHER ISSUES INVOLVING MINORS Occasionally, upon arrival at the scene of an emergency, there will be an adult patient with a minor child that is not ill or injured. In the event that the adult patient requires transport, and there is no responsible adult to leave the child with, the minor child should be transported with the adult patient to the appropriate treatment facility. The minor child should be buckled into a seat belt or the squad’s inflatable car seat, as appropriate.

The dispatcher is responsible for area coverage, and moving vehicles as appropriate to provide the best coverage. Paramedics are to act in the patient’s best interest, and should err on the side of caution.

54

Pediatric Protocol for Initiation of Intravenous Fluid Therapy (Advanced EMT, Paramedic)

General Guidelines A. These protocols apply to individuals under 13 years of age who weigh less than 100 pounds.

B. The authority for IV therapy or other necessary emergency treatment on children who do not have a parent or guardian present is by implied consent and the protocol should be followed. IVs on multiple trauma patients should be started enroute unless prolonged extrication is required.

Prep the site with a Providone-iodine (Betadine®) pad followed by an alcohol pad. If the patient is allergic to Iodine, use alcohol only.

C. No more than two peripheral IV attempts are to be made unless the child’s condition is critical or the transport time is excessive.

D. Establish an IV of 0.9% Sodium Chloride with the largest gauge angiocath compatible with vein size.

E. See “Protocol for Initiation of Intravenous Fluid Therapy,” General Guidelines for adults page 24.

F. Intraosseous access in pediatric patients (6 and under) in cardiopulmonary arrest may be established without attempting a peripheral IV. (Advanced EMT, Paramedic) Maintenance Rate-

4 ml/kg/hr for each kg up to 10 kg 2 ml/kg/hr for each kg from 10-20 kg 1 ml/kg/hr for each kg above 20 kg OR 2 ml/lb/hr for each lb up to 20 lb 1 ml/lb/hr for each pound form 20-40 lb 0.5 ml/lb/hr for each pound over 40 lb

Example, the patient weighs: 55 lb or 25 kg For the: first 20 lb of body weight = 40 ml/hr first 10 kg of body weight = 40 ml/hr second 20 lbs of body weight = 20 ml/hr second 10 kg of body weight = 20ml/hr, last 15 lbs of body weight = 7.5 ml/hr, last 5 kg of body weight = 5 ml/hr Total volume to be infused = 67.5 ml/hr = 65 ml/hr

55

Specific Guidelines for Pediatric Conditions ANAPHYLAXIS- 0.9% Sodium Chloride at the maintenance rate.

CARDIOPULMONARY- 0.9% Sodium Chloride at a keep open rate of 0.5 ml/kg/hr (0.25 cc/lb/hr.) A keep open rate should not exceed 25 ml/hr.

CEREBRAL AND SPINAL INJURY- 0.9% Sodium Chloride starting at 2/3 the maintenance rate. Do not push the systolic BP over 90 mmHg. (A higher BP may increase the intracranial pressure and worsen the injury.) Treat shock aggressively with fluid therapy despite head injuries.

DRUG OVERDOSE- 0.9% Sodium Chloride at the maintenance rate. Adjust the rate to maintain a systolic BP of at least 100 mmHg. FLUID CHALLENGE BOLUS- 20 ml/kg or 10 ml/lb.

HYPOGLYCEMIC REACTION- 0.9% Sodium Chloride at the maintenance rate.

TRAUMA- 0.9% Sodium Chloride at a rate titrated to maintain a systolic BP of 90-100 mmHg. A safe fluid replacement level is the maintenance rate. For severe shock the rate may be increased to twice the maintenance rate. Use fluid challenges to raise the BP. Fluid therapy is indicated in trauma cases including: 1.

2.

3.

4.

5.

Severe burns Severe bleeding Hip or femur fracture Symptoms of shock with no obvious sign of injury Mechanism of injury indicating potential for patient deterioration.

Pediatric Protocols for Medical Emergencies I.

Anaphylaxis A. Open the airway and assist breathing if necessary. Administer humidified oxygen and maintain SpO2 of 95 % (EMT, Advanced EMT, Paramedic) B. Administer Epinephrine (Adrenaline速) 1:1,000 solution, 0.01 ml/kg (0.05 cc/10 lbs) body weight Sub-Q. {0.01 mg/kg} (Advanced EMT, Paramedic) C. Initiate an IV of 0.9% Sodium Chloride at the maintenance rate and titrate the rate to maintain a systolic BP of 100 mmHg. (Advanced EMT, Paramedic) D. Administer Diphenhydramine (Benadryl速) 0.02 ml/kg (1mg/kg) of body weight IV bolus. (If unable to initiate an IV, Diphenhydramine may be given IM.) { 1 mg/kg} (Advanced EMT, Paramedic) E. Repeat Epinephrine (Adrenaline速) in 5 minutes if necessary. (Advanced EMT, Paramedic)

56

II.

Acute Asthmatic Attack A. Unless the child is in severe distress, avoid any unnecessary agitation of the child. This may mean that IV’s, venipuncture and even supplemental oxygen be withheld. (Consider allowing mom and dad to hold oxygen or nebulizer by “blow by”.)

B. Open the airway and assist breathing if necessary. Administer humidified oxygen via oxygen mask at 10-12 L/min. (EMT, Advanced EMT, Paramedic) C. Obtain a recent history regarding use of bronchodilating medications.

D. Obtain the patient’s vital signs and perform a rapid neurological assessment (does the child recognize the parents, is the child flaccid or does the child have a good fight, etc.). Note any use of accessory muscles for breathing, wheezing, grunting or strider.

E. If there are no contraindications, administer Albuterol (Proventil®, Ventolin®) 1.5 ml {1.25 mg} by nebulized mist. The oxygen flow should be set high enough to produce a continuous mist from the mouthpiece. Assist the patient to breathe the mist in while inhaling deeply on mouth piece and to exhale through the nose. Observe for any side effects. The treatment is complete when the nebulizer no longer mists. The mask may be held near the face if the child is unable to cooperate and/or resists the full face mask. If the patient has already taken an albuterol treatment prior to the squad arrival without relief or an Albuterol treatment is administered by the paramedic and the patient’s condition has not improved, a 250 mcg unit dose of Ipratropium Bromide (Atrovent®) may be administered by nebulized mist. Additional treatments of Albuterol and or Ipratropium Bromide may be given with permission from the T.F. (Advanced EMT, Paramedic) Administer a continuous Proventil nebulized treatment by placing 2 (two) doses of Proventil in the nebulizer and providing a nebulized mist during transport.

Or If the patient is not exchanging sufficiently to use the aerosol and is cyanotic or in severe respiratory distress, administer Epinephrine (Adrenalin®) 1:1,000 solution, 0.01 ml/kg (0.05 cc/ 10 lb) of body weight Sub-Q. {0.01 mg/kg} (Advanced EMT, Paramedic) F. Initiate an IV drip of 0.9% Sodium Chloride at twice the maintenance rate and titrate the rate to maintain a systolic BP of 100 mmHg. (Advanced EMT, Paramedic)

III.

Cardiac A. General Guidelines 1. Most cardiac arrhythmias are due to inadequate oxygenation, respiratory distress and/or hypothermia. Therefore, a patent airway, adequate oxygenation and ventilation and a warm environment are necessary for restoring a viable rhythm.

2. Open the airway and assist breathing if necessary. Administer humidified oxygen and maintain SpO2 of 95 % (EMT, Advanced EMT, Paramedic) 3. Obtain the patient’s vital signs (including the apical and brachial pulse rates over one full minute) and obtain a SAMPLE history from the primary care giver.

4. Place the chest electrodes in the lead II position for constant monitoring and assess the cardiac rhythm. Obtain 12 lead EKG on all potential cardiac patients and transmit to receiving facility if the treatment facility is equipped. (Paramedic) 57

5. Initiate an IV of 0.9% Sodium Chloride and run at a rate of 0.5 ml/kg (0.25 cc/lb/hr). The keep open rate should not exceed 25 ml/hr. (Advanced EMT, Paramedic) 6. Continue squad monitoring of vital signs, and watch for changes in the EKG. (Paramedic) 7. Transport pediatric cardiac patients as soon as possible.

8. Treat the following complications: B.

Acute Congestion Heart Failure or Pulmonary Edema 1. Keep the child in the sitting position.

2. Assure adequate ventilation and oxygenation.

3. Administer Furosemide (Lasix®) 0.1 ml/kg (0.5 ml/10 lbs) body weight IV. (Furosemide may be given IM if an IV is not available) {1 mg/kg} (Paramedic) 4. Monitor the patient’s vital signs. (EMT, Advanced EMT, Paramedic)

C.

Cardiogenic Shock - a child with cardiac decompensation who has progressed to obvious signs of shock.

1. Assure adequate ventilation and oxygenation.

2. Mix Dopamine 400 mg into 250 ml 0f 0.9% Sodium Chloride{26.6 mcg/minidrop} is used initiate the drip at a rate of 0.5 minidrops/kg/min (0.25 minidrops/lb/minute) {13.3 mcg/kg/min} (Paramedic) 3. Titrate the Dopamine drip to maintain a systolic BP of 100 mmHg. (Paramedic) 4. Monitor the patient’s vital signs every minute (EMT, Advanced EMT, Paramedic)

D.

PVCs - that are coupled, in bursts, occur more than 6/minute or are multifocal.

1. Provide oxygen and ventilation as needed. (EMT, Advanced EMT, Paramedic) 2. Administer a Lidocaine bolus of 0.5 ml/kg (2.5 ml/ 1 lb) body weight IV or IO {1 mg/kg}(Paramedic) 3. If pre-mixed Lidocaine {66.6 mcg/minidrop} is used, start the drip at 0.5 minidrops/kg/minute (0.25 minidrops/lb/minute) {33.3 mcg/kg/minute 13.3 mcg/lb/minute} and titrate the rate to the desired response. Do not exceed 1 minidrop/kg/minute (0.5 minidrops/lb/minute) (Paramedic) 4. Administer a second bolus of 0.5 ml/kg (2.5 ml/10 lb) body weight IV or IO 15 minutes after first bolus if PVCs continue. {1 mg/kg} (Paramedic)

E.

Dysrhythmias – Treat per the algorithms (Paramedic). See appendix B for Pediatric algorithms.

58

IV.

V.

VI.

Hypoglycemic Reaction A.

Make a venipuncture and draw blood samples. (Advanced EMT, Paramedic)

B.

Initiate an IV of 0.9% Sodium Chloride at a keep open rate of 0.5 ml/kg/hr (0.25 cc/lb/hr). A keep open rate should not exceed 25 ml/hr. (Advanced EMT, Paramedic)

C.

Test the patients blood with a glucometer. (EMT, Advanced EMT, Paramedic)

D.

If the blood sugar is below 60 administer 25% Dextrose 2 ml/kg (1 cc/lb) body weight slow IV (25% Dextrose is made by wasting ½ of a D50W syringe then refilling the syringe with 0.9% Sodium Chloride to its original volume.) {0.5 gm/kg} (Advanced EMT, Paramedic)

E.

If the blood glucose is over 300, proceed to the Diabetic Keto-Acidosis Protocol.

F.

Maintain an adequate airway and provide additional life support if necessary.

Diabetic Keto-Acidosis A.

Make a venipuncture and withdraw blood samples. (Advanced EMT, Paramedic)

B.

Initiate an IV of 0.9% Sodium Chloride at a keep open rate of 0.5 ml/kg/hr (0.25 cc/lb/hr).

A keep open rate should not exceed 25 ml/hr. (Advanced EMT, Paramedic)

C.

Test the patients blood sample with a glucometer (EMT, Advanced EMT, Paramedic). If the blood sugar is over 300, increase the IV to twice the maintenance rate. (Advanced EMT, Paramedic)

D.

Maintain an adequate airway and provide additional life support if necessary.

Seizures A. Maintain an open airway, and guide the childâ&#x20AC;&#x2122;s movements to prevent injury to the head and extremities. Once the seizure activity has stopped, turn the child on its side to help prevent further compromise of the airway. (EMT, Advanced EMT, Paramedic) B.

Administer humidified oxygen and maintain SpO2 of 95 %. (EMT, Advanced EMT, Paramedic)

C.

Suction the oral cavity and nasopharynx as needed. Do not interrupt oxygenation for more than 15 seconds. (EMT, Advanced EMT, Paramedic)

D.

Initiate an IV of 0.9% Sodium Chloride at a keep open rate of 0.5 ml/kg/hr (0.25 cc/lb/hr).

A keep open rate should not exceed 25 ml/hr. (Advanced EMT, Paramedic)

59

E.

VII.

VIII.

If Status Epilepticus (continuous seizing) - Administer Lorzepam (Ativan) 0.05 mg/kg slow IV or IO over 1-2 minutes (Dilute with equal amount of 0.9 % Sodium Chloride.). May repeat in 10-15 minutes if necessary. Contact the TF as soon as possible. (Advanced EMT, Paramedic) OR If IV or IO access cannot be established, administer 0.5 mg/kg Diazepam (Valium) rectally.

Utilizing a 1 cc syringe, insert the syringe, with no needle approximately 3 cm (1.5 inches) into the rectum and inject the medication. This dose may be repeated in 5 minutes if necessary. Contact the TF as soon as possible. (Paramedic)

All Unconscious Children A.

Maintain open airway using jaw-lift with manual in-line cervical stabilization if neck trauma is suspected. (EMT, Advanced EMT, Paramedic)

B.

Assure adequate ventilation and oxygenation. (EMT, Advanced EMT, Paramedic)

C.

Check the patient’s blood sugar with glucometer. (EMT, Advanced EMT, Paramedic)

D.

If the blood sugar is less than 60, refer to the Hypoglycemia protocol. If the blood sugar is greater than 300 refer to Diabetic Keto-Acidosis protocol.

E.

Initiate an IV with 0.9% Sodium Chloride at the maintenance rate. Adjust the rate according to the protocols for any other problem the patient may have. (Advanced EMT, Paramedic)

F.

Place the chest electrodes for constant cardiac monitoring and assess the cardiac rhythm.

Treat dysrhythmias according to the appropriate protocols. (Paramedic)

Trauma

The priorities of trauma treatment are the same as for adults except for the fluid challenge boluses.

See “Pediatric Protocol for Initiation of Intravenous Fluid Therapy”. Specific guidelines for Pediatric Conditions, Fluid Challenge Bolus.

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Needle Cricothyrotomy for Pediatric patients (Paramedic) Patients age 13 years and younger Indications Inability to control the airway by other methods Impacted foreign bodies Severe facial trauma or oropharyngeal hemorrhage Severe laryngeal trauma Laryngeal spasm Obstructing tumors Burns of the face and or upper airway precluding intubation Pharyngeal hematoma usually secondary to cervical fractures Pediatric Needle Cricothyrotomy (Paramedic) Procedure Locate the cricoid membrane between the thyroid cartilage and the cricoid cartilage Prep the site with Betadine Use a 14ga IV catheter with a 3cc syringe attached and puncture the skin in the midline Over the cricoid membrane Once through the membrane advance the IV catheter at a 45 degree angle a few millimeters caudally and aspirate with the syringe while advancing.

Advance the catheter over the needle Remove the needle Recheck placement by aspirating with the syringe Secure the catheter with tape Attach a 7.0 or 7.5mm ET tube adaptor to the syringe Ventilate patient by using a bag valve device

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Adult Dosage Chart for Infusion Medications Weight in Kg. 50

55

60

65

70

75

80

85

90

95

100

Weight in lbs. 110

121

132

143

154

165

176

187

198

200

220

Drug

Dosage

Number of minidrops / minute to be given

Dopamine

2 µg/kg/min 4

4

5

5

5

6

6

6

7

7

8

400 mg 5 µg/kg/min 9 in 250 ml or pre-mixed 10 µg/kg/min 19 1600 µg/ml 15 µg/kg/min 28

10

11

12

13

14

15

16

17

18

19

21 31

23 34

24 37

26 40

28 42

30 45

32 48

34 51

36 54

38 56

(26.6 20 µg/kg/min 38 µg/minidrop)

41

45

49

53

56

60

64

68

71

75

Epinephrine Add 1 mg Epinephrine (1:1,000) to 250 ml of 0.9% Sodium Chloride The usual starting dose is 30 minidrops/minute (2 µg/minute) And titrate the rate to achieve a heart rate over 60 bpm. µg/minute

minidrops/minute

1 2 3 4

15 30 45 60

Lidocaine Lidocaine comes Pre-mixed 0.4 % (400 mg/100 ml) or it can be made by adding 1 gram (1000 mg) of 20% Lidocaine in 250 ml of 0.9% Sodium Chloride. Start the infusion at a rate based on the amount of Lidocaine bolus needed to control the dysrhythmia.

Total bolus dose required mg/minute minidrops/minute 1 15 1 2 30 1-2 3 45 2-3 4 60

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Pediatric Dosage Chart for Bolus Medications Weight in Kg. Weight in lbs.

5 11

10 22

15 33

20 44

25 55

30 66

35 77

40 88

45 ______ 99

DRUG Atropine3 0.1 mg/ml Atropine 0.4 mg/ml Dextrose 4 0.25 gm/ml Diazepam-Rectal 5 5mg/ml Lorazepam-IV 2 mg/ml

DOSAGE Number of milliliters (1 ml=1 cc) to be given.

0.02 mg/kg 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 0.2 ml/kg_______________________________________________________ 0.02 mg/kg 0.25 0.50 0.75 1.0 1.25 1.50 1.75 2.0 2.25 0.05 ml/kg______________________________________________________ 0.5 gm/kg 10 20 30 40 50 60 70 80 90 2 ml/kg _______________ 0.5 mg/kg 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 0.1 ml/kg ___________________________________________________ 0.05 mg/kg 0.13 0.26 0.39 0.52 0.63 0.75 0.88 1.0 1.1 0.025 ml/kg _______________

Diphenhydramine 50 mg/ml Epinephrine Cardiac 6 Epinephrine

1 mg/kg 0.1 0.02 ml/kg 0.01 mg/kg 0.1 ml/kg 0.01 mg/kg

Sub-Q 1:1,000

0.01 ml/kg

Furosemide 10 mg/ml Lidocaine 20 mg/ml Sodium Bicarb 7 1 mEq/ml Defibrillation Energy level Approximate ET size

1 mg/kg 0.1 ml/kg 1 mg/kg 0.05 ml/kg 1 mEq/kg 1 ml/kg.

2 J/kg

0.2

0.3

0.4

0.5

0.6

0.7

0.5

1.0

1.5

2.0

2.5

3.0

0.05

0.1

0.15

0.2

0.25

0.3

0.5

1.0

1.5

2.0

2.5

3.0

0.25

0.5

0.75

1.0

1.25

1.5

5

10

15

20

25

30

10 J

20 J

30 J

40 J

50 J

60 J

(16+age)/4 3.0 or little finger 3.5

4.0 4.5

5.0 5.5

0.8 0.9 1.0 __________________ 3.5 4.0 4.5 __________________ 0.35 0.4 0.45

_________________

5.5 6.5

3.5 4.0 4.5 ________________ 1.75 2.0 2.25 ________________ 35 40 45 ________________ 70 J 80J 90J ________________ ________________

3

Atropine 0.1 mg/ml is the same as Atropine 1:1,000.

4

to make Dextrose 0.25 gm/ml waste one half (25 ml) of an amp of 50% dextrose and add the same volume wasted (25 ml) of 0.9% Sodium Chloride to obtain the original volume

5

This is to be drawn into a 1 ml syringe which is then inserted without a needle into the childâ&#x20AC;&#x2122;s rectum

6

All ET doses for all indications use 1:1,000 solution. The initial IV or IO dose for all conditions as doses for V-Fib and Asystole use 1:10,000 solution

7

To be administered only when ordered by the TF physician.

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Pediatric Dosage Chart for Infusion Medications Weight in Kg Weight in lbs

5 11

Drug Dosage8 0.9% Sodium Chloride 0.5 ml/kg/hr 2.5 Keep open rate 25 ml/hr max 0.9% Sodium Chloride (See protocol text) 20 Maintenance 0.9% Sodium Chloride 20 ml/kg 100 Fluid Challenge ml Dopamine 2 µ/kg/min 0.4 400 mg in 250 ml 5 µ/kg/min 1 1600µ/ml 13.3 µ/kg/min 2 26.6 µ/minidrop 20 µ/kg/min 4 Lidocaine Pre-mix 20 µg/kg/min 2 4 mg/ml 33.3 µg/kg/min 2 66.6 µg/minidrop 50 µ/kg/min 4 Epinephrine9 0.1 µg/kg/min 4 2 mg in 250 ml of 0.2 µg/kg/min 8 0.9% Sodium 0.5 µg/kg/min 19 Chloride 0.7 µg/kg/min 27 1.0 µg/kg/min 37

10 22

5.0 40 200 ml 0.8 2 5 8 3 5 8 8 15 38 53 75

15 33

20 44

25 55

30 66

35 77

40 88

45 99

Number of Minidrops / minute to be given 7.5 10.0 12.5 15.0 17.5 20.0 22.5 ___________________ 50 60 65 70 75 80 85 ___________________ 300 400 500 600 700 800 900 ml ml ml ml ml ml ml 1 1.5 2 2 3 3 3 3 4 5 6 7 8 9 5 10 12 15 18 20 22 11 15 19 22 26 30 34 4 6 8 9 10 12 14 5 10 12 15 18 20 22 11 15 19 22 26 30 34 11 15 19 22 26 30 34 22 30 38 45 52 60 68 57 76 95 114 133 152 171 80 106 132 160 185 212 337 112 150 187 225 262 300 337

8

These dosages encompass a range from the lowest dosage to the highest dosage shown. The specific dosage given (within the acceptable range) is not as important as the effect the drugs have on the patient. Be certain to monitor the patient and titrate the dosages accordingly.

9

These infusions are to be started only by order of the TF physician. The resulting concentrations are 8 µg/ml

64

Protocol Drug Interactions and Precautions (Consult with Medical Control if Present) All patients should be checked for known DRUG ALLERGIES, which contraindicates administration in all cases.

Adenosine:

Use in patients on Digitalis therapy has occasionally been associated with ventricular fibrillation.

Methylzanthines, such as caffeine and theophylline products, block receptor sites and higher dosages of Adenosine may be required.

Carbamazepine products (Atretol® , Tegretol® ) and Dipyridamol (Persanthine® - a platelet adhesion inhibitor often used with Coumadin after cardiac valvular surgery) increase the degree of heart block and potentiate effect of Adenocard. May require reduced dosage.

Safe use in pregnancy has not been established.

Albuterol:

Use in the presence of other sympathetic agonists (bronchodilators/anti-asthma medications) may increase unpleasant side-effects.

Beta-blockers* may decrease the effects of Albuterol.

Aspirin:

Active ulcer or asthma are relative contraindications.

Aspirin already in the system may cause a higher dosage level than appropriate, and interfere with positive benefits. Ask about previous intake.

Atropine:

Give cautiously in the presence of suspected ischemia, and assure adequate oxygenation prior to Sulfate: administration.

Give rapidly IV - dosages of less than 0.5 mg may cause paradoxical bradycardia.

Diazepam: (Valium®)

Other CNS depressants and alcohol potentiate the affect.

Masks symptoms in victims of head injury.

Is a potent venous irritant, and should not be administered faster then 1 ml/min. and only through a large vein. Incompatible when mixed with many other medications - always give by itself and flush thoroughly with clear fluid.

Diphenhydramine: Contraindicated in acute asthma attack.

(Benedryl®) Potentiated by CNS depressants, other antihistamines, narcotics and alcohol.

65

Dopamine: May cause hypotension when given in combination with Dilantin®.

(Intropin®) May precipitate tachydysrhythmias or ventricular fibrillation when given in hypovolemia.

Contraindicated in the presence of pheochromocytoma ( a specific tumor of the adrenal gland) Dosage should be decreased if the patient is taking an MAO inhibitor (Marplan®, Nardil®, Parnate®) Epinephrine: Incompatible with solutions having alkaline pH. Requires adequate flushing of tubing before and after administration. Should not be mixed with other drips.

Doses in excess of 20 µg/min may produce marked increase in BP if not in cardiac arrest.

May cause or extend myocardial infarction when given in ischemia.

May precipitate or worsen ventricular ectopy, especially in digitalis intoxication.

Furosemide: Do not use in patients with allergy to sulfa drugs.(Lasix®) 50% Glucose:Avoid administration in the presence of increased intracranial pressure.

Glucagon:

Use cautiously in the presence of cardiovascular or renal disease.

Ipratropium: Avoid getting mist in the eyes, as it is generally irritating and may cause blurring of vision. It can aggravate glaucoma, if present Bromide: (Atrovent®) Do not use in patients with allergy to soybeans, soya lecithin products, peanuts, Atropine, Belladonna, Ipratropium, Hyoscyamine or Scopolamine.

Lidocaine: Increased chance for toxicity when given to patients already taking Procainamide (Pronestyl®, Guanidine, Phenytoin (Dilantin® ), or Beta Blockers*.

Contraindicated in Mobitz II and III AV Blocks and in heart rates below 60.

Reduce dosage by ½ in patients over 70 years.

Lorazepam (Ativan®):

Not to be used in association with other CNS drugs due to potentiation.

Morphine:

Avoid administration in hypotension, volume depletion, depressed ventilation and caution in the Sulfate: presence of Beta- blockers*.

66

Nitroglycerin:

Contact receiving facility if Viagra, Cialis or Levitra have been taken.

Do not administer if BP is below 90 systolic.

Limit administration to BP drop of 10 mm in normotensive patients and 30 mm in hypertensive patients.

Romazicon:

Used to reverse respiratory depression and sedative effects from pure Benzodiazepine (Versed) overdose.

Succinylcholine:

Has no effect on consciousness, pain threshold, or cerebration, Must be used With adequate sedation.

Sodium Bicarbonate:

Avoid mixing with other solutions - precipitates easily.

Thiamine:

No contraindications in the emergency setting.

Versed:

Adverse reactions for a patient given Versed as an agent to facilitate conscious intubation include hypotension. Flumaxenuil (Romazicon) 0.2mg should be used to reverse this adverse reaction.

Should not be used in patients who have taken CNS depressants.

Contraindicated in glaucoma, shock, coma, alcohol intoxication, Overdose, barbiturates, alcohol or narcotic use.

* Beta-blockers:

Generic - Esmolol, Propranolol, Metoprolol, Atenolol Trade -

Betaloc, Betapace®,Blocadren®, Bevibloc®,Cartrol®,Corgard®, Inderal®, Kerlone®, Levatol®,Lopressor®, Sectrol®, Sotacor®, Tenoretic® Toprol®, Tenormin®, Visken®, Zebeta®

67

This 2013 version of the Jackson County Emergency Medical Services Written Physicianâ&#x20AC;&#x2122;s Authorization and Medical Protocol for Basic and Advanced Life Support is approved for use by operating units of JCEMS, and the EMT, Advanced EMT and Paramedics responding to emergency situations as its agents.

_______________________________________________ Dr. Jason Reaves, M.D. JCEMS Medical Director

Original, signed copies of this document are on file at the Ohio State Board of Pharmacy, Columbus, Ohio.

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