A&E Emergency Services, LLC

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1 A&E Emergency Services, LLC Ambulance Protocols September 2014 Committed to Excellence

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3 Table of Contents Universal Patient Care Protocol Adult Cardiac Adult Acute CHF / Pulmonary Edema Adult Bradycardia Adult Cardiac Arrest Adult Chest Pain / Suspected MI Adult Post Resuscitation Adult Symptomatic PVC s Adult Tachycardia Pediatric Cardiac Pediatric Bradycardia Pediatric Cardiac Arrest Pediatric Post Resuscitation Pediatric Tachycardia General Medical / Trauma Allergic Reactions / Anaphylaxis Childbirth Hypertensive Emergencies Hypo-Hyperglycemia Hypo-Hyperthermia Nausea or Vomiting Non-Hypovolemic Hypotension Overdose / Poisoning / Toxic Exposure Pain Management Respiratory Distress or Failure Seizures Stroke / TIA Traumatic Injuries Special Protocols Advanced Directives Carbon Monoxide Exposure Communications Failure Destination Determination Field Determination of Death Interfacility Transfers Patient Refusals Patient Restraint Physician on Scene Scene Rehab Special Event & Operations Wellness Care Procedures Airway Management CPAP Cricothyrotomy ECG & Lead monitoring Intubation (Nasotracheal) Intubation (Orotracheal) Naso-Orogastric Tube Needle Thorachostomy Portable Ventilator Rapid Sedation Intubation (RSI) Rescue Airway (Combitube) Rescue Airway (King) Spinal Immobilization S.T.A.R.T. Triage Transcutaneous Pacing Venous Access (EZ-IO) Venous Access (IV) Venous Access (Port, Hickman or Picc Line) Medications Adenosine (Adenocard) Albuterol Amiodarone (Cordarone) Aspirin Atropine Dextrose Diazepam (Valium) Diphenhydramine (Benadryl) Dopamine (Intropin) Epinephrine (1:1000 & 1:10,000) Epinephrine (Racemic) Fentanyl (Sublimaze) Furosemide (Lasix) Glucagon (Glucagen) Hydromorphone (Dilaudid) Ketamine (Ketalar) Lidocaine (Xylocaine) Magnesium Sulfate Meperidine (Demerol) Methylprednisolone (Solu-Medrol) Metoprolol (Lopressor) Midazolam (Versed) Morphine Sulfate Naloxone (Narcan) Nitroglycerin Ondansetron (Zofran) Oxygen Promethazine (Phenergan) Sodium Bicarbonate Succinylcholine (Anectine) Vecuronium (Norcuron)

4 Universal Patient Care Protocol SCOPE OF PRACTICE STATEMENT All assessments, interventions, treatments and procedures performed by each provider, should always be within A&E Emergency Services, LLC EMS system credentialing and state approved scope of practice. ENSURE SCENE SAFETY & Personal Protective Equipment PRN. SCENE SURVEY - Assess MOI - NOI, number of patients, and special circumstances. Quickly triage all patients, update EOC and request additional resources PRN. EQUIPMENT / SUPPLIES always take to the patient PRN, to facilitate care and promote healing. GENERAL IMPRESSION AND LOC - take spinal precautions PRN or in unknown situations. Alert alert to their environment, comprehending appropriately and competent. Verbal requires verbal communication to stimulate alertness and interaction. Painful requires painful stimulus to generate response of any type. Unresponsive does not respond to any stimulus. AIRWAY open, self-maintained / protected, free from obstruction? Head-tilt / chin lift or jaw thrust, NPA, OPA, Heimlich, CPR, Magill s, needle thoracostomy, intubation, rescue airway, PRN. BREATHING - present & adequate? Auscultate breath sounds and assess rate, quality, pattern, appearance, effort, Spo2 and consider CO. Monitor waveform capnography if any indication of cardiopulmonary compromise. Maintain adequate oxygenation /ventilation titrating to effect & Spo2 to 94%, Co mmHg. o Nasal cannula, NRB, CPAP, BVM, auto-vent, pharmacology, PRN. CIRCULATION present & adequate? Assess rate and quality, peripheral vs central, skin condition, EKG. Maintain adequate perfusion to SBP trauma, medical. o BLS shock management, IV therapy, pharmacology, cardioversion, pacing, defibrillation, CPR. PRIORITIZE Stable vs. Unstable? Trend the patient. (Alert & oriented, breathing effectively, adequate hemodynamics vs. altered LOC, respiratory failure, inadequate perfusion). Time & adjust assessments / interventions according to the pt s level of urgency. o Priorities should promote healing, ensure comfort and reach definitive care in a timely manner. SECONDARY SURVEY AND ON-GOING ASSESSMENT Pts. trending towards instability require more frequent assessments and rapid interventions to address immediate life threats vs. those leaning to stability and physiologically allowing time to make fine therapeutic adjustments and address general complaints and comfort measures. LEVEL OF CONSCIOUSNESS Continuously assess the patient s level of consciousness and ability to comprehend. o A.V.P.U. alert, verbal, painful, unresponsive. o Comprehends average personal information, history and current events. o Comprehends current situation, condition and treatment/transport recommendations. Assess for factors that influence LOC and comprehension. o Vitals, blood glucose, trauma, temperature, shock, anxiety, stroke, alcohol or drugs. HISTORY Signs / symptoms chief complaint, indications. Allergies medications, foods, insects, chemicals and what happens with the allergy. Medications all current medications, herbs, supplements or vitamins. Past medical history pertinent history, medic alert tags. Last oral intake fluid and food. Events leading up to current problem

5 Onset when did this event or change start; was it sudden, gradual or chronic? Provocation or palliation Does anything provoke this problem or make it better? Quality patient s description? o Sharp, dull, crushing, pressure, burning, constant, intermittent, achy, hot, chilled, etc. Radiation Does the pain/problem stay in one place or project, radiate or refer to another? Severity Patient rates problem from 1 to 10 with 10 being the worst they have experienced? o Assess at onset, present and as treatment progresses. Time Exact start time if possible, if intermittent and duration. PHYSICAL EXAM - a thorough physical exam (with consent), according to the situation or need, is a required vital component to determine the most appropriate course of action for all patients. Expose, visualize, palpate, auscultate, question, & investigate all possibilities. o Vitals, blood glucose, temperature, EKG, pulse oximetry & capnography PRN. Specific Assessment elements Head Assess for airway obstructions, audible stridor, wheezing or congestion, airway odor, trismus, blood or fluid in the ears, nose, eyes or mouth, pupil size and reactivity, facial droop, dysconjugate gaze, nystagmus. Neck tracheal deviation, JVD, accessory muscle use, subcutaneous emphysema. Thorax equal rise and fall, paradoxical movement, accessory muscle use, retractions, wheezing, crackles, rales, rhonchi, muffled heart tones or murmur, subcutaneous emphysema, swelling Abdomen guarding, rigidity, masses, pulsations, herniations. Pelvis hematuria, rectal or vaginal bleeding, urinary or fecal incontinence. Extremities Presence and strength of pulses, motor function and sensory. Skin tugor, rash, urticaria, petechia, diaphoresis, pallor. Any signs, symptoms or mechanism of trauma in all of the above. o High index of suspicion towards any mechanism with the potential for causing harm, regardless of the immediate presence of signs or symptoms. RE-EVALUATE TREATMENT & TRANSPORT DECISIONS ONGOING ASSESSMENT - Unstable patients q 5 minutes, stable patients q minutes. Assess ABCs, mental status, vital signs, EKG, PMS and interventions. Intubated, sedated or altered patients - obsessively re-evaluate airway, waveform capnography, pulse oximetry and adequacy of oxygenation/ventilation/circulation. Re-assess after each intervention or change in condition. RADIO REPORT Contact the receiving facility early and relay pertinent information. Unit ID, number of patients, transport mode, patient(s) age, gender, chief complaint, mental status, pertinent findings, vitals, interventions, current status, Broselow color for all pediatrics and ETA. TRANSFER OF CARE Maintain constant patient management (all therapeutics and mechanisms of monitoring) until a complete transfer of care, to the receiving Paramedic, RN or MD, has occurred. Complete documentation, obtain signature from the receiving staff and leave copy of report. PATIENT CARE REPORT Document all patient contacts thoroughly on the approved patient care reporting system. Demographics, pertinent history, assessments & findings, vital signs, treatments and response, supervisor or medical control consults and orders received, or any relevant special circumstances This Page Intentionally Left Blank

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7 Adult Cardiac Section Contents Adult Acute CHF / Pulmonary Edema Adult Bradycardia Adult Cardiac Arrest Adult Chest Pain / Suspected MI Adult Post Resuscitation Adult Symptomatic PVC s Adult Tachycardia

8 Adult Acute CHF / Pulmonary Edema Initiate CPAP if moderate to severe respiratory distress. Assess temperature. If patient febrile >100.5 F consult Medical Control prior to Lasix PARAMEDIC If B/P > 140/80 and no contraindications Nitroglycerin 0.4mg / 1 tablet SL q5 min. titrated to relief of pulmonary edema. Maximize total dose 1.2mg or 3 Tablets Stop administration of Nitro if: Severe headache develops Symptoms worsen Systolic BP drops greater than 30mmHg from base line Furosemide (Lasix) mg Slow IV/IO Option: If hypotensive SBP <100 Dopamine (intropin) 5 20mcg/kg/min titrate to effect.

9 Adult Bradycardia UNSTABLE (inadequate perfusion, altered mental status, severe dyspnea, severe chest pain) IV/IO access immediately available Atropine 0.5mg IV/IO every 3 5 minutes PRN Max total dose 3mg Adjust max total dose to 0.04 mg/kg for patient s 165lbs (75kg). PARAMEDIC IV/IO access not available, atropine ineffective or rapid deterioration Transcutaneous BPM. Increase milli-amps until capture then increase by 5-10 milli-amps. o Assess for mechanical capture / patient improvement. Consider sedation, pain control and hemodynamic support PRN. Pain Management Pacing ineffective and/or hypotension despite pacing and fluid challenge Dopamine (Intropin) Infusion 5 20 mcg/kg/min titrate to effect. Option: Dopamine ineffective and patient remains distressed & hypotensive Epinephrine Infusion 2 10mcg/min titrate to effect. STABLE BUT SYMPTOMATIC Atropine 0.5mg IV/IO every 3 5 minutes, as indicated. Max total dose 3mg or 0.04 mg/kg if patient 165lbs (75kg).

10 Adult Cardiac Arrest Resuscitation is to occur and continue at the initial patient location until: return of spontaneous circulation, determination of death or transport is required to insure safety or quality of care. IMMEDIATE PRIORITIES Immediately start & maintain Chest Compressions / CPR, Establish AED / Cardiac Monitor & defibrillate PRN, Initiate IV/IO Access, Administer medications and fluids PRN, Secure rescue airway, Treat reversible causes. Confirm unresponsive, pulseless and insure C-spine BASIC Immediate CPR and AED Application (cardiac monitor if ALS on scene). Assess q 2 min & defibrillate PRN (analyze witnessed arrest immediately). Establish Rescue Airway (Do not interrupt CPR, defibrillation, IV/IO). Full immobilization prior to movement or transport. A 1000ml bolus PRN. Immediately apply ECG, capnography and pulse oximetry during CPR Assess q 2 min & defib Vfib / V-tach PRN (analyze witnessed arrest immediately). o 1 st shock 200j, 2 nd 300j, all subsequent shocks 360j. o Monitor CPR effectiveness (rate, depth, capnography and pulse oximetry). o Place OG tube & evacuate PRN. Epinephrine 1:10,000 1mg IV/IO q 3-5 minutes. If repeated boluses are required to maintain perfusion. o Epinephrine 2-10 mcg/min mg ETT q 3-5 minutes if IV/IO not available. PARAMEDIC If VF / VT Amiodarone (Cordarone) 300mg diluted in 20-30ml NS IV/IO Push. (if available) 150mg diluted in 20-30ml NS in 3 5 minutes if VF/VT continues. Or Lidocaine (Xylocaine) 1.5mg/kg IVP, may repeat with mg/kg IVP q 5-10 minutes Max total dose 3mg/kg Option: if Torsades De Pointes or know hypo-magnesemia Magnesium Sulfate 2g IV/IO dilute 10ml NS. Additional Reversible Cause Orders Hypoglycemia see appropriate protocol. Tension pneumothorax - Needle thoracostomy. Opiates (Narcotics) suspected or unknown: Narcan 2mg IV/IO every 3-5 minutes. Beta Blocker overdose suspected: Glucagon 1mg IV/IO q 3-5min PRN. o Max total dose 10mg. Max total 5mg. o ETT double to dose. Metabolic Acidosis, known hyperkalemia or tricyclic overdose: Sodium Bicarbonate 1mEq/kg IVP/IO. Calcium Channel Blocker overdose suspected: Glucagon 1mg IV/IO q 3-5min PRN. Max total 5mg. MD Always consult Medical Control prior to discontinuing care.

11 Adult Chest Pain / Suspected MI B P Aspirin 324 mg (chew & swallow) Establish 12 & 15 Lead EKG immediately and pre-alert receiving facility of STEMI Establish IV prior to Nitro administration AEMT Nitroglycerin 0.4 mg / 1 tablet SL q 5 min. PRN to complete pain/pressure relief. Maximum total dose 1.2 mg or 3 Tablets. Stop administration of Nitro if severe headache develops or symptoms worsen. Transport promptly to the closest PCI capable facility agreeable to the patient Ondansetron (Zofran) 4mg IV/IO/PO PARAMEDIC Morphine Sulfate 2 4mg slow IV/IO q 5 minutes titrated to pain / pressure relief. Max total dose of 10mg. Option: if Morphine contraindicated Fentanyl (Sublimaze) mcg slow IV/IO PRN q 5-10 minutes as indicated. Max total dose 400 mcg. Option: if hypersensitive to Versed Diazepam (Valium) 5 mg IV/IO over 2 min up to 10mg for most adults Max total dose 30mg. STEMI confirmed Metoprolol (Lopressor) 5mg q 5 minutes slow IV/IO over 2-3 min. Give total of three doses (15mg). MD Always consult Medical Control prior to discontinuing care or obtaining refusals.

12 Adult Post Resuscitation IMMEDIATE CONSIDERATIONS FOR INSTABILITY Bradycardia Transcutaneous Pacing and / or Bradycardia or hypotension Epinephrine Infusion 2-10 mcg/min titrate to effect. Maintain SBP >90mm Hg or MAP >65mm Hg Option: Epinephrine Infusion ineffective Dopamine (Intropin) Infusion 5-20 mcg/kg/min titrate to effect. Maintain SBP >90mm Hg or MAP >65mm Hg Post defibrillation anti-arrhythmic if none previously administered Amiodarone (Cordarone) 150mg in 100ml NS IV/IO Infusion over 10 minutes. Repeat once PRN. Option: Torsades De Pointes or known hypomagnesemia Magnesium Sulfate 2g in 100ml NS IV/IO infusion over 10 minutes. PARAMEDIC Induced Hypothermia Inclusion Criteria Age Non-traumatic cardiac arrest Comatose and ROSC within 60 minutes of arrest. No active / recent bleeding No known Septic Shock No known pre-existing coagulopathy (Warfarin OK) No Do Not Resuscitate (DNR) or Do Not Intubate (DNI) Baseline Temp 93 F (34 C) Hypothermia procedure 1. Rescue airway required. Intubation required if rescue airway is not available or functioning inadequately. 2. Initiate transport to hypothermic resuscitation center. Activate Level 1 Cardiac Emergency. 3. Sedation & Neuromuscular blockade. Versed (midazolam) 5mg slow IV/IO over 2-3 min. Repeat PRN. Vecuronium (Norcuron) 0.1mg/kg IV/IO (see reference chart) Max single dose 10mg. 4. Core Temp <93 (monitor and maintain). 5. Core Temp >93 Apply ice packs to neck, groin, and axilla areas. Rapid infusion of cold saline via peripheral IV/IO Max 2 liters including fluids infused during arrest management. 6. If cardiac arrest re-occurs discontinue hypothermia & resume arrest management.

13 Adult Symptomatic PVC s Correct Hypoxia and Bradycardia first. PARAMEDIC If continued symptomatic PVC s Amiodarone (Cordarone) 150mg in 100ml NS IV/IO Infusion over 10 minutes. Repeat once PRN. Lidocaine (Xylocaine) mg/kg IV/IO Repeat mg/kg q 5 10min up to 3mg/kg Option: if associated with stimulant use or anxiety Midazolam (Versed)1-2mg Slow IV/IO/IN q 5-10min. PRN. Max total dose 5mg. Option: if Midazolam (Versed) contraindicated Diazepam (Valium) 5 mg IV/IO over 2 min up to 10mg for most adults Max total dose 30mg.

14 Adult Tachycardia UNSTABLE (Non-Sinus Tach) (Inadequate perfusion, altered LOC, severe dyspnea, severe chest pain) Cardioversion (Consider sedation first if time permits) Narrow or Wide complex / regular rate 100J, then PRN 200, 300, 360. Narrow complex / irregular rate 120J, then PRN 200, 300, 360. Wide complex / irregular rate 200J, then PRN 300, 360. Pain management protocol PRN. Option: Narrow or Wide complex / regular rate, & waiting on cardioversion prep. Adenosine (Adenocard) 6mg rapid IV/IO with 20ml Saline Rapid Flush. If Not Effective, Repeat 12mg. PARAMEDIC Post cardioversion care for continued arrhythmia or prophylaxis Amiodarone (Cordarone) 150mg in 100ml NS infused over 10 minutes. Repeat once PRN. SVT: (Regular narrow complex > 150 bpm). Vagal Maneuvers Do Not Use Carotid Sinus Massage. STABLE BUT SYMPTOMATHC (Non-Sinus Tach) Narrow or Wide complex / regular and monomorphic. Adenosine (Adenocard) 6mg rapid IV/IO push with 10ml rapid saline flush. If not effective, 12mg. Unresolved SVT or A-fib (on set <48hr), A-flutter, Atrial or Junctional Tach, M.A.T. Metoprolol (Lopressor) 5mg q 5min slow IV/IO over 2 3 minutes. Max total dose 15mg. Unresolved Wide Complex or Diltiazem / Metoprolol / Adenosine contraindicated Amiodarone (Cordarone) 150mg in 100ml NS infused over 10 minutes PRN. Max total dose 300mg. Torsades De Pointes. Magnesium Sulfate 2g in 100ml NS infused over 10 minutes. Repeat once PRN

15 Pediatric Cardiac Section Contents Pediatric Bradycardia Pediatric Cardiac Arrest Pediatric Post Resuscitation Pediatric Tachycardia

16 Pediatric Bradycardia BASIC Signs of instability (Inadequate perfusion, altered mental status, poor respiratory effort) Immediate CPR and prepare for AED if arrest occurs (Cardiac monitor if on Scene). Assess q 2 min and continue PRN. UNSTABLE (inadequate perfusion, altered mental status, poor respiratory effort) IV/IO access immediately available & CPR in progress Epinephrine 1:10, mg/kg IV/IO q 3-5 minutes. See RightDose Guide Max single dose 1mg ETT Option 1:1, mg/kg q 3-5 minutes. Max single dose 2.5mg PARAMEDIC Positive responses to Epinephrine bolus and re-occurring bradycardia. Epinephrine Infusion 0.1 1mcg/kg/min titrate to effect. See RightDose Guide Primary AV Block or increased vagal tone Atropine 0.02mg/kg IV/IO every 3 5 minutes, as indicated. See RightDose Guide Repeat once PRN Minimum single dose 0.1mg Maximum single dose 0.5mg Maximum Total dose child 1mg Maximum Total dose adolescent 3mg IV/IO access not available or epinephrine / atropine ineffective: Transcutaneous Pacing pacing BPM. Increase milli-amps until capture, then increase by 5-10 milli-amps. Assess for mechanical capture / patient improvement. Pain Management

17 Pediatric Cardiac Arrest Resuscitation is to occur and continue at the initial patient location until: ROSC, determination of death or transport is required to insure safety or quality of care. IMMEDIATE PRIORITIES Immediately start & maintain Chest Compressions / CPR, Establish AED / Cardiac Monitor & defibrillate PRN, Initiate IV/IO Access, Administer medications and fluids PRN, Secure rescue airway, Treat reversible causes. Confirm unresponsive, pulseless and insure C-spine. BASIC Immediate CPR and AED Application (cardiac monitor if ALS on scene). Assess q-2min & defib PRN (analyze witnessed arrest immediately). Establish Rescue Airway (Do not interrupt CPR, defibrillation, IV/IO) Full immobilization prior to movement or transport. A 20 ml/kg bolus PRN. Immediately apply ECG, capnography and pulse oximetry during CPR Assess q-2min & defib Vfib / V-tach PRN (analyze witnessed arrest immediately). o (No shock to exceed adult dose) Monitor CPR effectiveness (rate, depth, capnography and pulse oximetry). Place OG tube & evacuate PRN. Epinephrine 1:10, mg/kg IV/IO q 3-5 minutes. See RightDose Guide If repeated boluses are required to maintain perfusion. o Epinephrine 0.1mcg/kg/min (see guide) titrate to effect. ETT option 1: mg/kg q 3-5 minutes if IV/IO not available. o Max single dose 2.5mg PARAMEDIC If VF / VT Amiodarone (Cordarone) 5mg/kg diluted in 10-30ml NS IV/IO Push q 3-5 minutes PRN. See RightDose Guide Maximum of 3 doses totaling15mg/kg. Or Lidocaine (Xylocaine) 0.5mg/kg IVP, See RightDose Guide Option: if Torsades De Pointes or know hypo-magnesemia Magnesium Sulfate 50mg/kg IV/IO push, dilute in 10ml NS. See RightDose Guide Maximum single dose 2000mg (2g) Additional Reversible Cause Orders (See RightDose Guide) Hypoglycemia see appropriate protocol Tension pneumothorax Needle thoracostomy Opiates (Narcotics) suspended or unknown: Beta Blocker overdose suspected: Narcan 0.1mg/kg IV/IO every 3-5 minutes Glucagon 1mg IV/IO q 3-5min PRN o ETT 0.25mg max of 5mg o 0.5mg if 20kg o Max total of 5 doses o Max total 5 doses Metabolic acidosis, known hyperkalemia or tricyclic Calcium Channel Blocker overdose suspected: overdose: Glucagon 1mg IV/IO q 3-5min PRN Sodium Bicarbonate 8.4% 1mEk/kg IVP/IO o 0.5mg if 20kg Infants 1 month 4.2% - 0.5mEq/kg o Max total 5 doses MD Always consult Medical Control prior to discontinuing care or obtaining refusals.

18 Pediatric Post Resuscitation BASIC Bradycardia, poor perfusion, altered LOC Continue CPR and prepare for AED if arrest occurs (Cardiac monitor if ALS on Scene). Assess q 2 min and continue PRN. IMMEDIATE CONSIDERATIONS FOR INSTABILITY Bradycardia or hypotension despite fluid challenge Epinephrine Influsion 0.1 1mcg/kg/min titrate to effect. See RightDose Guide Option: Epinephrine Infusion ineffective or normotensive Dopamine (Intropin) Infusion 5 20 mcg/kg/min titrate to effect. See RightDose Guide PARAMEDIC Post defibrillation anti-arrhythmic if none previously administered Amiodarone (Cordarone) 5mg IV/IO diluted in NS infused over minutes. See RightDose Guide Repeat twice PRN. Or Lidocaine (Xylocaine) 0.5mg/kg IVP, See RightDose Guide Option: Torsades De Pointes or known hypomagnesemia Magnesium Sulfate 50mg/kg IV/IO diluted in NS infused over minutes. See RightDose Guide Maximum dose 2000mg (2g) Transport to pediatric level 1 resuscitation center Initiate ER notification early.

19 Pediatric Tachycardia Sinus Tachycardia Search for and treat underlying cause. Supraventricular Tachycardia s (SVT) QRS <0.09 seconds Infants: rate typically >220bpm Children: rate typically >180bpm Wide Complex Tachycardia s SVT (VT or VT or SVT with Aberrancy) QRS>0.09 seconds PARAMEDIC Option while preparing for Adenosine or cardioversion Vagal Maeuvers with SVT Ice pack upper half of face, valsalva, carotid sinus massage IV/IO access present with SVT or Wide complex regular rate and monomorphic Adenosine (Adenocard) 0.1mg/kg rapid IV push & flush. See RightDose Guide Max single dose 6mg Repeat once 0.2mg/kg o Max single dose 12mg UNSTABLE & No IV/IO present or Adenosine ineffective If first shock ineffective, 2j/kg. Consider pain management first if time permits. Pain management Option: if UNSTABLE & conversion unsuccessful or tachycardia re-occurs Amiodarone (Cordarone) 5mg/kg IV/IO diluted in NS infused over minutes. See RightDose Guide Repeat twice PRN Option: if Amiodarone contraindicated. Lidocaine (Xylocaine) 0.5mg/kg IVP, See RightDose Guide

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21 General Medical / Trauma Section Contents Allergic Reactions / Anaphylaxis Childbirth Hypertensive Emergencies Hypo-Hyperglycemia Hypo-Hyperthermia Nausea or Vomiting Overdose / Poisoning / Toxic Exposure Pain Management Respiratory Distress or Failure Seizures Stroke / TIA Traumatic Injuries

22 Allergic Reactions / Anaphylaxis B P Basic Allergic Reactions (No airway or hemodynamic changes) Supportive care & monitor for any changes in airway or hemodynamics. Assist patients with self-administration of allergy medications such as Benadryl. Basic allergic reactions and anaphylaxis Diphenhydramine (Benadryl) 25-50mh IV or (IM if IV not available). Pediatrics: 1mg/kg See RightDose Guide o Max single dose 50mg Anaphylaxis Indicated (Allergic reaction symptoms with any changes in airway and or hemodynamics) AEMT Epinephrine 1: mg/ 0.3ml IM q 5-10 min. PRN. Pediatrics: 0.01mg/kg See RightDose Guide o Max single dose 0.3mg Albuterol Nebulized 2.5mg. Repeat PRN. NEVER GIVE IV / IO Albuterol 2.5mg / Atrovent (Ipratropium) 0.5mg nebulized q5-10 min. PRN. Consider CPAP PARAMEDIC Methylprednisolone (Solu-Medrol) 125mg IV/IO. Pediatrics: 2mg/kg. See RightDose Guide o Max single dose 60mg. Option: If stridor present and moderate to severe dyspnea: Racemic Epinephrine 0.5ml of 2.25% in 3ml NS nebulized q 5-15min. PRN. Option: moderate / severe reactions unresponsive to Epinephrine: Glucagon (Glucagen) 1mg IV/IO/IN q 5 minutes PRN. Pediatrics: 0.5mg 20kg. See RightDose Guide Severe Reactions: respiratory or cardiac failure unresponsive to initial primary treatments Epinephrine 2-10mcg/min titrate to effect. Pediatrics: 0.1-1mcg/kg/min. See RightDose Guide

23 Childbirth BASIC STANDARD DELIVERY: Support baby s head and remove amniotic sac from the face during delivery. Suction the mouth first and then the nose with bulb syringe. Deliver shoulders and continue supporting baby s head and body. Keep baby on same level of mother s vagina until cord stops pulsing. Dry, stimulate & wrap (keep baby warm). Place umbilical clamps 7 from baby and 3 apart and cut cord. Note time of delivery and 1 and 5 minutes POST DELIVERY CARE: Allow mother to nurse PRN (prior to transport, if no contraindications). Transport in secure approved device (car seat /Pedi-Mate). If placenta delivers prior to transfer of care, save all placenta / afterbirth tissues. POST-PARTUM HEMORRHAGE: o Place sterile dressing over vaginal opening, DO NOT pack vagina. o Flatten mother s legs & hold together (No need to squeeze) & elevate legs / feet. o Massage fundus in circular motion (grapefruit-sized object in lower abdomen). o Encourage the mother to nurse baby which will promote uterine contractions. o If perineum is torn, control bleeding with direct pressure. Complication Options: Miscarriage: Transport fetus or tissue with the patient to the receiving facility. BREECH / Limb Presentation: Prepare for urgent transport, pelvis; head down unless delivery is imminent. DO NOT pull on limb in attempt to deliver baby. If body delivers, gently support by holding pelvis and avoid explosive delivery. Gently rotate torso orienting shoulders anterior to posterior. Guide upward delivering posterior shoulder, then downward for anterior. If head delivery delayed, insert two fingers to create an airway to the baby s nose. Place mother in knee to chest position to deliver the head if necessary. Gently lift the baby upward creating a better delivery angle. If the head cannot deliver, maintain airway and establish rapid transport. UMBILICAL CORD COMPLICATIONS: Cord wrapped around neck o Gently slip over the head. o If unable to slip, immediately clamp, cut and remove the cord from the neck. Prolapsed cord o Prepare for urgent transport, pelvis; head down to relieve pressure on pelvis and cord. o Check umbilical cord for pulses, cover with wet sterile dressing. o Insert several fingers into vagina and relieve pressure on the cord, until transfer of care. A IV Access 1000ml/hr MD Consult medical control for pain control options PRN.

24 Hypertensive Emergencies Assess Cincinnati Pre-hospital Stroke Scale Facial Droop: (have the patient show teeth or smile) Normal Both sides of face move equally -0 Abnormal One side of face does not move as well as the other -1 BASIC Arm Drift: (close eyes & extends both arms straight out with palms up for 10 sec) Normal Both arms move the same or both do not move at all -0 Abnormal Pt. slurs words, uses the wrong words or is unable to speak -1 Abnormal Speech: (have the patient say you can t teach an old dog new tricks ) Normal Pt. uses correct words with no slurring -0 Abnormal Pt. slurs words, uses the wrong words or is unable to speak -1 Any indication of stroke move to stroke protocol No stroke indications provide supportive care P BP 200/120 and symptomatic (severe headache, MI, CHF, AAA) Nitroglycerin 1 tab sublingual q 5 min. (0.4mg tab)

25 Altered LOC or indications of dehydration Fluid bolus IV/IO q5-10 minutes PRN. Hypo Hyperglycemia Hyperglycemia (glucose 250 & symptomatic) Hypoglycemia (glucose 40 newborns, 60 infant - child, 80 adolescent - adult, & symptomatic) AEMT Alert, oriented, able to safely follow commands and intact gag reflex Oral glucose 24g q 5-10 minutes PRN IV/IO access available, altered LOC or unable to swallow: D50W 25g slow IV/IO q5-10 minutes PRN (adults) Option: IV/IO access or Intranasal via paramedic not rapidly available Glucagon (Glucagen) 1mg IM 0.5mg if 20kg. Post Hypoglycemic Care: After achieving a normal glycemic range it is imperative that substantive oral intake, including complex carbohydrates and protein be ingested as soon as possible to promote stability. Always promote transport to ED for physician evaluation. PARAMEDIC Option: IV/IO access not rapidly available: Glucagon (Glucagen) 1mg IN primary (IM option) 0.5mg if 20kg. Pediatrics See RightDose Guide D25W 0.5g/kg slow IV/IO q 5 10 minutes (infant Child) (newborns) D10W 0.2g/kg

26 Hypo Hyperthermia Fever: (Illness related) to 105 F Passive/gradual cooling measures. 105 F Switch to active cooling measures o Expose & cool, moist compresses. BASIC Hypothermia: Remove wet / cold clothing Do not rub skin or immerse in hot water Place in supine position if possible Avoid rough handling or excessive activity Utilize blankets, Heat Packs, Warm Environment & Warm Humidified Oxygen. Heat Exhaustion: Remove clothing & start passive cooling Utilize air conditioning Consider gradual re-hydration with Medical Control consult. Use caution to not induce hypothermia. Heat Stroke: (core temp 105 F, altered LOC, red skin & possibly no sweating). Remove clothing & apply aggressive cooling immediately Use ICE and Water if available. Apply packs to groin, axilla & neck. A Hypothermia warm fluid bolus PRN. Hyperthermia room temperature fluid bolus PRN. PARAMEDIC Option: modified Arrhythmias Therapy for Core Temp 86 F. Defibrillations/Cardioversion/Transcutaneous Pacing: Max 3 initial defibrillations/cardioversion until core temp above 86 F. If pacing not initially effective, re-attempt PRN when core temp above 86 F. Cardiac Medications: First round of cardiac drugs only until core temp above 86 F.

27 Nausea or Vomiting B Supportive measures Consider Oxygen PARAMEDIC Active Nausea or Vomiting (Six months of age or greater): Ondansetron (Zofran) 4mg IV/IO PRN. Pediatrics: 0.1mg/kg See RightDose Guide o Max single dose 4mg. Repeat once PRN. Option: If Zofran contraindicated Promethazine (Phenergan) mg in 100ml NS IV/IO Infusion over 5 10 min. Pediatrics: (Consult Medical Control) See RightDose Guide Immediately discontinue administration if burning or pain occurs at the site.

28 Non-Hypovolemic Hypotension PARAMEDIC Non-hypovolemic hypotension unresponsive to fluid challenge & supportive measures Dopamine (Intropin) Infusion 5 20mcg/kg/min titrate to effect. Pediatrics: Same as adult dosing See RightDose Guide If Dopamine Infusion ineffective: Epinephrine 2 10mcg/min titrate to effect. Pediatrics: 0.1 1mcg/kg/min. See RightDose Guide

29 Overdose / Poisoning / Toxic Exposure B Ensure Scene Safety: Hazmat, Law Enforcement & or Spec Opts as indicated Gather information on medications / substances / toxins exposed to or ingested. Dystonic reactions: (sustained involuntary muscle contractions associated with neuroleptic or stimulating agent). See Seizure Protocol PARAMEDIC Unknown or confirmed opiate use and airway, breathing or circulation compromised: Naloxone (Narcan) mg IV/IO/IN q 3-5 minutes PRN. Pediatrics: 0.1mg/kg See RightDose Guide o Max single dose 2mg Max total dose 10mg or 5 doses for pediatrics. Use caution and titrate to avoid withdrawal. Organophosphate Exposure with SLUDGE symptoms (insecticides, fertilizer): Atropine 2 3 mg IV/IO q 5 10 minutes PRN Pediatrics: 0.05mg/kg See RightDose Guide Aggressively reassess patient for changes. Assure adequate oxygenation. Beta blocker overdose Glucagon (Glucagen) 1mg IV/IO q 3 5 min PRN 0.5mg if 20 kg Max total 5 doses. Calcium channel blocker overdose Glucagon 1mg IV/IO q 3 5 min PRN 0.5mg if 20 kg Max total 5 doses. MD Consult medical control for treatment options.

30 Pain Management Manage the pain and associated anxiety of injuries, illnesses or treatment procedures (immobilization, manipulation, cardioversion or pacing, etc.) as early and liberally as possible if no hypotension, bradycardia, respiratory depression or other contraindications exist. Nausea control / prophylaxis Ondansetron (Zofran) IV/IO/PO 4mg. Pediatrics: 0.1mg/kg See RightDose Guide o Must be 6 months of age. o Max single dose 4mg. PARAMEDIC Fentanyl (Sublimaze) mcg slow IV/IO/IN q 5-10 min. PRN. Max total dose 400 mcg. Contact Medical Control to administer over 100mcg. Pediatrics: 1mcg/kg IV/IO or 1.5mcg/kg IN. See RightDose Guide o Max single dose 100mcg. o Repeat PRN, not to exceed 4 single doses. Midazolam (Versed) 1-2.5mg slow IV/IO/IN q 5-10 min. PRN. Max total dose 10mg. Contact Medical Control to administer over 5mg Pediatrics: 0.1mg/kg IV/IO or 0.5mg/kg IN. See RightDose Guide o Max single dose of 4mg IV/IO or 5mg IN. o Repeat once PRN. Option if hypersensitive to Fentanyl Morphine 2-4mg slow IV/IO q5-10 min. PRN. Max total dose 20mg. Contact Medical Control to administer over 5mg. Pediatrics: 0.1mg/kg See RightDose Guide o Max single dose of 4mg. o Repeat PRN, not to exceed 4 single doses. Option if Versed hypersensitivity Diazepam (Valium) 5 mg IV/IO over 2 min up to 10mg for most adults Max total dose 30mg. Contact Medical Control to administer over 5mg. Pediatrics: 0.2mg/kg IV/IO See RightDose Guide

31 Respiratory Distress or Failure B A Supportive care & monitor for any changes in airway or breathing. Assist patient with their prescribed rescue inhaler / breathing treatment. Asthma / COPD / bronchospasms / wheezing / rhonchi Albuterol 2.5mg nebulized q 5 10 min. PRN. If croup / stridor present and moderate to severe dyspnea or altered LOC: Racemic Epinephrine 0.5ml of 2.25% in 3ml NS nebulized q 5-10 min. PRN Asthma / COPD / bronchospasms / wheezing / rhonchi Albuterol 2.5mg / Ipratropium (Atrovent) 0.5mg nebulized q 5-10 min. PRN. Consider CPAP If rales / pulmonary edema present see: Acute CHF /Pulmonary edema. PARAMEDIC Magnesium Sulfate 2g in 100ml NS infusion over 10 minutes. Pediatrics: 50mg/kg See RightDose Guide Max single dose 2000mg (2g) Methylprednisolone (Solu-medrol) 125mg IV/IO. Pediatrics: 2mg/kg See RightDose Guide Max single dose 60mg Moderate to severe reactions unresponsive to Albuterol / Ipratropium / CPAP: Epinephrine 1: mg/ 0.3ml IM q 5-10 min. PRN. NEVER GIVE IV / IO Pediatrics: 0.01mg/kg See RightDose Guide Max single dose 0.3mg Severe Reactions: respiratory or cardiac failure unresponsive to initial primary treatments Epinephrine 2-10mcg/min titrate to effect. Pediatrics: 0.1-1mcg/kg/min See RightDose Guide

32 Seizures B Supportive care & monitor for any changes in airway or hemodynamics. Position, protect and insure adequate respiratory effort. Continuous or multiple seizures without regaining consciousness for more than 5 min No immediate IV/IO access available Midazolam (Versed) Intranasal 5mg q 5 10 min PRN. Pediatrics: 0.5mg/kg See RightDose Guide o Max single dose 5mg Max total dose 10mg PARAMEDIC Immediate IV/IO access available Diazepam (Valium) 5 mg IV/IO over 2 min up to 10mg for most adults Max total dose 30mg. Pediatrics: 0.2mg/kg IV/IO See RightDose Guide Option: Immediate IV/IO if hypersensitivity to Ativan (Lorazepam) Midazolam (Versed) 2mg q 3 5 min. Pediatrics: 0.1mg/kg See RightDose Guide o Max single dose 4mg Max total dose 8mg Option: eclampsia suspected correct seizures with benzodiazepine first then consider magnesium administration if no contraindications. Magnesium Sulfate 2g in 100ml NS infused over minutes. Option: Dystonic reactions: (conscious and oriented patients with sustained involuntary muscle contractions associated with neuroleptic or stimulating agent). Diphenhydramine (Benadryl) 25 50mg IV or (IM if IV not available). Pediatrics: 1mg/kg See RightDose Guide o Max single dose 50mg If symptoms do not subside in 3 5 minutes consider benzodiazepine regime.

33 Stroke / TIA Assess Cincinnati Pre-hospital Stroke Scale q15 min Facial Droop: (have the patient show teeth or smile) Normal Both sides of face move equally -0 Abnormal One side of face does not move as well as the other -1 BASIC Arm Drift: (close eyes & extends both arms straight out with palms up for 10 sec) Normal Both arms move the same or both do not move at all -0 Abnormal Pt. slurs words, uses the wrong words or is unable to speak -1 Abnormal Speech: (have the patient say you can t teach an old dog new tricks ) Normal Pt. uses correct words with no slurring -0 Abnormal Pt. slurs words, uses the wrong words or is unable to speak -1 If any one of these signs are abnormal, probability of stroke is 72%. Determine time of onset if possible. Activate Stroke Team at receiving facility as soon as possible. P BP 200/120 with stroke symptoms and no other associated serious complications Supportive care and transport to stroke center.

34 Traumatic Injuries B A Control blood loss with direct pressure. Apply wide band tourniquet if direct pressure is not effective. Position, Stabilize & Immobilize injuries according to PHTLS & BLS Guidelines. IV Access Protocol (Saline) Manage blood loss hypotension maintaining a systolic BP between 80 & 90mm Hg. Pain Management Chest & abdominal injuries Cardiac tamponade suspect: (Beck s Triad JVD, Hypotension, muffled heart tones) Rapid transport and aggressive fluid resuscitation to support pre-load. Tension pneumothorax suspected with signs of instability: Needle Thoracostomy. PARAMEDIC Abdominal evisceration: Seal with moist sterile dressings. Intubation pre-medication if head injury & neuro exam indicates signs of increasing ICP Lidocaine 1mg/kg IV/IO 3-5 minutes prior to intubation. Pediatrics: same as adult dose. See RightDose Guide Burns thermal or electrical Stop Burning Process and monitor airway. Utilize Sterile Water if possible to cool and stop the burning process. o Discontinue as soon as possible to prevent hypothermia. Use dry clean sheets to cover and protect the patient, add blankets as indicated. Utilize humidified oxygen with airway involvement and prepare for intubation PRN. Chemical or Radiation Utilize haz-mat as indicated. Brush off solids and flush liquids with copious fluid, remove clothing as indicated. Electrical Ensure spinal precautions, monitor for for arrhythmias and and consider secondary injuries.

35 Special Protocol Section Contents Advanced Directives Carbon Monoxide Exposure Communications Failure Destination Determination Field Determination of Death Interfacility Transfers Patient Refusals Patient Restraint Physician on Scene Scene Rehab Special Event & Operations Wellness Care

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37 Advanced Directives A&E Emergency Services, LLC and all supporting First Responder agency personnel must honor any valid advanced directive, including but not limited to Do Not Resuscitate (DNR), Do Not Intubate (DNI), Physicians Order for Scope of Treatment (P.O.S.T.) and or Living Wills. Ensure that the forms are properly completed and signed by the patient or Durable Power of Attorney for Healthcare (DPAHC) or Appointed Health Care Agent (HCA). ****Advanced Directive does not mean do not resuscitate unless clearly indicated**** Living Wills / Advance Directives: Must have patients name and signature. Must be witnessed by two adults or notarized by notary public. TN State DNR: Must have patient s full name. Attending physician s statement. o Date, printed name and signature of attending physician. Patient statement. o Date, printed name and signature of witness. o Printed name and signature of patient or durable power of attorney for health care. P.O.S.T. (physician orders for scope of treatment): Must have the patient s name and signature. Orders, basis for orders and physician s signature. Other State DNR forms Acceptable if they are complete and appear to be valid. If you have any questions as to the validity of a document and or what actions are appropriate, contact Medical Control immediately and maintain initial interventions as indicated until you receive medical directions. In the event of patient transport, copies of the advanced directives should accompany the patient and be turned over to the receiving facility staff. In the event of the patient s death, the paramedic on scene shall obtain a copy of the Advanced Directives and they shall become a part of the EMS medical record. In either situation document the presence, usage of and hand off of advanced directives in your narrative. EMS and first responder personnel have a duty to act when presented with a viable patient and a non-valid advanced directive. Explain the situation as professionally as possible to family or health care agents and continue care as indicated. Document thoroughly the situation in your narrative and add a copy of the incomplete form to your documentation if possible.

38 Carbon Monoxide Exposure This protocol is designed to allow EMS and First Response personnel, licensed and credentialed to utilize the Masimo RAD 57 device, to augment the standard assessment of individuals potentially exposed to carbon monoxide. The RAD 57 is not intended to be a single determinant of carbon monoxide exposure nor does it detect other toxins that can produce similar signs and symptoms. A comprehensive multi-disciplined approach to scene and patient assessment is the best practice to insure identification of exposure and effective management. INDICATIONS Known or suspected CO exposure o Fire, gas appliances or heat, combustion engines, smoking, etc. Unknown situations with unexplained symptoms relatable to CO exposure. Structure or wild-land fire scene management. Warnings All females of child bearing years should be assessed for pregnancy or the potential of pregnancy. Fetal hemoglobin has a greater attraction for CO than maternal, therefore all pregnant patients exposed to CO should be evaluated at the hospital. The absence or low level of CO is not a reliable predictor of other toxic exposures in fire related incidents. Signs and symptoms of CO exposure Headache Nausea / vomiting Flu-like symptoms Impaired judgment / altered mental status Dizziness Vision problems / reddened eyes Arrhythmias, Chest pain Shortness of breath Seizures, Syncope, Coma

39 CARBON MONOXIDE EXPOSURE UNIVERSAL PATIENT CARE PROTOCOL Measure COHb % (SpCO) SpCO 0% to 5% SpCO > 5% SpCO > 12% or SpO2 < 90% SpCO < 12% and SpO2 >90% No further medical evaluation of SpCO required (Pregnancy warning) 100% Oxygen by NRB and Transport Yes Symptoms of CO and/or Hypoxia No If performed with scene rehab, proceed with protocol. If cardiac / respiratory / neurological symptoms present, go to appropriate protocols No treatment for CO exposure required (Pregnancy warning) Recommend smoker cessation treatment Recommend evaluation of home / work / other.

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41 Communications Failure In the event that radio or telephone communications with Medical Control or the EMS Supervisor can not be established due to system failures and immediate interventions are needed to support life and promote healing of seriously injuried or ill patients, all authorized EMS and First Responder personnel may carry out established online Medical Control options as indicated appropriate by patient condition and according to provider level scope of practice if deemed necessary. Medical Control & the EMS Supervisor should be notified as soon as possible for futher direction. Thorough documentation in the epcr should include: Description of communications failure. Indications for treatment. Times, treatments & medications given. Patient response. Medical Control & Supervisor notification. This protocol should not be used to terminate resuscitative efforts unless all available means have been exhausted and transport cannot be established due to circumstances beyond crew capabilities. EMS Supervisor should report events to the chain of command for review.

42 Destination Determination (Revised September, 2011). Sick or injured persons who are in need of transport to a health care facility by a ground or air ambulance requiring licensure by the State of Tennessee should be transported according to these destination rules. (1) Trauma patients - The goal of the pre-hospital component of the trauma system and destination guidelines is to minimize injury through safe and rapid transport of the injured patient. The patient should be taken directly to the center most appropriately equipped and staffed to handle the patient s injury as defined by the region s trauma system. These destinations should be clearly identified and understood by regional prehospital personnel and should be determined by triage protocols or by direct medical direction. Ambulances should bypass those facilities not identified by the region s trauma system as appropriate destinations, even if they are closest to the incident. (2) Beginning no later than six (6) months after the designation of a trauma center in any region, persons in that region, who are in need of transport who have been involved in a traumatic incident and who are suffering from trauma or a traumatic injury as a result thereof as determined by triage at the scene, should be transported according to the following rules. a. Adult (greater than or equal to fifteen (15) years of age) and Pediatric (less than fifteen (15) years of age) Trauma Patients will be triaged and transported according to the flow chart labeled Field Triage Decision Scheme in Resources For Optimal Care of the Injured Patient: 1999, or any successor publication. The Pediatric Trauma Score shall be used as published in Basic Trauma Life Support for Paramedics and Other Advanced EMS Providers, Fourth Edition, Copies of the charts are available from the Division. 1. Step One and Step Two patients should go to a Level 1 Trauma Center or Comprehensive Regional Pediatric Center (CRPC), either initially or after stabilization at another facility. EMS field personnel may initiate air ambulance response. 2. Step One or Step Two pediatric patients should be transported to a Comprehensive Regional Pediatric Center (CRPC) or to an adult Level 1 Trauma Center if no CRPC is available. Local Destination Guidelines should assure that in regions with two CRPC s or one CRPC and another facility with Level 1 Adult Trauma capability, that seriously injured children are cared for in the facility most appropriate for their injuries. 3. For pediatric patients, a Pediatric Trauma Score of less than or equal to 8 (<8) will be considered as a cutoff level for Step One patients. 4. Local or Regional Trauma Medical Control may establish criteria to allow for nontransport of clearly uninjured patients. 5. Trauma Medical Control will determine patient destinations within thirty (30) minutes by ground transport of a Level 1 Trauma Center or CRPC. b. Exceptions apply in the following circumstances: 1. For ground ambulances, when transport to a Level I Trauma Center will exceed thirty (30) minutes, Trauma Medical Control will determine the patient s destination. If Trauma Medical Control is not available, the patient should be transported to the closest appropriate medical facility. 2. For air ambulances, Step One patients will be transported to the most rapidly accessible Level I Trauma Center, taking safety and operational issues into consideration. Step Two, Three, and Four patients will be transported to a Level I Trauma Center as determined by the air ambulance s Medical Control. The Flight Crew will make determination of patient status on arrival of the air ambulance. 3. Air ambulances will not transport chemical or radiation contaminated patients prior to decontamination. 4. If the Trauma Center chosen as the patient s destination is overloaded and cannot treat the patient, Trauma Medical Control shall determine the patient s destination. If Trauma Medical Control is not available, the patient s destination shall be determined pursuant to regional or local destination guidelines. 5. A transport may be diverted from the original destination: i. if a patient s condition becomes unmanageable or exceeds the capabilities of the transporting unit; or ii. if Trauma Medical Control deems that transport to a Level I Trauma Center is not necessary. c. Utilization of any of the exceptions listed above should prompt review of that transport by the quality improvement process and the medical director of the individual EMS providers. d. Trauma Medical Control can be accomplished by a Trauma or Emergency Physician on duty at a designated

43 Trauma Center or by protocols established in conjunction with a Regional Level I Trauma Center. (3) Pediatric Medical Emergency - Pediatric patients represent a unique patient population with special care requirements in illness and injury. Tennessee has a comprehensive destination system for emergency care facilities in regards to pediatric patients where there are variable levels of available care, as defined in Rule a. There are circumstances in pediatric emergency care as determined by local medical control where it would be appropriate to bypass a basic or a primary care facility for a general or comprehensive regional pediatric center. 1. Examples of such circumstances include, but are not limited to the following i. On-going seizures ii. A poorly responsive infant or lethargic child iii. Cardiac arrest iv. Significant toxic ingestion history v. Progressive respiratory distress (cyanosis) vi. Massive gastrointestinal (GI) bleed vii. Life threatening dysrhythmias viii. Compromised airway ix. Signs or symptoms of shock x. Severe respiratory distress xi. Respiratory arrest xii. Febrile infant less than two months of age. 2. Pediatric medical emergency transport may be diverted from the original destination if the patient s condition becomes unmanageable or exceeds the capability of the transporting unit, in which case the patient should be treated at the closest facility. 3. Pediatric medical emergency air ambulance transports must go to a Comprehensive Regional Pediatric Center. b. Pediatric trauma patients should be taken to trauma facilities as provided in paragraph (2). (4) Any patient who does not qualify for transport to a Trauma Center or a Comprehensive Regional Pediatric Center should be transported to the most appropriate facility in accordance with regional or local destination guidelines. (5) Adults or children with specialized healthcare needs beyond those already addressed should have their destination determined by Medical or Trauma Control, by regional or local guidelines, or by previous arrangement on the part of patient (or his/her family or physician). (6) A transport may be refused or an alternate destination requested. If so, non-transport of the patient, or transport of the patient to an alternate destination shall not violate this rule and shall not constitute refusal of care. Authority: T.C.A , , , , and Administrative History: Original rule filed October 15, 2002; effective December 29, (Revised Sept. 2011).