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1 Altered Mental Status/Coma Asthma Chest Pain CPAP Hypoglycemia Intraosseous Infusion (EZ IO) Adult Intraosseous Infusion (EZIO) Pediatric Poisoning and/or Overdose Seizure Spinal Immob. Decision Tree s Content Page Updated 1/30/14

2 Altered Mental Status/Coma ABC s Oxygen Assist Ventilations, as needed. Consider IV/IO NS. Detailed Assessment. Check blood sugar 1 2. Consider cardiac monitor 3 Possible causes: Head Injury CVA Diabetes Seizure Overdose Hypotension. Hypertension. Poisonings. Metabolic. Psychiatric. Sepsis 90 mmhg 80 BP Blood Sugar < 90 mmhg < 80 Consider Narcan 4 See SHOCK protocol See Hypoglycemia protocol Increased LOC Glasgow Coma Scale Eye Spontaneous 4 Opening To Voice 3 To Pain 2 ne 1 Best Oriented 5 Verbal Confused 4 Response Inappropriate words 3 Incomprehensible words 2 ne 1 Best Obeys Commands 6 Motor Localizes Pain 5 Response Withdraws (Pain) 4 Flexion 3 Extension 2 ne 1 Increased LOC Transport Keep patient warm Monitor LOC, Vital Signs, SpO2, & Respiratory Status May repeat Narcan every 5 min as needed Clinical Response to Dextrose or Narcan Blood Sugar SpO2 IV Fluid Totals Medical History Exam Vital Signs 1. Detailed Assessment: Document Glasgow Coma Scale. Check odor on breath. Look for Medical Alert tags, needle tracks, and evidence of trauma. If trauma noted, consider C-spine precautions. 2. Observe environment closely for signs of potential overdose. If suspected overdose, see overdose protocols. 3. If applicable, print a rhythm strip from the cardiac monitor for ER staff. 4. Narcan may be administered prior to Dextrose. Narcan 0.4 mg IV/IO or IM, prn (some agonist/antagonist narcotic overdoses may require higher doses of Narcan, i.e. methadone). Narcan via intranasal (IN) 0.8 mg - 2 mg (split the total dose between each nostril). If no response may repeat IN dose x 1. Pediatric dose: < 20 kg 0.01 mg/kg, > 20 kg 0.4 mg initial dose repeat, prn. Constricted pupils may suggest narcotic overdose. Be prepared to restrain combative patient.. Reviewed: 5/11/15 Revised: 5/12/15 ALTERED MENTAL STATUS/COMA Copyright 2000 William Porter Porter's EMS s

3 Asthma ABC s Oxygen 100% 1 Assist Ventilations, as needed IV/IO NS Resp distress - Albuterol via nebulizer 2 Albuterol: 2.5 mg in 2 cc NS - Consider Anaphylaxis reaction Transport Keep patient warm Monitor LOC, Vital Signs, SpO2, & Respiratory Status Airway Breath Sounds Skin Color Vital Signs, SpO2 Treatment Response to treatment 1. If COPD co-exists titrate Oxygen to maintain SpO2 > 90%. 2. Albuterol: may repeat continuously. Discontinue use if patient develops chest pain. Reviewed: 05/12/14 Copyright 2000 William Porter Porter's EMS s ASTHMA

4 Chest Pain Suspected Ischemic Chest Pain ABCs. Vital Signs. room air Oxygen Consider cardiac monitor IV/IO NS 1 Consider the following treatment options: Nitroglycerin SL 0.4 mg 2 Aspirin PO 324 mg 3 3/3/15 Transport per County Emergency Cardiac operating procedure Keep patient warm Monitor LOC, Vital Signs, SpO2 & Respiratory Status ABCs Medical History Signs & Symptoms Quality of Pulses SpO2, VS Color, Diaphoresis Lung Sounds Response to Treatment 1. Be aware that ischemic cardiac pain can present as abdominal or back pain, especially in females & older patients. 2. Nitroglycerin SL sublingual is contraindicated if systolic BP < 90 mmhg. If the patient has taken Viagra or Levitra within 24 hours, or Cialis within 48 hours do not administer Nitroglycerin. If the patient meets criteria administer 1 dose sublingual (under the tongue). Max of 3 doses total given at one dose at a time of 0.4 mg per dose every 3-5 minutes for chest pressure/pain. Recheck BP prior to each dose. 3. Aspirin is contraindicated in cases of known hypersensitivity. Aspirin may be withheld if the patient has definitely taken 324 mg of Aspirin within the last 24 hours. Reviewed: 3/2/15 Revised: 3/3/15 Copyright 2000 William Porter Porter's EMS s CHEST PAIN

5 CPAP For patients with moderate to severe respiratory distress or progressive symptoms 1 Apply oxygen as indicated Prepare patient for CPAP - inform them of procedure and sensation of CPAP Place CPAP mask and seucre to patient Possible Causes: COPD CHF Pneumonia Aspiration Asthma If adjustable PEEP, start setting at 5 cm H2O. Increase in 2.5 cm H2O increments as needed for oxygenation 2 Assess lung sounds and vitals after placement Administer medications as indicated Monitor for side effects of positive pressure ventilation 4 - Give in-line nebulized medications if indicated 3 - If giving oral/sublingual medications, try to administer prior to CPAP placement to prevent aspiration. Otherwise, remove mask to give needed medications (i.e. NTG, ASA). Allow them to be completely swallowed or dissolved. Reassess breath sounds/vital signs frequently (slowing of heart rate is a typical sign of improvement) For progressive respiratory failure, consider calling ALS 5 tify receiving facility that the patient is arriving on CPAP Contraindications: Unconscious Vomiting Hypotension (SBP<90 mmhg) Trauma Suspected Pneumothorax Inability to seal mask Patient unable to cooperate (this can often be mitigated with effective coaching) 11/18/15 1. Use CPAP early or if initial round of therapy is ineffective. For example, if arriving to a COPD call and the patient looks poor at the initial evaluation (i.e. hypoxia, increased work of breathing) move quickly to CPAP with nebulized therapies. 2. Do not increase PEEP if systolic BP is < 90 mmhg. 3. For patients with severe asthma prioritize administration of continuous albuterol. CPAP can be a useful adjunct if they are having ineffective respiratory effort or to assist in medication delivery if no improvement from albuterol treatments alone. 4. Positive pressure ventilation can cause hypotension by decreasing venous return. For dehydrated patients who have pneumonia or COPD, a small fluid bolus may be necessary to avoid hypotension once CPAP is started. Watch for gastric distension and vomiting. Remove mask if vomiting occurs. 5. If patient continues to deteriorate despite CPAP, remove CPAP and assist ventilations with 100% O2 via BVM as needed. Prepare for advance airway placement. Reviewed: 11/18/15 Revised: 11/18/15 CPAP Porter's EMS s Copyright William Porter

6 Hypoglycemia ABC s Oxygen Assist Ventilations, as needed Check blood glucose level Consider cardiac monitor > 80 Blood sugar < 80 Ability to Swallow Administer Oral Glucose 1 IV/IO NS Dextrose 50% 25g IV slowly 2 Blood sugar < 80 Repeat Dextrose 50% 25g IV slowly > 80 Transport Keep patient warm Monitor LOC, Vital Signs, SpO2, and Respiratory Status. Observe for decreased LOC 3 Airway Respiratory Effort Vital Signs, SpO2 Treatment Signs & Symptoms. Blood Sugar Readings 1. Full glass of sweetened juice or Glucose Oral PO. Must be able to swallow. 2. Administer 0.5 g/kg Dextrose 25% in children (1-12 years). For infants (newborn 1 year) administer 0.5 g/kg Dextrose 12.5%. Recheck blood sugar following initial Dextrose dose. If blood sugar remains < 80, repeat initial dose. 3. Observe for decreased LOC, focal neurological findings, and hypothermia. Reviewed: 05/12/14 Copyright 1996 William Porter Porter's EMS s HYPOGLYCEMIA

7 Intraosseous Infusion - Adult Indications: Adult EZ IO infusion is an option in unstable (altered LOC, hypotensive) patients where IV access is or is anticipated to be difficult or prolonged. Relative Contraindications/Precautions:. Fracture of the bone selected for IO infusion (consider alternate site). Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site). Previous significant orthopedic procedures (IO within 24 hours, prosthesis - consider alternate site). Infection at the site selected for insertion (consider alternate site) Conscious patient Unconscious patient Initiate EZ IO access according to the Instructions for Placement 40 kg and over use Blue 25 mm 15g EZ IO needle Over 40 kg with excessive tissue over site use Yellow 45mm 15g EZ IO needle Under 40 kg use Pink 15mm 15g EZ IO needle Use IV fluids and medications as dictated per protocol. Verifying correct IO placement with either aspiration of bone marrow or resistance free flushing with 10 ml NS via a syringe. Set up gravity infusion or pressure infusion as needed. Maintain fluid flow rate or administer fluids according to specific protocols Watch for IO complications. Correct or discontinue as appropriate. ie: localized tissue edema, irritation, adverse reactions, leakage, low flow rate. Record time of IO initiation, discontinuation, and changeover to hospital IV devices and solutions. Review: 05/12/14 Porter's EMS s Copyright William Porter INTRAOSSEOUS INFUSION (ADULTS) with the EZ IO

8 Intraosseous Infusion - Pediatric Indications: Pediatric EZ IO infusion is an option in unstable (altered LOC, hypotensive) patients where IV access is or is anticipated to be difficult or prolonged. Relative Contraindications/Precautions:. Fracture of the bone selected for IO infusion (consider alternate site). Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site). Previous significant orthopedic procedures (IO within 24 hours, prosthesis - consider alternate site). Infection at the site selected for insertion (consider alternate site) Conscious patient Unconscious patient Initiate EZ IO access according to the Instructions for Placement 40 kg and over use Blue 25 mm 15g EZ IO needle Over 40 kg with excessive tissue over site use Yellow 45mm 15g EZ IO needle Under 40 kg use Pink 15mm 15g EZ IO needle Use IV fluids and medications as dictated per protocol. Verifying correct IO placement with either aspiration of bone marrow or resistance free flushing with 10 ml NS via a syringe. Set up gravity infusion or pressure infusion as needed. Maintain fluid flow rate or administer fluids according to specific protocols Watch for IO complications. Correct or discontinue as appropriate. ie: localized tissue edema, irritation, adverse reactions, leakage, low flow rate. Record time of IO initiation, discontinuation, and changeover to hospital IV devices and solutions. Review: 05/12/14 Porter's EMS s Copyright William Porter INTRAOSSEOUS INFUSION (Pediatric) with the EZ IO

9 Poisoning and/or Overdose ABC s Oxygen, Assist Ventilations, as needed Consider cardiac monitor Check Blood Sugar & Temperature Detailed Assessment IV/IO NS Consider calling Poison Control 1 Internal Contamination: What was ingested Time of consumption Amount consumed Past medical history External Contamination: Protect self and crew Remove contaminated clothing Flush contaminated skin and eyes with copious amount of water Carbon Monoxide Poisoning () - S/S: mild HA, dyspnea on mild exertion, irritability, fatigue, N/V, confusion, ataxia, syncope, seizures, incontinence, respiratory arrest, skin may be bright red in some cases - Provide 100% Oxygen with a tight fitting NRB at LPM Narcotics () - S/S: CNS and/or respiratory depression, drowsiness, N/V, pinpoint pupils, coma, cyanosis, bradycardia - Consider Narcan 2 Organophosphate Exposure () (Parathion, Malathion, Pesticides & Herbicides) - S/S: Salivation, Lacrimation, Urination, Defecation, Gastric emptying, Emesis - Consider Oxygen Transport Keep patient warm Monitor LOC, Vital Signs, SpO2, Cardiac Rhythm, Respiratory Status, CO levels 3 Signs & Symptoms Treatment Clinical Response to treatment Vital Signs, SpO2 Airway Management 1. Poison Control EMS #: Consider administering Narcan before supraglottic airway insertion. A brief trial of Narcan may quickly reverse the patient s condition. Narcan may be administered prior to Dextrose. Narcan 0.4 mg IV/IO or IM, prn (some agonist/antagonist narcotic overdoses may require higher doses of Narcan, i.e. methadone). Narcan via intranasal (IN) 0.8 mg - 2 mg (split the total dose between each nostril). If no response may repeat IN dose x 1. Pediatric dose: < 20 kg 0.01 mg/kg, > 20 kg 0.4 mg initial dose repeat, prn. Constricted pupils may suggest narcotic overdose. Be prepared to restrain combative patient. 3. CO levels > 10 is consider serious. Reviewed: 5/11/15 Revised: 5/12/15 POISONING AND/OR OVERDOSE Copyright 2000 William Porter Porter's EMS s

10 Seizure ABC s. Consider C-spine precautions Oxygen Assist Ventilations, as needed Detailed Assessment Consider cardiac monitor IV/IO NS Protect patient from injury during and after seizure. After seizure has stopped consider placing patient in lateral recumbent position if trauma absent. > 80 Blood Sugar < 80 Dextrose 50% 25g IV/IO 1 Elevated Temp Consider external cooling methods 2 Dr. Larry O. Smith 3 Transport Anticipate additional seizures Monitor: LOC, Vital Signs, SpO2, & Respiratory Status ABCs Activity During Seizure Duration of Seizure Postictal Phase Vital Signs SpO2 Lung Sounds Color Treatment Response to Treatment Communication with Medical Control 1. Administer 0.5 g/kg Dextrose 25% in children (1-12 years). For infants (newborn 1 year) administer 0.5 g/kg Dextrose 12.5%. Recheck blood sugar following initial Dextrose dose. If blood sugar remains < 80, repeat initial dose. 2. Loosen clothing, mist and/or fan patient. 3. Provide a quiet, calm environment. Reviewed: 05/12/14 Copyright 2000 William Porter Porter's EMS s SEIZURE

11 Spinal Immobilization Decision Tree Patient conscious at time of exam Patient denies LOC after injury Patient Alert, Oriented x 3 Patient is unaffected by alcohol or any mind altering substance Significant findings: Significant injury above clavicles Loss of consciousness Paralysis, weakness, numbness, tingling within extremities Point tenderness over spine Patient reliable historian Patient denies spinal pain Patient denies spinal tenderness on palpation Patient denies neuro deficits Patient has no other (distracting) injury Provider may choose not to immobilize 1 Airway Respiratory Status Circulation Neurologic Status Detailed Assessment Vital Signs, SpO2 Treatment 1. Consider immobilizing if significant MOI, and/or extreme of age (<15 or >60). Reviewed: 05/12/14 Copyright 1996, 1998, 2000 William Porter Porter's EMS s Spinal Immobilization Decision Tree