Field Reference Protocol 2016

Transcription

1 Field Reference Prtcl 2016 Octber, 2015, Revised January 1, 2016, Revised June 15,

2 1. General General Cnsideratins Rutine Standard f Care AIRWAY / RESPIRATORY Airway Management Oral and Nasal Intubatin RSI Pharmaclgy and Prcedure Pst-Intubatin: Analgesia, Sedatin, and Paralysis Acute Brnchspasm Cardigenic Pulmnary Edema Acute Pulmnary Emblism CARDIAC Acute Crnary Syndrme Cardiac Dysrhythmias TACHYcardia Cardiac Dysrhythmias BRADYcardia Cardiac Arrest Atrial Fibrillatin and Atrial Flutter Neurprtective Therapeutic Hypthermia MEDICAL Anaphylaxis and Allergic Reactins Diabetic Emergencies GI Bleed Ischemic and Hemrrhagic CVA, TIA, and Nn-Traumatic SAH Abdminal Artic Aneurysm Artic Dissectin Sepsis HYPOkalemia HYPERkalemia Magnesium Derangements HYPOcalcemia Seizure Management Refractry Shck Antihypertensive Medicatin Reference TRAUMA Abdminal and Pelvic trauma Burns Majr Chest Trauma Extremity Trauma Scalp, Facial, and Neck Trauma Traumatic Brain Injury Near Drwning Ocular Trauma Spinal Trauma Acute Resuscitatin f the Unstable Trauma Patient MISCELLANEOUS Alchl Emergencies Behaviral (Suicidal) Frstbite HYPERthermia HYPOthermia Overdse ANALGESIA in the patient withut an advanced airway SEDATION in the patient withut an advanced airway Suspected Cyanide txicity PROCEDURES Packed Red Bld Cells Tranexamic Acid Management f Cagulpathy Rapid reversal f cagulpathy in nn-traumatic ICH EZ-IO Intrasseus Vascular Access...37 Octber, 2015, Revised January 1, 2016, Revised June 15,

3 7.6. Scalp Wund Stapling fr hemrrhage cntrl Pelvic Binder MECHANICAL VENTILATION Nn-Invasive Mechanical Ventilatin (NPPV) Brnchdilatr Administratin fr ventilated patients Transvenus / Epicardial Pacemaker Needle Thracstmy Simple Thracstmy Tube Thracstmy Arterial Cannulatin Radial Arterial Cannulatin Femral Eschartmy Hemstatic Gauze Surgical Cricthyrtmy Needle Cricthyrtmy PEDIATRICS Pediatric Mnitring and General Cnsideratins Pediatric Airway Management Pediatric Cardiac Arrest Pediatric Fluid Resuscitatin and Maintenance Pediatric Hypthermia Pediatric Sepsis Pediatric Pisning Pediatric Respiratry Failure Pediatric Seizures Pediatric Refractry Shck Pediatric Spinal Injury Pediatric Sedatin Pediatric Analgesia Pediatric DKA Pediatric Cyantic Heart OBSTETRICAL EMERGENCIES General Cnsideratins with Pregnant Patients Vaginal bleeding asssciated with pregnancy Pain and/r nausea in pregnancy Pregnancy Induced Hypertensin Preterm Labr Premature rupture f membranes Trauma in Pregnancy Unplanned deliveries Cmplicatins f Delivery Ruptured Ectpic Pregnancy Appendix A Intubatin Tips Drug Mixing Reference Octber, 2015, Revised January 1, 2016, Revised June 15,

4 1. General 1.1. General Cnsideratins Optimize pre-departure interventins t diminish the ptential fr enrute deteriratin Respnd aggressively t deteriratin with interventins guided by the prtcls and, if necessary, with On Line Medical Directin (yu may ften be best served by starting with an LOM Medical Directr) Seek t achieve applicatin f tertiary r quaternary care perspective and technlgy t integrate int the care f the patient frm the referring surce int that f the receiving facility POLICY: The Critical Care Transprt Team, under the guidance f designated On Line Medical Directin (O.L.M.D.) will fllw the utlined prtcls and prcedures t meet the needs f the patient, their family and the referring staff. These guidelines apply t bth the paramedic and nurse disciplines f the LifeFlight f Maine Critical Care Transprt Team Nte: This prtcl manual will nt suffice as a tutrial r substitute fr training, educatin, experience and a cmmitment by prviders t lifelng learning Rutine Standard f Care Universal precautins Vital sign mnitring cmmensurate with clinical manifestatin f the patient and, at a minimum, every 30 minutes As patient acuity dictates, interventins include Cardiac Mnitr Pulse Oximetry Nasal Capngraphy Serial BP mnitring Serial 12 Lead Electrcardigraphy Analgesia and sedatin apprpriate t the patient s cnditin Apprpriate airway management Apprpriate respiratry assistance Oxygen therapy via Nasal Cannula, NRB, r ther device as apprpriate fr the patient cnditin Apprpriate ventilatr management, when applicable Reliable intravenus access fr medicatin and fluid administratin Apprpriate fluid therapy and bleeding cntrl Gastric decmpressin as indicated fr patient cnditin Identify r btain a thrugh histry and physical exam Identify r btain diagnstic infrmatin necessary t supprt a wrking diagnsis and the treatment plan that fllws Aseptic technique fr all invasive prcedures Unless specified, all medicatins are t be administered via peripheral IV r IO Cntinuus wavefrm capngraphy fr ALL intubated patients Cntinuus wavefrm mnitring if the patient has a PA/Arterial Catheter r ICP mnitr Dcumented bld glucse in patients with altered mental status Prvide cmplete verbal reprt t receiving staff Assure referring assessment, diagnstics, and treatments have been included in transfer f care Paper handff frm, dcumenting care prvided by LOM crew, is REQUIRED NOTE: Ketamine shuld nt be used as prcedural sedatin. Unless being administered fr RSI, cntact with LOM medical directin MUST be made if intended t be used n a patient withut a Supraglttic r endtracheal airway in place. Octber, 2015, Revised January 1, 2016, Revised June 15,

5 2. AIRWAY / RESPIRATORY 2.1. Airway Management Clinical Indicatins Respiratry Distress and/r hypxia Obstructed Airway Apnea Ineffective xygenatin r ventilatin Anticipated clinical curse 2.2. Oral and Nasal Intubatin Indicatin Cmprmised xygenatin r ventilatin Cmprmised airway patency Anticipated r realized patient r crew safety Any prisner r patient in prtective custdy being transprted by an LOM crew in an aircraft shuld be discussed with a Medical Directr r OLMC (Refer t LOM Plicies and Prcedures 7.10) Any cmbative patient being transprted by an LOM crew in an aircraft (Refer t LOM Plicies and Prcedures 7.11) Cnsider discussin with LOM medical cntrl if plan is t transprt patient in the back f a grund ambulance withut chemical restraint Prcedure As prescribed in the LOM CCTTP 2015 Prtcl 2.3 As practiced in simulatin and at the CCTI Airway Lab Utilizatin f the RSI checklist is expected t mitigate errr and reduce risk f negative effects frm LOM interventins Each attempt at intubatin shall be dcumented as a separate line entry n the interventins page f the patient care recrd. An attempt is defined as laryngscpy with the intent t place a tracheal device if a desirable view is achieved, prir t a drp in saturatin r BVM interventin LOM medical directin recmmends utilizatin f the bugie and the CMAC laryngscpe fr all intubatin attempts, when pssible Cnfirmatin f placement As prescribed in LOM 2015 Prtcl 2.3 Cntinuus mnitring f ETCO2 wavefrm is required and shuld be cnnected t the BVM prir t initiatin f prcedure, when pssible While CXR is a useful tl, it is nt mandatry, des nt cnfirm placement, merely depth and can be deferred by the LOM crew wh visualizes balln lcatin during placement f the endtracheal tube When pssible, Gastric Decmpressin shuld be achieved in all intubated patients When pssible, the head f the stretcher shuld be elevated t Fr nastracheal intubatin prcedure, refer t Maine EMS Blue Respiratry sectin fr details If intubatin is unsuccessful, cnsider placement f Supraglttic Airway (King r LMA) If Supraglttic Airway AND BLS maneuvers are ineffective (Can t intubate, Can t ventilate) Age 8 Refer t FRP 7.19 fr surgical cricthyridtmy Age < 8 Refer t FRP 7.20 fr needle cricthyridtmy Be sure that dcumentatin includes: Indicatin fr prcedure Octber, 2015, Revised January 1, 2016, Revised June 15,

6 Vital signs (including pulse ximetry) befre, during and after prcedure including printed ETCO2 wavefrms and values Medicatins, rutes and dses ETT size and depth Verificatin f prper placement f ETT Pediatrics: Cuffed ETT in the pediatric ppulatin is the standard. This shuld nt be cause fr changing an therwise functining uncuffed ET tube, which has been previusly placed Use a length based resuscitatin tape r apprved digital equivalent!"!!"# (!"!"#$%) (Nrmal ETT size calculatin 0.5mm)! 2.3. RSI Pharmaclgy and Prcedure NOTE: This prcedure shuld be used in cnjunctin with the LOM RSI Checklist PREPARATION D N Harm As it relates t the patient and the prcedure yu are perfrming Anticipate and prepare patients fr prbable physilgic decmpensatin as it relates t existing r anticipated Hemdynamic instability Hypxia Metablic Acidsis Oxygenatin/Denitrgenatin NRB fr three minutes r 8 Vital capacity breaths, if pssible Nn-Invasive Psitive Pressure ventilatin with PEEP BVM with 100% FiO2 and PEEP valve PSV with PEEP using the Revel ventilatr and mask Mnitr Cnsider changing AUTO cuff frequency t every 2 minutes ECG, SpO2, Wavefrm capngraphy, NIBP Reliable and patent IV/IO access Medicatins Premedicatin Inductin Paralytic Pst-intubatin sedatin and analgesia POSITIONING If pssible, elevate the head t sniffing psitin Cnsider semi-fwlers psitin fr mrbidly bese patients Maintain spinal immbilizatin as indicated Equipment, Mnitrs, Assistants arund prcedure lcatin Nasal Cannula Passive Flw Apneic Oxygenatin at 15lpm CMAC and back up laryngscpe ETT and alternative size Bugie Supraglttic device BVM with PEEP, cnnected t xygen and capngraphy Surgical airway kit PREMEDICATION Atrpine 0.02 mg/kg Cnsider if AGE < 1 cnsider BE AWARE, sme Nn-LOM prviders may ask fr atrpine in children less than 5 years f age Octber, 2015, Revised January 1, 2016, Revised June 15,

7 MINimum dse 0.1mg MAXimum dse 0.5mg Fentanyl 1-3 mcg/kg Cnsider blunting respnses t intubatin with suspected increased ICP Use cautin in multisystem trauma patients MINimum dse: Nne MAXimum dse: 250mcg INDUCTION If pssible, Cnsider reducing the dse f inductin agent if the patient is hemdynamically unstable Etmidate 0.3mg/kg MINimum dse: Nne MAXimum dse: 40mg Onset: secnds Duratin: 3 12 minutes Ketamine 1 2mg/kg MINimum dse: Nne MAXimum dse: 500mg Onset: 30 secnds Duratin: 5 15 minutes High Flw Nasal Cannula if nt already turned t 15lpm PARALYSIS Succinylchline 2mg/kg CAUTION: Repeat dses f Succinylchline have ptential t cause severe bradycardia. Cnsider pretreating with Atrpine 0.02 mg/kg up t 0.5mg Cnsider Nn-deplarizing agent MINimum dse: Nne MAXimum dse: 200mg Onset: secnds Duratin: 4 12 minutes CONTRAindicatins Knwn r suspected hyperkalemia (K+ > 5.5) Histry f Malignant Hyperthermia Burns > 5 days healed Crush injuries > 5 days healed Spinal Crd Injury / CVA > 5 days 6 mnths Neurmuscular disease, mypathy Intra-abdminal Sepsis > 5 days reslutin f infectin Rcurnium mg/kg MINimum dse: Nne MAXimum dse: Nne Onset: 1 2 minutes Duratin: minutes Vecurnium 0.15mg/kg MINimum dse: Nne MAXimum dse: Nne Onset: secnds Duratin: minutes INTUBATION Refer t FRP POST-INTUBATION Adults - Refer t FRP 2.4 Pediatrics - Refer t FRP and Octber, 2015, Revised January 1, 2016, Revised June 15,

8 2.4. Pst-Intubatin: Analgesia, Sedatin, and Paralysis Analgesia If staff are utilizing Ketamine as sedatin, cncurrent dsing f analgesia is nt indicated Fentanyl BOLUS mcg/kg q 5 10 mins Fentanyl INFUSION mcg/kg/hr Mrphine BOLUS 1 10mg q 15 Mrphine INFUSION mg/kg/hr Ketamine BOLUS mg/kg q 15 mins Ketamine INFUSION mg/kg/hr Sedatin Midazlam BOLUS 1 5 mg q 5 10 mins Midazlam INFUSION mg/kg/hr Lrazepam BOLUS 1 4 mg q 15 minutes Lrazepam INFUSION mg/kg/hr Prpfl BOLUS via IV Pump 1 2 mg/kg blus Repeat as needed If MAP > 65 Prpfl INFUSION 5 200mcg/kg/min If MAP > 65, titrate as indicated Ketamine BOLUS mg/kg q 15 mins Ketamine INFUSION mg/kg/hr Paralysis Special Cnsideratin If patient s minute ventilatin is abve the ventilatr settings, prir t medicatin, crrect ventilatr settings as needed and apprpriate If staff feel that they are nt able t manage the patient s effectively withut the use f muscle relaxants (i.e. paralytics,) medical directin supprts the use f these medicatins. It is imperative t have a detailed neurlgical exam recrded. Rcurnium mg/kg q 30 minutes as needed MAX dse 150mg Vecurnium 0.1 mg/kg q 45 minutes as needed MAX dse 10mg NOTE: Ketamine shuld nt be used as prcedural sedatin. Unless being administered fr RSI, cntact with LOM medical directin MUST be made if intended t be used n a patient withut a Supraglttic r endtracheal airway in place Acute Brnchspasm Octber, 2015, Revised January 1, 2016, Revised June 15,

9 (DuNeb r Cmbivent) Albuterl 2.5mg/Ipratrpium0.5mg Mixed in nebulizer and given ver 5 15 minutes Cntraindicated in patients with peanut allergy After 2 dses, cnsider cntinuus albuterl nebulizer and discntinue ipratrpium administratin If INTUBATED Place MDI adapter n inhalatin circuit f ventilatr tubing Initial brnchdilatr therapy shuld cnsist f any cmbinatin f the fllwing Albuterl MDI 8 puffs, pausing in between puffs t allw adequate distributin and effect Albuterl and/r Ipratrpium via in line NEB One initial dse f Ipratrpium is all that is necessary Subsequent inhalatin medicatin shuld cnsist f Albuterl Identify r prvide dse f Methylprednislne 125mg Cnsider Magnesium Sulfate 2g in 100mL ver 30 minutes If abve ineffective, administer Epinephrine 1: mg IM q 15 minutes x 3 dses in patients with life threatening respiratry distress r refractry shck. Use cautin in patients with cardivascular disease r ver the age f Cnsider NPPV and Refer t FRP Permissive hypercapnea is preferable t inducing vlutrauma Special CASES Crup Dexamethasne (Discuss with sending clinician) 0.6 mg/kg PO / IV MAX 10mg (IV can be given PO) Racemic Epinephrine 0.05 ml/kg f 2.25% slutin t a max dse f 0.5mL via NEBulizer Epiglttitis r undifferentiated stridr If patient is unable t maintain secretins r a patent airway, cnsider securing airway in an perating rm with multiple ptins and resurces available t the LOM crew Identify r btain brad spectrum antibitics if suspected infectius prcess 2.6. Cardigenic Pulmnary Edema Identify r btain histry, exam, and diagnstics t cnfirm diagnsis If MAP belw 65, Refer t FRP If MAP > 65 Nitrglycerin 0.4mg SL Nitrglycerin Drip mcg/min Fursemide mg Cnsider prviding ttal daily dse up t a MAX f 80mg Cnsider NPPV and Refer t FRP If abve therapies fail, r patient presents in respiratry failure, cnsider RSI, refer t FRP Acute Pulmnary Emblism Cnsider anticagulatin therapy, blus fllwed by infusin as directed by sending clinician prtcls r LOM prtcl as fllws Heparin 80 units/kg Heparin 18 units/kg/hr Abslute CONTRAindicatins t Heparin Abslute (Cnsider facilitating transprt t emblectmy capable facility) Recent surgery Hemrrhagic CVA Active bleeding (Other than menstruatin r epistaxis) Artic Dissectin Octber, 2015, Revised January 1, 2016, Revised June 15,

10 Intracranial r Spinal crd tumrs Cnsider invlving LOM medical directr t assist in this decisin Fr persistent hemdynamic instability and hypxia, cnsider cnsulting LOM medical directr t facilitate discussin between sending/receiving physicians fr fibrinlytic therapy prir t departing the referring facility. 3. CARDIAC 3.1. Acute Crnary Syndrme Special Cnsideratins Inferir MI has high likelihd fr RV Invlvement Beta blckers may have a limited rle in MI t reduce wrklad n the heart Thrmblytic therapy criteria Inclusin criteria 12 hurs r less frm nset f symptms ECG demnstrating new LBBB r ST Elevatin > 1mm in mre than 1 lead Exclusin criteria Abslute Active r recent internal bleeding (< 10 days) CVA < 6 mnths r any hemrrhagic CVA Intracranial r spinal surgery / trauma within past 2 mnths Recent trauma r surgery at a nn-cmpressible site (<10 days) Suspected Artic Dissectin r Pericarditis Knwn allergy t fibrinlytic Relative Knwn bleeding disrder Pregnancy Severe and Uncntrlled Hypertensin (SBP > 200 r DBP > 120) CPR > 10 minutes Current Cumadin therapy with INR > 2 Hemrrhagic pthalmic cnditins Ischemic CVA > 6 mnths Recent puncture r prcedure t nn-cmpressible bld vessel Significant trauma r majr surgery within last 2 mnths, but mre than tw weeks prir Treatments fr STEMI, NSTEMI, and Unstable Angina Aggressively manage pain with analgesics, sedatives, and vendilatrs Refer t FRP 6.7 and FRP 6.8 Aspirin 324mg PO Nitrglycerin Cntraindicated with use f Erectile Dysfunctin medicatins Sildenafil Tadalafil Vardenafil Alprstadil Avanafil Cautin in suspected Right Ventricular Infarctin SL spray r tab 0.4mg every 3 5 minutes Infusin Mix 50mg/250mL D5W Excel r PAB mcg/min titrate as indicated Heparin BOLUS 60 units/kg MAX dse 4000units Octber, 2015, Revised January 1, 2016, Revised June 15,

11 Heparin INFUSION fr prtracted transprts greater than 1 hur 12 units/kg/hur MAX dse 1000 units/hr Cnsider administratin f Clpidigrel mg PO Cnsider administratin f Ticagrelr 180mg PO 3.2. Cardiac Dysrhythmias TACHYcardia ACLS Algrithm 3.3. Cardiac Dysrhythmias BRADYcardia ACLS Algrithm 3.4. Cardiac Arrest ACLS Algrithm With ROSC and cmprmised neurlgical functin, cnsider Therapeutic Hypthermia FRP Terminatin r resuscitatin Asystle in 2 r mre leads. Prlnged interval between estimated time f arrest and initiatin f resuscitatin. Patient age and severity f cmrbid disease. Absent brainstem reflexes. > 20 minutes effrt withut a sustained perfusing rhythm. EtCO2 < 10 after 20 minutes resuscitatin Atrial Fibrillatin and Atrial Flutter ACLS Algrithm NOTE: Cnsider underlying cause f atrial dysrhythmias prir t rate cntrl (ie. Sepsis r trauma) Pearls and Pitfalls Obtain a 12 lead ECG t cnfirm the presence f Atrial Fibrillatin r Atrial Flutter and dcument ventricular rate If the patient is symptmatic, but has stable hemdynamics CHOOSE ONE anti-dysrhythmic Diltiazem 0.25 mg/kg ver 2 minutes MAX dse 20mg If ineffective, 0.35 mg/kg ver 2 minutes MAX dse 25mg If effective, initiate Diltiazem infusin MIX 125mg(25mL) in 100mL NS r D5W Infuse at 5 15 mg/hr OR Metprll 5mg ver 2 minutes Repeat every 5mg MAX 15mg CAUTION with patients in CHF, CHB, Valvular failure OR Amidarne 150mg in 50mL NS ver 10 minutes If effective, initiate Amidarne infusin Mix 90mg in 50mL, 180mg in 100mL, 450mg in 250mL, r 900mg in 500mL NS (1.8 mg/ml) Infuse at 1mg/min, with inline 0.2 micrn filter, nting exact time f initiatin and reprt ttal dse prvided t receiving facility If the patient is hemdynamically unstable Synchrnized cardiversin j Cnsider sedatin r analgesia per FRP 6.7 r 6.8 fr patient with anxiety r agitatin (Nnintubated) Octber, 2015, Revised January 1, 2016, Revised June 15,

12 3.6. Neurprtective Therapeutic Hypthermia Inclusin criteria > 18 years f age Cardiac Arrest with ROSC (regardless f presenting rhythm) Cmatse (Unable t fllw cmmands) Mechanically ventilated SBP > 90 Less than 6 hurs since ROSC and less than r equal t ne hur f resuscitatin time Less than 15 minutes frm cllapse t CPR If time unknwn, initiate TH Exclusin criteria Cntinued arrhythmia r hemdynamic instability Evidence f Sepsis Hemrrhage Cma unrelated t rest Recent trauma r surgery DNR r any cnditin precluding treatment in the pinin f the referring physician r flight crew ***Pregnancy is NOT an exclusin criteria*** Prcedure Cnsult and/r cnfirm with accepting prvider Hwever: If a prvider is unavailable, initiate cling as early as pssible Gal temperature is 33 C Evaluate and recrd neurlgic status prir t initiatin f sedatives and/r paralytics, if pssible Rapid IV infusin f 30mL/kg 4 C Lactated Ringers Cnsider ice packs in axilla and/r grin Suppress shivering with lng acting neurmuscular blckade (with apprpriate analgesia and sedatin) Vecurnium 0.1 mg/kg blus MAX 10mg Rcurnium mg/kg blus Mnitr temperature (Esphageal, Rectal, Fley) Gal temperature remains 33 C (91.4 F) Cnsider arterial line 4. MEDICAL 4.1. Anaphylaxis and Allergic Reactins Mild reactin Diphenhydramine 50mg Methylprednislne 125mg Cnsider Fluid Blus f 500mL NS Cnsider Albuterl, refer t FRP mg via NEB May cnsider cntinuus nebulizer MAX dse 7.5mg Cnsider Famtidine Octber, 2015, Revised January 1, 2016, Revised June 15,

13 20mg Cnsider Epinephrine 1: mg IM May repeat x 2 q 15 minutes In patients with risk f cardivascular disease, there will be cardivascular sequelae with the use f epinephrine Mderate t Severe reactin Cnsider RSI early fr airway swelling, refer t FRP 2.3 All f the abve treatments fr mild reactin If hemdynamically unstable, refer t FRP 4.13 Cnsider Epinephrine 0.1mg 1:10,000 ver 5 minutes OR Infusin: Central: mix 2 4 mg in 250mL NS r D5 Peripheral: mix 1 2 mg in 250mL NS r D5 Start infusin at 0.05 mcg/kg/min and increase by 0.05 mcg/kg/min as indicated MAX dse 0.5 mcg/kg/min 4.2. Diabetic Emergencies HYPOglycemia Treatment f a knwn diabetic with decreased LOC r patient with altered mental status with hypglycemia (BS < 80 mg/dl) Dextrse 25g If suspected r knwn ETOH abuse, Thiamine 100mg Glucagn (If unable t gain IV/IO access) 1mg IM HYPERglycemia Review lab values (if already btained and dcument fr chart and receiving facility): CBC CMP, Mg, and Phsphate Serum B-Hydrxybutyrate (Serum ketnes) Venus bld gas UA If labs are unavailable, cmplete VBG and BMP n ISTAT If Chlride available, calculate anin gap = (NA-(Cl+CO2)) Analyze data, and if fllwing criteria is met, refer t FRP Bld glucse > 200mg/dl Venus ph < 7.3 Bicarbnate (HCO3) < 15 mml/l UA demnstrates ketnes Anin gap greater than If abve criteria are nt met fr DKA r all data has nt been btained as utlined abve, discuss with OLMC necessity f therapy. 0.9% Nrmal Saline at maintenance therapy can be initiated. In discussin with OLMC, rate can be adjusted based upn diagnsis and hemdynamic stability If labs are unbtainable, d nt initiate insulin therapy. Cnsult medical cntrl fr additinal ptins. Octber, 2015, Revised January 1, 2016, Revised June 15,

14 DKA Prtcl Patient t remain NPO Stp insulin pump, if applicable Fluid therapy If patient has histry f heart failure r an alternative diagnsis where fluid verlad is a cncern, cnsult LOM Medical Directr r Receiving physician Nrmal Saline 1000mL/hr x 1 Nrmal Saline 500mL/hr x % Nrmal Saline 500mL/hr x % Nrmal Saline 200mL/hr Once glucse < 250mg/dL achieved D5W 0.45% NS 200mL/hr Insulin therapy Initiate regular Insulin 100units/100mL NS infusin at 0.1 units/kg/hr (typically between 6 10 units/hr) Serial Bld Glucse levels shuld be checked every 30 minutes Glucse Change in BG frm previus (mg/dl) Actin > 250 Increased by > 50 Cnfirm functinal infusin > 250 Increased by 1 49 N Change Or any decrease > 250 Decreased by > 100 Decrease rate by 50% < 250 Decreased by > 100 Decrease rate by 50% Change IVF t D5W 0.45% NS < 250 Decreased by 1 99 N Change Or an increase < 200 Decreased by > 60 Decrease rate by 50% and cntact receiving physician fr further IVF and insulin rate changes < 200 Decreased by 1 59 N Change < 100 N/A Decrease rate by 50% Ptassium repletin Infuse cncurrently with insulin therapy Serum Ptassium Actin > 5 Cntinue current therapy Between 4 and 5 Infuse 10mEq x 2 Between 3 and 4 Infuse 10mEq x 3 < 3 Infuse 10mEq x 4 Octber, 2015, Revised January 1, 2016, Revised June 15,

15 Sdium Bicarbnate 8.4% Generally nt needed and remains cntrversial. Cnsider (with OLMD,) if ph < 6.9, HCO3 < 5 K+ greater than 6.5 WITH ECG changes Decreased MAP refractry t fluid administratin and vaspressr use. MIX 100mEq Sdium Bicarbnate 8.4% in 1 liter f NS, infuse at 100mL/hr Cnsider IV blus dsing under advisement frm OLMD Cntact receiving prvider when Euglycemia is achieved Anin gap < 12 Ptassium has nrmalized 4.3. GI Bleed Identify r btain INR, Hemglbin, and Lactate NG/OG tubes are NOT cntraindicated, cnsider OG r NG Tube If INR > 1.4, cnsider discussing reversal ptins f INR with sending and/r receiving physician, refer t Cnsider PRBCs, refer t prtcl If balln tampnade (Blakemre Tube) is necessary, endtracheal intubatin shuld be cmpleted prir t its placement t prevent airway bstructin during transprt Treatment ptins Pantprazle 80mg blus every 12 hurs Fr undifferentiated and knwn Upper GIB, cnsider Octretide 40 80mcg (typically 50mcg) blus fllwed by 50 mcg/hr infusin In cases f severe bleeding frm esphageal varices, cnsider Vaspressin units/min (This higher dse is specific t GIB) 4.4. Ischemic and Hemrrhagic CVA, TIA, and Nn-Traumatic SAH Cnsider ABG t assess adequacy f ventilatin and/r xygenatin If the patient has significant alteratin in mental status and is unable t prtect the airway withut assistance, cnsider RSI, refer t FRP 2.3 Determine exact time and nset f symptms. Cmplete a neurlgical exam, including apprpriate strke scre (NIHSS r Cincinnati) If altered mental status and BS < 80 mg/dl, refer t FRP Elevate head f bed t 30 degrees, if pssible Cmplete a neurlgic exam including apprpriate strke scre (NIHSS, if perfrmed by sending, r Cincinnati) Identify r btain INR If > 2.0, cntact receiving fr ptins, refer t FRP 7.3 r D NOT treat hypertensin in the prehspital setting withut imaging differentiating pathlgy Maintain the fllwing BP parameters fr ALL patients If MAP < 70, refer t FRP 4.13 If ICP mnitr in place, maintain CPP between , cnsidering pressrs, if necessary Fr IFTs with a cnfirmed radilgic diagnsis, maintain the fllwing ANTIhypertensive bld pressure parameters, refer t FRP 4.14 Ischemic CVA: SBP < 180mmHg Intraparenchylmal Hemrrhagic CVA: SBP < 160mmHg Spntaneus, Nn-Traumatic SAH: SBP < 140mmHg Cnsider arterial line Octber, 2015, Revised January 1, 2016, Revised June 15,

16 If the patient received tissue plasmingen activatr (tpa) dcument the time f blus and time f infusin, clinician wh rdered, and any nted cmplicatins If the patient has received Nimdipine, they are NOT eligible fr Nicardipine Cnsider seizure prphylaxis ONLY if current r recent seizure activity Cntact receiving fr cnsultatin and ptins with recent seizure If patient actively seizing, refer t FRP In the presence f clinically severe neurlgical deteriratin Altered Mental Status Unequal Pupils Hypertensin, Bradycardia, Irregular Respiratins Unless specified by receiving physician Hypertnic 3% NS (Preferred chice fr all patients) 5 ml/kg t MAXimum f 250mL ver 15 minutes Mannitl (Fr SBP > 90 and requested by referring physician) 1 g/kg ver 15 minutes 4.5. Abdminal Artic Aneurysm Identify r btain INR If > 1.4, cntact receiving fr ptins f FFP and Vitamin K (Refer t FRP 7.2 and 7.3) Cnsider arterial line Hyptensive patient Titrate fluids t target SBP , r that which maintains cerebral perfusin Cnsider PRBCs, refer t FRP 7.1 Cnsider vaspressrs if hyptensin has nt respnded t fluid and cllid resuscitatin, refer t FRP Hypertensive patient Cnsider aggressive analgesia and anxilysis prir t prgressing t antihypertensives Pririty shuld be fcused n systlic bld pressure cntrl ver that f the HR Use Nicardipine t achieve target SBP , Refer t FRP 4.14 If hypertensin persists, cntact receiving clinician fr ther ptins 4.6. Artic Dissectin Obtain apprpriate histry and cmplete physical exam with assessment f pulses in all extremities Identify r btain INR If > 1.4, cntact receiving fr ptins f FFP and Vitamin K (Refer t FRP 7.2 and 7.3) Cnsider arterial line Hyptensive patient Titrate fluids t keep systlic BP at 90 systlic, r that which maintains cerebral perfusin Cnsider PRBCs, refer t FRP 7.1 Cnsider vaspressrs if hyptensin has nt respnded t fluids and bld If HR > 70 AND SBP < 90, cntact receiving clinician fr rate cntrl ptins Hypertensive patient Cnsider aggressive analgesia and anxilysis prir t prgressing t antihypertensives Use Esmll t achieve HR beats per minute If the patient s BP remains elevated, cnsider Nicardipine (r ther agent) t achieve target SBP mmhg Refer t FRP Dissectin with cncurrent mycardial infarctin by ECG analysis Avid thrmblytics, aspirin, and heparin Treat hyptensin and hypertensin as abve Cnsult immediately with receiving physician team and transprt t apprpriate destinatin. Octber, 2015, Revised January 1, 2016, Revised June 15,

17 4.7. Sepsis Identify r btain apprpriate brad spectrum antibitic therapy prir t transprt Identify r btain lactate If pssible, btain bld cultures prir t administratin f antibitics Cnsider arterial line if patient requires resuscitatin and vaspressr therapy If patient has hyptensin r Lactate > 4 Cnsider NS blus 30 ml/kg Cmplete RUSH exam if Ultrasund is available Dpamine and Phenylephrine are secndary agents in the treatment f sepsis and shuld nly be used when n ther alternative exists. If hyptensin persists, refer t FRP 4.13 t maintain MAP > 65 If hyptensin persists despite vaspressr use, cnsider administratin f Hydrcrtisne 100mg, if available If hemglbin < 7.0, refer t FRP 7.1 fr PRBC infusin If bld glucse > 180, refer t FRP 4.2 fr aggressive cntrl f hyperglycemia If ph < 7.15, cnsider cntacting receiving physician fr ptin f Sdium Bicarbnate 4.8. HYPOkalemia Special Cnsideratins Cautin with urine utput < 0.2mL/kg fr tw hurs Cautin with creatinine > 2.0 NEVER blus Ptassium as fatal cardiac dysrhythmias can ccur Indicatins and Clinical Management Serum Ptassium Central IV Peripheral IV Oral r NG/OGT MAX dse < mEq/hr 10mEq/hr 40mEq x 1 100mEq mEq/hr 10mEq/hr 40mEq x 1 80mEq 3.0 t mEq/hr 10mEq/hr 40mEq x 1 40mEq 4.9. HYPERkalemia Special Cnsideratins Acute Renal Failure Cnsider dialysis D NOT administer kayexalate Avid Calcium if digxin txicity is suspected, Refer t Nausea/Vmiting/Abdminal pain Dysrhythmias and Hyptensin Slurred and dwnslping ST-T, especially in V Magnesium Mix 1g in 100mL NS and infused 20 mg/kg at a rate nt t exceed 125mg/min ONLY in the setting f digxin-txic cardiac related hyperkalemia Clinical Management Serum Ptassium Treatment Optins 5.5 t 6.0mml/dL Cardiac Mnitr and repeat Ptassium level Lasix 1mg/kg with MAX dse 80mg 6.0 t 7.0 (without ECG Abve treatments Changes) Insulin 0.1units/kg with MAX dse 10units > 7.0 (OR widened QRS, instability, r cardiac arrest Dextrse 0.25g/kg with MAX dse f 25g Abve treatments Calcium Glucnate 100mg/kg with MAX dse f 1g Octber, 2015, Revised January 1, 2016, Revised June 15,

18 Sdium Bicarbnate 1mEq/kg with MAX dse f 100mEq Pssible EKG Findings: Magnesium Derangements Special Cnsideratins Cautin with urine utput < 0.2mL/kg/hr fr 2 hurs r mre HYPOmagnesemia Indicatins Value Treatment f hypmagnesemia depends n the degree f deficiency and the clinical effects. Oral replacement is apprpriate fr mild symptms, while IV replacement is indicated fr severe clinical effects Mst patients with symptmatic hypmagnesemia and nrmal renal functin, typically receive magnesium sulfate fr the first 24 hurs as a cntinuus IV infusin. If serum Magnesium < 1.5 meq/l infuse Magnesium Sulfate 2g mixed in 100mL ver 1 hur If cardiac dysrhythmias r seizures are present, infuse 2g Magnesium Sulfate ver 2 minutes HYPERmagnesemia Indicatins: Nn-specific and early symptms Nausea, Vmiting, cutaneus flushing Life threatening symptms Lss f deep tendn reflexes Muscle fatigue and weakness Respiratry and CNS depressin Calcium GLUCONATE (IV r Central Access) 100 mg/kg at a rate nt t exceed 200 mg/min MAX dse 1g Calcium CHLORIDE (ONLY via Central Access) 100 mg/kg at a rate nt t exceed 100 mg/min MAX dse 1g Octber, 2015, Revised January 1, 2016, Revised June 15,

19 4.11. HYPOcalcemia HYPOcalcemia Indicatins: Inized Calcium < 1.0 Cnsider early with patients receiving multiple bld prducts Treatment Calcium GLUCONATE (IV r Central Access) 100 mg/kg at a rate nt t exceed 200 mg/min MAX dse 1g Calcium CHLORIDE (ONLY via Central Access) 100 mg/kg at a rate nt t exceed 100 mg/min MAX dse 1g Octber, 2015, Revised January 1, 2016, Revised June 15,

20 4.12. Seizure Management If suspected ETOH abuse, cnsider Thiamine 100mg Chse ONE benzdiazepine Lrazepam 1-2mg Midazlam 1 5mg IV r IM (IM is preferred primary methd if n IV access) In many cases, patients with refractry seizures lse airway reflexes after the administratin f benzdiazepines and ther anti-epileptics. Cnsider RSI if patient requires high dses f these medicatins. The use f paralytics can mask nging seizure activity Seizures refractry t abve therapy Fsphenytin (Cerebyx) 20 mg PE/kg at a rate nt t exceed 150 PE/min MAX dse 1500 mg PE Phenytin (Dilantin) 20 mg/kg at a rate nt t exceed 100 mg/min MAX dse 1500 mg Levitiracetam (Keppra) MIX 20 mg/kg in 100mL NS and infuse ver 15 minutes MAX dse 1g If intubated and BP allws, cnsider Prpfl If MAP > 65, Blus mg/kg If MAP > 65, infusin with MAX dse 200 mcg/kg/min The administratin f phenbarbital r prpfl infusins have been shwn t effectively suppress seizure activity. Cnsult OLMC r receiving physician fr ptins Refractry Shck Special Cnsideratins The fllwing prtcls shuld be used in a prgressive fashin. Discretin is left t crew as early prgressin t the next vaspressr may be beneficial. Vaspressin may be the nly pressr metablized in the bdy with ph < 7.15 Phenylephrine has very limited use and shuld never be initiated by LOM persnnel unless rdered by referring prvider. Vaspressr/Intrpe strategies initiated prir t LOM arrival, prving effective and physilgically apprpriate, may be cntinued, at the discretin f the LOM team. Therapeutic endpints fr resuscitatin MAP > 65 Urinary utput Distributive Shck If hyptensin can be directly attributed t vlume depletin, Cnsider fluid blus NS 30 ml/kg Nrepinephrine Initiate infusin at 0.05 mcg/kg/min and titrate fr MAP > 65 Cnsider additinal pressrs at 0.3 mcg/kg/min MAX dse 0.6 mcg/kg/min Vaspressin Initiate infusin at 0.03 units/min and cntinue at this fixed rate Epinephrine Initiate infusin at 0.05 mcg/kg/min and titrate fr MAP > 65 MAX dse 0.5 mcg/kg/min Cnsider cnsultatin with referring fr Dbutamine, if further intrpy is indicated. Initiate infusin at 5 mcg/kg/min MAX dse 20 mcg/kg/min Cardigenic Shck Octber, 2015, Revised January 1, 2016, Revised June 15,

21 If knwn vlume issue r RVMI, initiate rapid 30 ml/kg blus, hld all vendilatrs Nrepinephrine Initiate infusin at 0.05 mcg/kg/min and titrate fr MAP > 65 Cnsider additinal pressrs at 0.3 mcg/kg/min MAX dse 0.6 mcg/kg/min Dbutamine Initiate infusin at 5 mcg/kg/min MAX dse 20 mcg/kg/min Epinephrine Initiate infusin at 0.05 mcg/kg/min, titrate as indicated MAX dse 0.5 mcg/kg/min Special cnsideratin Few patients require chrntrpic supprt, but if patient is bradycardic, cnsider Dpamine Initiate infusin at 5 mcg/kg/min MAX dse 20 mcg/kg/min Hypvlemic Shck If knwn 25% vlume bld lss, initiate bld prir t fluids Cnfirm r initiate rapid 30 ml/kg NS fluid blus Treat suspected bld lss, refer t FRP 7.1 Cnsider antifibrinlytic therapy, TXA, refer t FRP 7.2 If n respnse t available PRBCs, cnsider Nrepinephrine Initiate infusin at 0.05 mcg/kg/min and titrate as apprpriate Cnsider additinal pressrs at 0.3 mcg/kg/min MAX dse 0.6 mcg/kg/min Shck f indeterminate etilgy Rapid administratin f istnic fluid at 30mL/kg Vaspressr therapy can include Nrepinephrine Initiate infusin at 0.05 mcg/kg/min and titrate fr MAP > 65 Cnsider additinal pressrs at 0.3 mcg/kg/min MAX dse 0.6 mcg/kg/min Vaspressin Initiate infusin at 0.03 units/min Antihypertensive Medicatin Reference Titrate medicatins belw t targets utline in FRP 4.4, 4.5, If HR > 60 and preferentially fr Artic Dissectin Esmll (Breviblc) Premixed 2500mg/250mL (10,000mcg/mL) Lading dse 1 mg/kg t MAX f 80mg ver 30 secnds Initiate infusin at 150 mcg/kg/min Titrate by 50 mcg/kg/min t desired HR f and a MAX f 300 mcg/kg/min If HR drps belw 60, reduce Esmll infusin If Hypertensin persists, add additinal antihypertensive (Nicardipine infusin as belw) Use extreme cautin in asthmatics, diabetics, impaired renal functin, r patient s with a histry f hyptensin and CAD. May cause arrhythmia, angina, MI, r death if stpped abruptly. May cause hypglycemia and mask the symptms If HR 60 and preferentially fr Artic Aneurysm and CVA s Nicardipine (Cardene) Mix 25mg/250mL Initiate infusin 2.5 mg/hr Cnsider increasing infusin at 5 10 minute intervals Increase infusin by 2.5 mg/hr MAX dse 15 mg/hr Octber, 2015, Revised January 1, 2016, Revised June 15,

22 ONCE desired BP achieved, cnsider incremental dse reductin t lwest rate pssible while still achieving desired SBP parameters, typically, this can be achieved at 3mg/hr. If unable t reach desired SBP parameters with MAX dse f Nicardipine, cnsider cntacting receiving clinician fr further ptins The ther cmmnly encuntered anti-hypertensives are listed belw. They are less desirable due t half-life and ther cmplicatins, but LOM staff can use clinical judgment t whether t cntinue these medicatins if desired effects are already btained: Clevidipine (Cleviprex) Labetall Hydralazine Nitrprusside Nte: Cntraindicated in patients with intracranial pathlgy Octber, 2015, Revised January 1, 2016, Revised June 15,

23 5. TRAUMA 5.1. Abdminal and Pelvic trauma Physical assessment Abdminal Stabilize impaled bjects Saline gauze fr evisceratins r pen abdminal wunds Cnsider use f hemstatic gauze, refer t FRP 7.18 Genitals and buttcks DO NOT place fley if evidence f bld at the meatus Saline gauze t perineal wunds Cnsider use f hemstatic gauze, refer t FRP Suspected hemrrhagic shck Refer t FRP Cnsider PRBC s fr signs f hemrrhagic shck, refer t FRP 7.1 Cnsider Tranexamic acid, refer t FRP E-FAST Ultrasund by credentialed prvider, if available Cnsider analgesia, refer t FRP 6.7 and FRP Unstable Pelvis Cmmercial binding device r sheet, refer t FRP Large pen abdminpelvic wunds Hemstatic agents as apprpriate, refer t FRP 7.18 Administer Cefazlin ver 10 minutes < 40kg Cntact receiving clinician 40 80kg 1g 80 kg 2g 5.2. Burns Majr Stp burning prcess and remve all clthing r chemical expsure Cnsider RSI fr any suspected airway invlvement, refer t FRP Oxygen therapy fr suspected smke inhalatin 100% until carbxyhemglbin can be btain and symptms reslve If there is suspicin fr cyanide pisning, refer t FRP Calculate % Ttal Bdy Surface Area (TBSA) Octber, 2015, Revised January 1, 2016, Revised June 15,

24 (%) Head Chest Abdmen Back Genitals R Arm L Arm R Leg L Leg Adult Child Octber, 2015, Revised January 1, 2016, Revised June 15,

25 In the absence f significant nn-burn related trauma, transprt t burn center if > 20% TBSA partial thickness burns > 10% TBSA partial thickness burns (AGE < 10 r > 50) > 5% TBSA full thickness burns Partial r full thickness burns t hand, face, genitalia, r jints Inhalatin injury Chemical r Electrical burns Circumferential burns f an extremity If unsure, cntact LOM medical directr, r apprpriate receiving center fr guidance as sn as pssible Assess fr circumferential burn injury restricting ventilatin r circulatin If patient is in peri-arrest state and unable t ventilate Eschartmy, refer t FRP Parkland Frmula (Thermal and Chemical burns) Infuse NS 4mL/kg x % TBSA Administer half in first 8 hurs (frm time f injury) Administer half in next 16 hurs Excess fluid resuscitatin Cnsider vaspressrs if fluid resuscitatin has exceeded Parkland frmula Excess fluid, with urinary utput as marker, has been shwn t increase mrtality ELECTRIC burn cnsideratins ONLY fr electrical burns 1 1.5mL/kg/hr urinary utput Cnsider mixing Sdium Bicarbnate 100mEq in 1L NS Infuse at 250 ml/hr Dress entrance and exit wunds Anticipate dysrhythmias and treat accrding t ACLS 5.3. Chest Trauma If airway management is needed, refer t FRP Suspected hemrrhagic shck Refer t FRP Cnsider PRBC s fr signs f hemrrhagic shck, refer t FRP 7.1 Cnsider Tranexamic acid, refer t FRP Large pen wunds Hemstatic agents as apprpriate, refer t FRP 7.18 Administer Cefazlin ver 10 minutes < 40kg Cntact receiving clinician 40 80kg 1g 80 kg 2g Open pneumthrax may require cclusive dressing taped n three sides Tensin pneumthrax Refer t FRP Once decmpressed, cnsider tube thracstmy by qualified prvider, if available Flail chest, pneumthrax, hemthrax Anticipated flight physilgy effects prir t transprt Review CXR, if available Cnsider placement f chest tube by qualified prvider, if available Crush syndrme t the thrax (Traumatic Asphyxia) Alkalinizatin *****Prir t Extricatin***** Octber, 2015, Revised January 1, 2016, Revised June 15,

26 Sdium Bicarbnate 50mEq Blus x 1 Mix 150mEq in 1000mL D5W and infuse at 250 ml/hr Immediately prir t extricatin, Sdium Bicarbnate 50mEq Blus x 1 Cnsider evaluating fr electrlyte derangement, specifically ptassium level Treat per FRP 4.9 Traumatic Arrest, refer t FRP Extremity Trauma Uncntrlled bleeding Turniquet prximal t bleeding site and dcument time ON PATIENT EXTREMITY Suspected hemrrhagic shck Refer t FRP Cnsider PRBC s fr signs f hemrrhagic shck, refer t FRP 7.1 Cnsider Tranexamic acid, refer t FRP Large pen wunds Hemstatic agents as apprpriate (FRP 7.18) Administer Cefazlin ver 10 minutes < 40kg Cntact receiving clinician 40 80kg 1g 80kg 2g Fractures r dislcatins Assess fr CSM and mark pulses If pssible, realign and splint Cmprmised circulatin distal t injury Reduce fracture/dislcatin with gal f imprved perfusin Cntact medical cntrl fr discussin and further ptins if unsuccessful Amputatin (If extremity is mangled, r if additinal trauma is present, prceed t nearest Trauma Center) Re-implantatin may require resurces available nly in Bstn Cntact MedCmm early t facilitate discussin with implantatin specialists (Cnsider pht f amputated part sent t re-implantatin surgen and OLMC t assist destinatin decisin) Cmplete amputatin Wrap stump and appendage in saline saked gauze Place in water-tight bag in cld water and transprt with patient Partial amputatin Splint and wrap in saline mistened dressing Save any avulsed part, place in water-tight bag in cld water and transprt with patient Crush syndrme (1 r bth cnditins belw must be met) One extremity fr mre than 2 hurs OR Tw extremities fr mre than 1 hur Alkalinizatin *****Prir t Extricatin***** Sdium Bicarbnate 50mEq Blus x 1 Mix Sdium Bicarbnate 150mEq in 1000mL D5W and infuse at 250 ml/hr Immediately prir t extricatin, 50mEq Blus x 1 Cnsider evaluating fr electrlyte derangement, specifically ptassium level Treat per FRP 4.9 Octber, 2015, Revised January 1, 2016, Revised June 15,

27 5.5. Scalp, Facial, and Neck Trauma If airway management is needed, refer t FRP The use f a paralytic in RSI intubatin is indicated with cautin in an unstable midface fracture due t distrtin f the anatmy Cncurrent preparatin fr needle/surgical cricthyrtmy shuld be perfrmed, refer t FRP 7.19 r Uncntrlled bleeding Cnsider hemstatic gauze, refer t FRP 7.18 Scalp (psterir t hairline) Apprximate the wund and staple, refer t FRP 7.6 Suspected hemrrhagic shck, refer t FRP Cnsider PRBC s fr signs f hemrrhagic shck, refer t FRP 7.1 Cnsider Tranexamic acid, refer t FRP Large pen wunds Hemstatic agents as apprpriate, refer t FRP 7.18 Administer Cefazlin ver 10 minutes < 40kg Cntact receiving clinician 40 80kg 1g 80kg 2g Octber, 2015, Revised January 1, 2016, Revised June 15,

28 5.6. Traumatic Brain Injury Cnsider neurprtective pretreatment with Fentanyl 3mcg/kg, at least 3 minutes prir t inductin Initially prvide ventilatin fr a gal EtCO mmHg. If time allws, crrelatin f pco2 shuld be perfrmed, with a gal f mmhg Elevate head f bed, if pssible Herniatin frm suspected intracranial mass effect Bradycardia Hypertensin refractry t aggressive analgesia/sedatin Altered respiratins Unilateral mydriatic pupil The CPC and LOM Medical Directrs recmmend first line smtic agent t be HYPERTONIC 3% Nrmal Saline Hypertnic Saline 3% 5 ml/kg t MAX f 250mL ver 15 minutes Mannitl If SBP > 90 and requested by referring r sending physician 1 g/kg ver 15 minutes Cnsider arterial line Recall that Cerebral Perfusin Pressure (CPP) = MAP ICP In rder t assure adequate CPP, maintain SBP > 90 in patients with suspected ICP increase 5.7. Near Drwning Fllw ACLS, refer t FRP Aggressive PEEP may be necessary t prvide adequate delivery f xygen If altered mental status and BS < 80 mg/dl, refer t FRP Cnsider hypthermia, refer t FRP Ocular Trauma Elevate head f bed, if pssible Penetrating injuries DO NOT put pressure n the eye Immbilize bject and secure Shield bth eyes t prevent mvement f injured eye Blunt Trauma DO NOT put pressure n the eye Shield bth eyes t prevent mvement f injured eye Prptsis (bulging f the eye) with cmprmised visual acuity Cnsider lateral canthtmy by qualified prvider Freign substance r abrasin Remve lse particulate matter with NS mistened cttn swab Identify chemical and treat as described in HazMat Handbk r cntact Pisn Cntrl Center If chemical, irrigate with 1000 NS per eye fr at least 15 minutes If chemical is a base and eye damage is evident, cntinue irrigatin until arrival at receiving Analgesia as per FRP 6.7 If there is n glbe injury, Tetracaine 0.5% slutin, 2 drps May repeat every 5 minutes x 3 Octber, 2015, Revised January 1, 2016, Revised June 15,

29 5.9. Spinal Trauma Refer t Maine EMS spinal assessment prtcl, refer t Green Evaluate fr precise levels f sensry and mtr deficit Fr suspected Neurgenic Shck, refer t FRP Treat pain and agitatin as per FRP 6.7 and FRP The LOM transprt airframe is an apprved immbilizatin tl If a lng spine bard is used, padding must be prvided t reduce pain and risk fr skin degradatin Refer t MaineEMS spinal immbilizatin prtcl Octber, 2015, Revised January 1, 2016, Revised June 15,

30 5.10. Acute Resuscitatin f the Unstable Trauma Patient Refer t FRP 2.1 fr Airway management strategies Identifying ccult intrathracic pathlgy is f primary imprtance and shuld be treated aggressively, refer t FRP Use f e-ultrasund shuld be utilized, if available, and used, cncurrently with physical exam, t determine presence f tensin pneumthrax r cardiac tampnade If patient is in periarrest frm a suspected blunt r penetrating intrathracic surce, cnsider perfrming bilateral pen thracstmy, refer t FRP Standard acute resuscitative evidence suggests a rapid prgressin t cllid administratin This is especially true when knwn, r suspected, bld lss exceeds 25% External bleeding cntrl is paramunt in the acute resuscitative phase It is essential t nte that resuscitatin techniques must fcus n identifying the injuries that are nt nly affecting the patient currently as well as additinal ptential injuries that may have a delayed effect. Treatment must fcus n arresting further bleeding and decmpensatin. Management f the unstable trauma patient utilizes a variety f resuscitatin techniques, but standard medical prtcls (ie. ACLS) shuld nly be utilized in identified patients and nt the standard f care in all trauma patients. Octber, 2015, Revised January 1, 2016, Revised June 15,

31 6. MISCELLANEOUS 6.1. Alchl Emergencies If altered mental status and BS < 80 mg/dl, refer t FRP 4.2 If the patient has a lng histry f alchl use, cnsider the use f Thiamine 100mg IV r IM prir t prviding dextrse, if pssible Withdrawal and Delirium Tremens Tremulusness with r withut seizures r behaviral agitatin Lrazepam 1 4mg q 10 minutes If patient develps seizures, refer t FRP Txic Alchls Isprpyl Alchl Methanl Ethylene Glycl Cnsider discussing treatment ptins with LOM, Referring, and/r Receiving clinician fr the fllwing ptins Fmepizle Emergent dialysis Cnsider cntacting medical cntrl fr Sdium Bicarbnate therapy 6.2. Behaviral (Suicidal) Cnsideratins If patient is deemed a risk t flight safety and air transprt is imperative, the patient shuld be chemically restrained and intubated per FRP Frstbite Cnsideratins Handle frstbitten part gently, prtecting frm further injury D nt attempt t thaw frstbitten parts enrute Evaluate fr systemic hypthermia, refer t FRP HYPERthermia Cnsideratins If temperature > 40.5 C (105 F) Radical cling via ice packs, wet skin fr evapratin Discntinue if shivering r CNS functin returns t nrmal If altered mental status and BS < 80 mg/dl, refer t FRP HYPOthermia Cnsideratins If temperature > 30 C (86 F) Treat patient in usual manner as per FRP 1.1, FRP 1.2 If temperature < 30 C (86 F) Life signs present Externally warm t 30 C (86 F) Cnsider transprt t center with Arteri-venus bypass capability Cardiac Arrest CPR shuld NOT be initiated if: Temperature < 15.5 C (60 F) Frzen chest wall precluding cmpressin Defibrillatin and antidysrhythmics Withheld until temperature > 30 C (86 F) Terminatin f resuscitatin Octber, 2015, Revised January 1, 2016, Revised June 15,

32 NOT until temperature > 35 C (95 F) Cntact medical cntrl fr mitigating circumstances If altered mental status and BS < 80 mg/dl, refer t FRP Overdse Frequently evaluate and reprt findings t receiving Pupil Size Reflexes Obtain 12 Lead ECG, nting QTc, QRS interval, and ther cardiac dysrhythmias If altered mental status and BS < 80 mg/dl, refer t FRP 4.2 If unknwn r suspected narctic verdse, cnsider Nalxne in 0.4mg increments up t 2mg Determine cntaminant, time, and methd f entry Pisn Cntrl Center Specific antidtes can be given under direct supervisin r discussin with referring prvider r pisn cntrl If patient is deemed a risk t flight safety and air transprt is imperative, the patient shuld be chemically restrained and intubated. Refer t FRP Cnsider serial 12-lead (diagnstic) ECG mnitring serial QRS and QTc intervals Cnsider cntacting medical cntrl fr administratin f Sdium Bicarbnate 6.7. ANALGESIA in the patient withut an advanced airway Fr pain in hemdynamically stable patients with adequate respiratry drive, manage aggressively and mnitr fr cmplicatins Fentanyl BOLUS mcg/kg every 5 10 minutes MAX 250 mcg INFUSION mcg/hr Mrphine BOLUS mg/kg every 5 10 minutes MAX 10mg INFUSION mg/hr Infusin Fr pain refractry t piates, hemdynamic instability, r cncerns fr depressing respiratry effrts with narctics Cntact LOM Medical Directin early fr treatment ptins and subsequent analgesic dsing f Ketamine If nt given within 30 minutes, Ondansetrn 0.1 mg/kg MAX dse 4 mg Ketamine Mix desired dse in 10mL syringe and administer ver 1 2 minutes Rapid administratin can cause nausea and apnea Advise patient t mentally mdel a pleasant thught BOLUS mg/kg MAX dse 30 mg May als initiate infusin after blus dse INFUSION mg/kg/hr MAX dse 20 mg/hr Althugh dissciative dses are usually in excess f 0.5 mg/kg, If patient des nt require airway management, but becmes agitated during emergence frm effects, cnsider Versed 0.01 mg/kg MAX dse 1mg Octber, 2015, Revised January 1, 2016, Revised June 15,

33 6.8. SEDATION in the patient withut an advanced airway Fr anxiety in hemdynamically stable patients with adequate respiratry drive, and unrelieved by verbal reassurance, manage aggressively and mnitr fr cmplicatins Midazlam mg Lrazepam mg Fr anxiety unrelieved by benzdiazepines, hemdynamic instability, r cncerns fr depressing respiratry drive with benzdiazepines Cntact LOM Medical Directin early fr treatment ptins and subsequent sedative dsing f Ketamine Ketamine 0.3 mg/kg MAX dse 30mg If pssible, administer ver 1-2 minutes, but it is nted this dse may be administered rapidly, ptentially causing apnea and vmiting, be prepared t supprt and/r manage the airway Althugh dissciative dses are usually in excess f 0.5 mg/kg, If patient des nt require airway management, but becmes agitated during emergence frm effects, cnsider Versed 0.01 mg/kg MAX dse 1mg If abve measures unsuccessful, patient is deemed a risk t flight safety and air transprt is imperative, cnsider RSI, refer t FRP Suspected Cyanide txicity Patients with smke inhalatin f caustic substances exhibiting neurlgic, respiratry, r cardivascular cmprmise Hydrxcbalamin Adult Mix 5g in 200mL NS and infuse at 800mL/hr Pediatric (< 40kg) Mix 5g in 200mL NS and infuse 70mg/kg ver 15 minutes Given high ptential fr cncmitant CO pisning, 100% xygen shuld be delivered until a carbxyhemglbin has been measured and symptms are absent. Octber, 2015, Revised January 1, 2016, Revised June 15,

34 7. PROCEDURES 7.1. Packed Red Bld Cells INDICATIONS ADULT Histry f bvius r suspected acute bld lss and received the greater amunt f 30mL/kg r 2 liters f crystallid SBP < 90 and/r clinical signs f shck PEDIATRIC Histry f bvius r suspected acute bld lss and received 40mL/kg f crystallid CONTRAINDICATIONS Patient refusal CAUTIONS Nne Pediatric dsing 10mL/kg PRBCs t MAX 40mL/kg Cnsider early in resuscitatin Cnsider deferring fluid blus if hemdynamic instability can directly be attributed t acute bld lss in excess f 25% patient vlume Cnsider placing bld t pressure bag fr rapid administratin Dcument HR, BP, and temperature every 5 minutes fr 15 minutes after initiatin Return the cmpleted transfusin dcumentatin t the bld bank If a suspected transfusin reactin has ccurred, ntify respective bld bank immediately and cmplete base specific paperwrk Tranexamic Acid INDICATIONS (Per the Maine Cmmittee n Trauma, as apprved by the CPC) Sustained Trauma (Blunt r Penetrating). Histry f Present Illness is dcumented in chart. Eligibility: Age Greater than 18 years and the fllwing: Signs and symptms cnsistent with severe hemrrhage (Internal r external bleeding) including: Penetrating wunds t head, neck, trs and extremities prximal t the need r elbw. Chest wall instability r defrmity (i.e. Flail chest) Tw r mre prximal lng-bne fractures Crushed, deglved, mangled r pulseless extremity. Amputatin prximal t the wrist r ankle Pelvic Fractures Open r Depressed Skull fracture Paralysis Hemdynamic Instability In the setting f hemrrhagic shck: Systlic Bld pressure less than 90 mmhg. Tachypnea greater than 24 breaths per minute r bradypnea less than 10 breaths per minute. Evidence f peripheral vascnstrictin including cl, pale skin and Delayed capillary refill f greater than tw secnds LifeFlight staff can cnsult with medical cntrl fr thse patients wh may benefit frm this medicatin including impending hemdynamic instability that staff feels will require additinal cllid transfusin CONTRAINDICATIONS Elapsed time frm insult > 180 minutes Thse patients wh have clear cntraindicatin fr antibrinlytic therapy agents (i.e. thrmbtic disease and disseminated intravascular cagulatin, etc) Cncurrent use f TXA and rfviia r PCCs is cntra-indicated. Octber, 2015, Revised January 1, 2016, Revised June 15,

35 Medical Cntrl discretin as t the apprpriateness f antifibrinlytic agents in this patient Weight Based Dsing fr TXA < 60kg 20mg/kg in 50mL NS ver 10 minutes 60 75kg 1.5g in 50mL NS ver 10 minutes > 75kg 2g in 50mL NS ver 10 minutes 7.3. Management f Cagulpathy INDICATIONS Serius r life threatening internal r external hemrrhage and/r high prbability f emergent surgical interventin As belw in the table CONTRAINDICATIONS Nne CAUTIONS Nne Diagnstic Criteria INR > 1.7 r PTT > 45 secnds INR > 1.7 r PTT > 45 secnds, n COUMADIN Fibringen < 150 mg/dl Platelets < 75,000 Treatment ptins Cnsult with receiving clinician fr FFP and PCC Vitamin K 10mg IV, Cnsult with receiving clinician fr FFP Cnsult with receiving clinician fr Cryprecipitate Cnsult with receiving clinician fr Platelets Octber, 2015, Revised January 1, 2016, Revised June 15,

36 7.4. Rapid reversal f cagulpathy in nn-traumatic ICH INDICATIONS Acute and actively bleeding ICH Patients n Vitamin K antagnist therapy INR > CONTRAINDICATIONS NOT indicated fr thrmbin inhibitrs (Dabigatran) r Factr Xa inhibitrs (Rivarxaban r Apixaban) DVT, PE, Ischemic CVA within 3 mnths Subacute r chrnic ICH Hypersensitivity t K Centra r any f its cmpnents (factrs, heparin, albumin) Disseminated Intravascular Cagulatin Heparin-induced Thrmbcytpenia Hepatic failure PROCEDURE Cnfirm ICH via CT Identify r btain INR Vitamin K 10mg in 50mL NS ver 20 minutes Persnally btain rder frm receiving physician, nting their name will be n the LOM patient care recrd fr prescribing the therapy. Reprt at receiving MUST be given t accepting prvider. IT IS NOT sufficient t prvide reprt t ancillary persnnel. Immediately ntify LOM Medical Directrs that this therapy was utilized. K Centra (Prthrmbin Cmplex Cncentrate) INR Dse MAX dse units/kg as described belw 2500 units units/kg as described belw 3500 units > units/kg as described belw 5000 units Ptency is defined by Factr IX cntent labeled n each vial Slutin MUST be warmed t C (68-77 F) N bld shuld enter the syringe, pssibility f fibrin clt frmatin Administer by intravenus infusin at a rate f 0.12 ml/kg/min (~3 units/kg/min,) up t a maximum rate f 8.4 ml/min (~210 units/min) [INFUSION rate cannot exceed 500 ml/hr] Octber, 2015, Revised January 1, 2016, Revised June 15,

37 7.5. EZ-IO Intrasseus Vascular Access INDICATIONS Patients in need f crystallids, cllids, r medicatins wh have pr vascular access CONTRAINDICATIONS Fracture f the bne selected fr IO infusin Excessive tissue at insertin site Previus rthpedic prcedures (Prsthesis) IO attempt in previus 24 hurs Infectin at insertin site PROCEDURE Identify apprved sites Prximal humerus Assure apprpriate arm psitining during and after attempt Medial mallelus Tibial tubersity Assure apprpriately sized needle On insertin, nly ONE black line shuld be visible when distal end f needle has made cntact with the bne If n lines are present, utilize lnger needle If bth lines are present, utilize shrter needle Cnfirm placement via aspiratin Adult If time allws and nt cntraindicated, infuse 40mg 2% Lidcaine (withut Epinephrine) ver 120 secnds t minimize pain during infusins Allw medicatin t dwell in IO space fr 60 secnds, if pssible Flush with 5 10mL Nrmal Saline Slwly administer 20mg 2% Lidcaine (withut Epinephrine) ver 60 secnds Infant / Child If time allws and nt cntraindicated, infuse 2% Lidcaine (withut Epinephrine) 0.5 mg/kg, MAX dse 40mg ver 120 secnds Allw medicatin t dwell in IO space fr 60 secnds, if pssible Flush with 2 5mL Nrmal Saline Slwly administer 2% Lidcaine (withut Epinephrine) 0.25 mg/kg, MAX 20mg ver 60 secnds Reassess fr infiltrate frequently Dcument all attempts in PCR, nting lcatin Octber, 2015, Revised January 1, 2016, Revised June 15,

38 7.6. Scalp Wund Stapling fr hemrrhage cntrl INDICATIONS Persistent hemrrhage after direct pressure and hemstatic gauze have failed t prvide hemstasis CONTRAINDICATIONS Wund is nt within the cnfines f the hairline PROCEDURE Apprximate the edges f the wund During clsure, a largely prtruding piece f gauze shuld remain visible t alert the receiving facility as t the ptential cntaminated nature f the clsure Dcument the number f staples used 7.7. Pelvic Binder INDICATIONS Suspected pelvic fracture with prbable diastasis and vascular cmprmise CONTRAINDICATIONS Nne PROCEDURE Center binder ver greater trchanters Cut the free end t leave 6-8 gap Attach Velcr straps and plate t free end f binder Tighten mechanism and clse fastener Octber, 2015, Revised January 1, 2016, Revised June 15,

39 7.8. MECHANICAL VENTILATION Initial Ventilatr Set up: Vlume Cntrl shuld be the standard breath type unless the patient: is experiencing high PIPs nt crrected by suctining and ther standard interventins is knwn r suspected t have ARDS / Acute Lung Injury has flw requirements that cannt be met with Vlume Cntrl Ventilatin is experiencing pr xygenatin / ventilatin despite maximal PEEP supprt with Vlume Cntrl Ventilatin is currently being ventilated in pressure cntrl and is ding well Tidal Vlume 8 cc/kg PREDICTED BODY WEIGHT in mst patients. This shuld be reduced t 4-6 cc/kg PREDICTED BODY WEIGHT in the setting f ARDS / Acute Lung Injury. Predicted / Ideal Bdy Weight can determined via the preprinted reference cards r be calculated via the fllwing, gender based frmulas: MALE: [height (in inches) - 60] FEMALE: [height (in inches) - 60] A Plateau Pressure shuld be assessed whenever the PIPs exceed 30 The tidal vlume shuld then be adjusted between 4 and 8 ml / kg PBW in an effrt t achieve a plateau pressure less than r equal t 30 Smaller than necessary tidal vlumes shuld nt be utilized due t the risk f CO2 retentin, acidsis, and atelectasis Ventilatin Mde Assist Cntrl unless the patient has been n SIMV and is ding well. If the patient is t be left n SIMV, cnsider adding Pressure Supprt t reduce the patient s wrk f breathing during spntaneus respiratins. Pressure Supprt Added slwly (5 10) and watch patient s wrk f breathing and exhaled vlumes n spntaneus breaths t determine if the pressure supprt shuld be increased further Rate: Adjust as needed t maintain PH and PCO2 within parameters. If tidal vlume reductin is necessary, adjustment f the ventilatr breath rate may be needed in rder t achieve / maintain the desired PCO2 and minute ventilatin. Prviders must be cgnizant f I:E ratis and avid inverse rati ventilatin CO2 retainers may nt need t be crrected t values that wuld be cnsidered nrmal fr healthy lungs A frmula that can be used t mre accurately make ventilatr adjustments t achieve r maintain a desired PaCO2: Use cautin when making these adjustments and assure inverse rati ventilatin is nt inadvertently achieved This frmula can nly be utilized with cnstant tidal vlumes Octber, 2015, Revised January 1, 2016, Revised June 15,

40 FIO2 Titrated t achieve SPO2 greater than r equal t 93% r as apprpriate fr the patient s cnditin. PEEP can be utilized t reduce FIO2 requirements PEEP Pressure f 3 5 cm H2O is cnsidered physilgic cm and abve will enhance xygenatin Alarms Apprpriate use f alarms are part f safely perating a mechanical ventilatr. This becmes particularly imprtant in the transprt envirnment. Guidelines fr apprpriate alarm settings are as fllws: Vlume Cntrl Ventilatin High Pressure Alarm: 10 Pints abve Baseline Lw Pressure Alarm: 10 Pints belw Baseline Pressure Cntrl Ventilatin High Pressure Alarm: 5 Pints abve Baseline Lw Pressure Alarm: 5 Pints belw Baseline Lw Minute Vlume Alarm: 10 t 15% belw Baseline ABG s shuld be cnsidered minutes after initiatin f mechanical ventilatin Ventilatin and Oxygenatin Maintenance: Manipulate ventilatr settings t maintain: ph po2 greater than r equal t 75 mm Hg r SPO2 greater than r equal t 93% r as apprpriate fr patient cnditin. pco mm HG. (Aim clser t 35 in the setting f suspected acute brain injury) Mnitr SpO2 cntinuusly. Mnitr EtCO2 and wavefrm capngraphy cntinuusly. D nt reduce minute vlume based slely n EtC02 values withut ABG crrbratin ARDS / Acute Lung Injury: Lung injury in the ARDS patient is nt unifrm. The delivered tidal vlume tends t take the path f least resistance and ges preferentially t the nn-injured areas f the lung. This puts thse previusly nn / less injured areas at risk fr ver distensin and ventilatr assciated lung injury which further cmplicates patient management. The risk can be minimized by adjusting tidal vlumes t maintain a plateau pressure f less than r equal t 30. Mde Assist Cntrl will be the standard mde with which t ventilate these patients. This will prvide maximal ventilatry supprt t the patient and help minimize wrk f breathing. Exceptins t this will be if there is a prblem with aut-peep r difficulties with aut-cycling f the ventilatr. Breath type Pressure r Vlume Ventilatin can be used. Pressure cntrl ventilatin Ensures pressure limited breaths which als limit PIP and Plateau pressure. Tidal vlume is delivered early in the breath which may imprve gas exchange and reduce the patient s wrk f breathing. Variable tidal vlumes are a mre natural way f breathing and may be mre cmfrtable fr the patient. Alarms must be set apprpriately with clse attentin paid t minute ventilatin / exhaled vlumes. If cmpliance deterirates, exhaled vlumes will decrease. This will wrsen CO2 retentin, acidsis and atelectasis if allwed t g uncrrected. Octber, 2015, Revised January 1, 2016, Revised June 15,

41 Vlume ventilatin prvides a cnsistent tidal vlume. Apprpriate alarm parameters are als necessary in this cntext. High PIP s are an indicatin f in increase the risk f bartrauma. PIP s are primarily an indicatr f upper airway pressures and high PIP s may indicate increased risk f bartrauma. Plateau pressures are a mre apprpriate indicatr f the pressures in the lwer airways and alveli. PIP s are mnitred n a breath t breath basis. Unless the patient is brnchspastic, it is likely that, at least a prtin f that pressure is being transmitted t the lwer airways and alveli. Remember that inspiratin is terminated when the high PIP alarm is triggered; this happening repeatedly can lead t hypventilatin. Tidal vlume 4 8 ml/kg PBW t maintain plateau pressure as described abve. Breath Rate 12 t 20 BPM. Remember, if it becmes necessary t decrease the tidal vlume due t high PIPs / Plateau pressures it may be necessary t increase the respiratry rate t maintain adequate minute ventilatin. PEEP 5 t 20cm Permissive hypercapnia may becme necessary t reduce breath rate and r tidal vlume t reduce PIPs / Plateau pressures. If this becmes an issue, attempt t maintain a PH f greater than 7.15 and a PCO2 f less than 80. If patient is chrnically hypercarbic fcus n maintaining Ph. Inspiratry time secnds. Lnger inspiratry times imprve xygenatin by increasing mean airway pressures. Keep in mind that lnger inspiratry times mean less time fr exhalatin. Insufficient expiratry time causes air trapping AKA aut-peep. FIO2 Adjust in an effrt t maintain pulse ximetry 88 t 92%. Keep FIO2 as lw as pssible while maintaining xygen saturatins within parameters ASTHMA AND COPD, Managing AutPEEP: These patients shuld be managed aggressively with NPPV, brnchdilatrs, and sterids t avid intubatin and mechanical ventilatin if pssible. If it becmes necessary t intubate the patient, it shuld be accmplished as sn as pssible. Respiratry failure and hypercapnia will develp rapidly nce the patient begins t tire. Aggressive Analgesia, Sedatin, and Paralysis (sner than later) may help differentiate slutins t AutPEEP and reduce ptential fr vlutrauma r bartrauma Mde If the patient is breathing spntaneusly, SIMV may be helpful in reductin f aut-peep. Cnsider adding pressure supprt t reduce wrk f breathing with spntaneus breaths. Tidal Vlume 4 8 ml/kg PBW t achieve plateau pressure less than r equal t 30. Breath Rate 6 t 25 BPM, these patients are at high risk t develp aut-peep. An inapprpriately high respiratry rate is ne f the causative factrs f aut-peep. Adjust the breath rate t allw fr full exhalatin prir t the next breath being initiated. Permissive hypercapnia is recmmended t reduce the risk f ventilatr assciated lung injury frm high airway pressures and bartrauma. PEEP 4 10 cm. The wrk f breathing can be decreased by prviding external PEEP t 75-80% f aut-peep in patients wh are spntaneusly breathing Octber, 2015, Revised January 1, 2016, Revised June 15,

42 There is n evidence such external PEEP wuld be useful during cntrlled mechanical ventilatin when there is n patient inspiratry effrt Inspiratry Time 0.6 t 1.0 secnds. Lnger than necessary inspiratry times are anther causative factr f aut-peep. Shrter inspiratry times allw fr lnger exhalatin times resulting in less risk f aut-peep. Keep the inspiratry time shrt enugh t allw the patient t fully exhale prir t the initiatin f the next breath. FIO2 Adjust t maintain po2 > 90 r as apprpriate fr patient cnditin. Breath type Vlume r Pressure may be used BURNS AND SMOKE INHALATION: In additin t direct injury and the resulting edema, this patient ppulatin is at risk fr airway cmprmise frm ARDS, pneumnia, pulmnary edema, pulmnary emblism, and carbn mnxide pisning. Patients with burn injuries / smke inhalatin f sufficient severity t warrant intubatin shuld be assumed t have carbn mnxide pisining and ventilated using 100% xygen until prven therwise. Mde Assist Cntrl is cmmnly used t prvide maximal supprt with minimal patient effrt. Tidal Vlume 4 8 ml/kg PBW t achieve a plateau pressure less than r equal t 30. Breath Rate 6 20 BPM Be aware f the ptential fr aut-peep secndary t air flw restrictins frm edema in these patients. PEEP 5 10 cm Adjust based n FIO2 requirements and hemdynamics. Inspiratry Time secnds FIO2 100% Until the pssibility f carbn mnxide pisining can be ruled ut with a carbxyhemglbin level. Octber, 2015, Revised January 1, 2016, Revised June 15,

43 7.9. Nn-Invasive Mechanical Ventilatin (NPPV) Special Cnsideratins NPPV with a transprt ventilatin is NOT identical t Bi-Level psitive airway pressure ventilatin. Alteratins in the ventilatr settings in an attempt t mimic BiPAP are necessary Care shuld be taken t develp a rapprt between the Revel ventilatr and the patient when using NPPV Indicatins Adult patients with respiratry cmprmise f sufficient severity t warrant ventilatry supprt where intubatin is nt desired r immediately necessary Respiratry distress with mderate t severe dyspnea, use f accessry muscles, and abdminal paradx Cntraindicatins Apnea Recent surgery t face, upper airway, r upper GI tract Altered level f cnsciusness Emesis Absent r insufficient ability t prtect the airway Prcedure Mask Seal Imperative t keep Revel ventilatr frm activating blwer alarm Set IPAP and EPAP as nted n referring BiPAP machine Reduce IPAP by 2-4 frm sending BiPAP and titrate as needed fr patient cmfrt D nt exceed 20 cmh20 n ttal inspiratry pressure Typical starting pressures may be IPAP and EPAP Cnsider changing the fllwing, if desired r necessary, t imprve patient cmfrt and synchrny with the Revel ventilatr during NPPV use Change Rise Time t Prfile 2 Increase Flw Terminatin t 40% Manage patient anxiety and ventilatr alarms Cnnect t patient Ventilatin and Oxygenatin Maintenance: Manipulate ventilatr settings in an attempt t achieve: PH PO2 greater than r equal t 75 mm Hg r SPO2 greater than r equal t 93% r as apprpriate fr patient cnditin. PCO r as apprpriate fr patient s clinical histry Mnitr SPO2 cntinuusly. Cnsider mnitr ETCO2 and wavefrm capngraphy Octber, 2015, Revised January 1, 2016, Revised June 15,

44 7.10. Brnchdilatr Administratin fr ventilated patients INDICATIONS Actively wheezing intubated patients Intubated patients exhibiting ther signs f airflw restrictin and lss f alvelar plateau pressure despite analgesia, sedatin, and/r suctining CONTRAINDICATIONS Ipratrpium is cntraindicated fr patient with allergies t sy lecithin r related fd prducts such as sybeans r peanuts Albuterl shuld be utilized judiciusly with HR increases f greater than 20 beats frm baseline Cnsultatin with medical cntrl may be apprpriate PROCEDURE Shake MDI and activate with three priming sprays If desired, the MDI adapter shuld be placed n the inspiratry limb f the circuit as clse t the patient as pssible If desired, nebulizatin device and liquid reservir shuld be place n the inspiratry limb f the circuit, as clse t the patient as pssible Initial brnchdilatr therapy shuld cnsist f any cmbinatin f the fllwing Albuterl MDI 8 puffs, pausing in between puffs t allw adequate distributin and effect Albuterl and/r Ipratrpium via in line NEB One initial dse f Ipratrpium is all that is necessary Subsequent inhalatin medicatin shuld cnsist f Albuterl Octber, 2015, Revised January 1, 2016, Revised June 15,

45 7.11. Transvenus / Epicardial Pacemaker INDICATIONS Indwelling and functining transvenus r epicardial pacermaker CONTRAINDICATIONS NONE PROCEDURE Assure mechanical and electrical capture Cnsider arterial line Cnsider resurcing the HR utput t the pulse ximetry wavefrm Evaluate fr failure t sense and versense and adjust sensitivity apprpriately Needle Thracstmy INDICATIONS Tensin Pneumthrax CONTRAINDICATIONS NONE Apprpriately sized needle t be used in patients < 40kg PROCEDURE Identify Landmarks 2nd Rib Midclavicular line 5th Rib Midaxillary line Cleanse with chlrhexidine r alchl, if time allws Make a small stabbing puncture with scalpel and then insert needle OVER the rib and int the pleural space Cnsider withdrawing plunger with syringe while inserting needle and/r after insertin t cnfirm placement by withdrawal f air Simple Thracstmy INDICATIONS Unreslved clinical signs f tensin pneumthrax despite at least 2 needle thracstmies Suspected pneumthrax in traumatic cardiac arrest In the setting f chest trauma and subsequent arrest, prvider shuld have a lw threshld fr perfrming a simple vs needle thracstmy due t the inability t determine the prcedure s efficacy when there is n cardiac utput CONTRAINDICATIONS Functining needle thracstmy PROCEDURE Identify insertin site Anterir axillary line lateral t the sternxiphid junctin Cleanse with chlrhexidine r alchl, if time allws Incise dwn t the 5th rib with scalpel Insert Kelly clamp ver the 5th rib, thrugh the pleura, and dilate t the size f a finger Insert glved finger and assess fr lung, assuring absence f ther rgans Cver with a dressing that will nt becme cclusive Tube Thracstmy INDICATIONS Pneumthrax, Hemthrax The rle f the LOM prvider is t facilitate insertin f a chest tube by the credentialed prvider, prir t departure CONTRAINDICATIONS Functining needle thracstmy Octber, 2015, Revised January 1, 2016, Revised June 15,

46 PROCEDURE Identify insertin site Anterir axillary line lateral t the 5th intercstal space junctin Cleanse with chlrhexidine r alchl Incise dwn t the 5th rib with scalpel Insert Kelly clamp ver the 5th rib, thrugh the pleura, and dilate t the size f a finger Insert glved finger and assess fr lung, assuring absence f ther rgans Assuring direct track int pleural space, insert chest tube medially and caudally until all drainage hles are inside the chest cavity Arterial Cannulatin Radial INDICATIONS Cnsider when tw r mre cnditins exist Recent, and suspected reemergence, f hyptensin Patients receiving vasactive medicatins Hypertensive patients Unreliable Nn-Invasive bld pressures in high acuity patients Access site fr cntinuus ABG and electrlyte analysis CAUTIONS INR > 1.8 and/r PT ver 37 secnds Platelets < 20,000 Failed Allen s test Absence f radial pulses CONTRAINDICATIONS Cmprmised circulatin in the limb Infectin in the limb Time needed t perfrm prcedure wuld unnecessarily delay patient transprt in presence f time critical injury r illness Dialysis shunt r fistula Patient weight < 40kg PROCEDURE Identify site Perfrm Allen s test Cnsider immbilizatin f wrist Cnsider lcal anesthetic f Lidcaine Cleanse with chlrhexidine r ther suitable antimicrbial agent If pssible and available, utilize the fllwing Sterile drape Sterile gwn Sterile glves Mask Place arterial line and cnnect t transducer Secure device with transparent dressing and ne r mre f the fllwing fashins Butterfly Steri-Strips Sutures Transduce the catheter and zer in standard fashin Arterial Cannulatin Femral INDICATIONS Cnsider when tw r mre cnditins exist Recent, and suspected reemergence, f hyptensin Octber, 2015, Revised January 1, 2016, Revised June 15,

47 Patients receiving vasactive medicatins Hypertensive patients Unreliable Nn-Invasive bld pressures in high acuity patients Access site fr cntinuus ABG and electrlyte analysis Anticipated r realized unsuccessful radial apprach CAUTIONS INR > 1.8 and/r PT ver 37 secnds Platelets < 20,000 Failed Allen s test Absence f radial pulses CONTRAINDICATIONS Time needed t perfrm prcedure wuld unnecessarily delay patient transprt in presence f time critical injury r illness Evidence f infectin near insertin site Cmprmised circulatin distal t insertin site PROCEDURE Identify site Cnsider lcal anesthetic f Lidcaine Cleanse with chlrhexidine r ther suitable antimicrbial agent Femral apprach must be dne as sterile as pssible utilizing the fllwing Sterile drape Sterile gwn Sterile glves Mask Place arterial line and cnnect t transducer Secure device in ne r mre f the fllwing fashins Butterfly Steri-Strips Sutures Transparent dressing Transduce the catheter and zer in standard fashin Eschartmy INDICATIONS Unless patient is in peri-arrest state directly related t lack f chest wall excursin, in cnsultatin with LOM medical directr r medical cntrl Impending r established vascular cmprmise f the extremities r digits Impending r established respiratry cmprmise due t trs burns CONTRAINDICATIONS Nne Special Cnsideratins Prcedure secndary t Airway, Breathing, and Circulatin interventins Avid the ulnar nerve at the elbw (See diagram belw) Avid the perneal nerve at the knee (See diagram belw) Avid incisin n the neck due t pssibility f damaging great vessels PROCEDURE If available, clean site with betadyne Using sterile scalpel, perfrm incisin thrugh eschar sufficiently t see bvius separatin f wund edges Chest Incise alng the mid axillary lines Octber, 2015, Revised January 1, 2016, Revised June 15,

48 Incise in a transverse fashin belw the cstal margin and/r the tp f the chest See diagrams belw fr ptins Limb Incise alng mid axial lines between flexr and extensr surfaces, bilaterally, if indicated Use cautin with incisins acrss the flexural creases r jints Cntrl bleeding Administer Cefazlin ver 10 minutes < 40kg Cntact receiving clinician 40 80kg 1g 80kg 2g Reassess fr reslutin f clinical indicatins Hemstatic Gauze INDICATIONS Hemrrhage uncntrlled by direct pressure, especially where a turniquet is nt feasible CONTRAINDICATIONS Knwn hypersensitivity PROCEDURE Place in direct cntact with wund Wrap with pressure dressing fcused n site f hemrrhage Octber, 2015, Revised January 1, 2016, Revised June 15,

49 7.19. Surgical Cricthyrtmy INDICATIONS Airway patency necessity when ther methds have failed CONTRAINDICATIONS The ability t btain airway cntrl by less invasive means Patients < 8 years ld Prcedure As prescribed in the LOM 2015 Prtcl bk As practiced in simulatin and at the CCTI Airway Lab Lcate the cricthyrid cartilage Apply Betadine r Chlrhexadine, if time allws Make skin incisin large enugh t accmmdate tracheal tube Obtain access int the trachea via the cricthyrid membrane Maintain this access and deliver a tracheal tube as per Prtcl r device used Inflate balln, secure Cnfirmatin f placement As prescribed in the LOM 2015 Prtcl bk Cntinuus mnitring f ETCO2 wavefrm is required When pssible, Gastric Decmpressin shuld be achieved in all intubated patients When pssible, the head f the stretcher shuld be elevated t 30 Octber, 2015, Revised January 1, 2016, Revised June 15,

50 7.20. Needle Cricthyrtmy INDICATIONS Airway patency necessity when ther methds have failed Patient is < 8 years f age with airway patency necessity when ther methds have failed CONTRAINDICATIONS Ability t effectively ventilate patient by any ther means Ability t secure airway with a cuffed tube PROCEDURE As prescribed in the LOM 2015 Prtcl bk As practiced in simulatin and at the CCTI Airway Lab Lcate the cricthyrid cartilage Apply Betadine r Chlrhexadine Attach a syringe t a 14g angicath and withdraw while inserting caudally thrugh the cricthyrid membrane When aspiratin f air is achieved, slide catheter ver the needle and remve the needle Secure the catheter and cnnect a Jet insufflatin device, r a BVM may be used remving the 15mm adapter frm a 3.0mm ETT and inserting int the hub f the catheter Cnfirmatin f placement Chest rise Octber, 2015, Revised January 1, 2016, Revised June 15,

51 8. PEDIATRICS 8.1. Pediatric Mnitring and General Cnsideratins Patients < 13 years f age Patients < 40kg Patients 13 years f age and 40kg can be addressed as adult patients and/r discussed with medical cntrl Pediatric Intensivists Cntact via MedCmm, if pssible LOM crew are encuraged t achieve dialgue with the pediatric intensivists in rder t ensure alignment f management plans between the sending and receiving clinicians These physicians have chsen t make themselves available t the LOM crew fr cnsultatin and medical cntrl, regardless f the patient destinatin If initial temperature < 36 C r > 38 C, cntinuusly mnitr via skin, esphageal, r rectal prbe during transprt Identify r btain glucse measurement Treatment f HYPOglycemia (< 80mg/dL) Dextrse g/kg < 40kg D ml/kg If hypglycemia persists, cnsider infusin D mg/kg/min Glucagn < 20kg 0.5mg IM > 20kg 1mg IM Table f nrmal VS limits AGE HR BP RR 0 1 Mnth < 1 year years (2*Age) years (2*Age) years (2*Age) Pediatric Airway Management CAUTION: Unless an asthmatic is in extremis (cmprmised mental status frm hypercapnea r hypxia,) d nt intubate prir t achieving dialgue with receiving pediatric intensivist Rapid Sequence Inductin CONTRAINDICATIONs t Ketamine In instances where ICP may be elevated, due t a mechanical CSF bstructin, Etmidate remains the inductin agent f chice Cuffed ETT size 14!Age (in years) (Nrmal size 0.5mm fr cuff) ETT depth is apprximately (age) Refer t FRP Pediatric Cardiac Arrest PALS algrithm Octber, 2015, Revised January 1, 2016, Revised June 15,

52 8.4. Pediatric Fluid Resuscitatin and Maintenance Nrmal Saline Blus 20 ml/kg CAUTION Aggressive fluid resuscitatin in pediatric DKA patient is cntraindicated Maintenance infusin Weight < 10kg D5W 0.225% NS Weight > 10kg D5W 0.45% NS Infusin Calculatr 0 10kg 4mL/kg/hr 10 20kg 40mL/hr + (Weight 10) * 2mL/kg/hr > 20kg 60mL/hr + (Weight 20) * 1mL/kg/hr 8.5. Pediatric Hypthermia Fr Adult Hypthermia, refer t FRP 6.5. Differences are listed belw: If a perfusing cardiac rhythm is present, treat hyptensin with warmed Nrmal Saline, 20mL/kg. Repeat x 2 fr cntinued hyptensin If hyptensin persists, Dpamine 5 mcg/kg/min and titrate t MAX f 20 mcg/kg/min as needed If hypglycemic (BS < 80 mg/dl,) refer t FRP Pediatric Sepsis Ensure that apprpriate antibitics have been initiated Cntact receiving pediatric intensivist Identify r btain lactate If febrile, Acetaminphen 15 mg/kg PO / PR / PNGT / POGT If patient Hyptensive, refer t FRP If altered mental status and BS < 80 mg/dl, refer t FRP Pediatric Pisning Treat as per adult, refer t FRP Pisn Cntrl Center Fr CNS depressin Cnsider Narcan 0.1mg/kg MAX dse 2mg Octber, 2015, Revised January 1, 2016, Revised June 15,

53 8.8. Pediatric Respiratry Failure Pediatric Airway Management: FRP Surgical Cricthyrtmy FRP Needle Cricthyrtmy FRP Special Airway Cases FRP Blunt chest trauma FRP Needle Thracstmy FRP Pediatric Seizures If febrile, Acetaminphen 15 mg/kg PO / PR / PNGT / POGT If hypglycemic (BS < 80,) refer t FRP Anticnvulsants Chse One Benzdiazepine Midazlam 0.1 mg/kg Repeat x 1 Lrazepam 0.15 mg/kg Repeat x 1 Watch fr respiratry depressin and hyptensin; be prepared t secure the airway, refer t FRP 2.3if necessary If seizures persist and cannt be cntrlled Age > 1 Fsphenytin 20 pe/kg in 100mL ver minutes MAX dse 1500 mg PE Watch fr cardiac dysrhythmias Infuse at rate < 150 pe/min If Age < 1, patient has allergy t Fsphenytin, r cntinues t have seizures Levetiracetam (Keppra) Cnsult with PICU intensivist Phenbarbital Cnsult with PICU intensivist Pediatric Refractry Shck mL/kg blus NS, may repeat x Cntact Pediatric Intensivist Shck refractry t crystallid Dpamine 2 20 mcg/kg/min Epinephrine mcg/kg/min Dbutamine 2 30 mcg/kg/min fr patients with knwn cardigenic etilgies Pediatric Spinal Injury INDICATIONS: Any patient with a knwn spinal clumn injury, a (spinal) neurlgical deficit, r a mechanism f injury cnsistent with pssible spinal injury will be prperly immbilized fr transprt Fllw Maine EMS prtcl Green 4-8 fr spinal immbilizatin and refer t FRP 5.9 spinal injury fr clearance and IFT Transprt. Octber, 2015, Revised January 1, 2016, Revised June 15,

54 PROCEDURE: Immbilize patient with device that functins best fr patient s size. Refer t FRP 2.3 if RSI is indicated Cnsider analgesia and anxilysis t reduce mvement Refer t FRP 8.12 and 8.13 Treat neurgenic shck per FRP 8.10 Octber, 2015, Revised January 1, 2016, Revised June 15,

55 8.12. Pediatric Sedatin Sedatin blus in Nn-Intubated patients Midazlam 0.1mg/kg IV/IO/IM every 5 minutes MAX dse 10mg Lrazepam 0.15mg/kg MAX dse 4mg Cntact OLMD fr ptin f Ketamine 0.5 mg/kg IV Ketamine 3 5 mg/kg IM If hyper-salivatin is present, cnsider Atrpine 0.01 mg/kg with a minimum dse f 0.1mg Sedatin in the Mechanically Ventilated patient Midazlam 0.1 mg/kg IV/IO/IM MAX dse 4mg Lrazepam 0.15 mg/kg Ketamine mg/kg Prpfl (blus) 0.5 2mg/kg blus Prpfl (infusin) mcg/kg/min Pediatric Analgesia Analgesia Acetaminphen 15 mg/kg PO r PR Fentanyl 1 2mcg/kg CAUTION SLOW IV blus due t higher incidence f rigid chest syndrme Cnsider Intra-nasal rute if atmizer is available, mcg/kg Mrphine 0.1mg/kg Fr infants < 3 mnths mg/kg q 10 minutes Pediatric DKA Indicatin: Pediatric patients presenting with related signs and symptms fr pssible DKA, such as Kussmaul breathing, pr peripheral perfusin, altered mental status, a histry f weight lss, plyuria, plydipsia, r plyphagia Cnsideratins: Cncmitant sepsis as a precipitant fr the hyperglycemia Rapid reductins in serum bld glucse levels (Mre than 100mg/dl per hur) may cause prfund cerebral edema and shuld be avided High risk patients fr cerebral edema include patients < 5 years f age ph <7.0 Newly diagnsed DM Dehydrated patients with marked elevatins in BUN. IV Blus f insulin is nt indicated Initiatin f insulin infusin is nt mandatry, but shuld be cnsidered fr wrsening acidsis r a lng transprt Call pediatric intensivist prir t initiatin f insulin therapy Diagnstic Criteria fr DKA T meet criteria fr entering DKA prtcl, patients shuld meet ne f the clinical indicatins listed abve, and the fllwing bichemical parameters Glucse > 200, althugh in infants, this may nt be the case HCO3 < 15 meq/l VBG ph < 7.25 ABG ph < 7.3 Octber, 2015, Revised January 1, 2016, Revised June 15,

56 Presence f elevated serum ketnes (> 1.5 mml/l) Psitive urine ketnes (large) Knwn r high index f suspicin f diabetes mellitus Evaluatin and Treatment VBG at least hurly, including glucse D NOT reduce glucse > 100 mg/dl/hr Neurlgical assessments every hur Watch fr signs f cerebral edema (altered mental status, severe headache, hypertensin and bradycardia) cnsider cntacting pediatric intensivist fr ptins f Mannitl gm/kg IV blus 3% Nrmal Saline, dsage at discretin f the receiving physician Fluid Management If patient HYPOtensive, Nrmal Saline Blus 20 ml/kg x 1 ONLY Cnsult Pediatric Intensivist if further fluid needed. 0.45% Nrmal Saline at 1.5 x maintenance Pediatric Maintenance Fluid Requirement in DKA Apprximate Weight ML/HR f 0.45% NS Saline 5 kg 30 ml/hr 10 kg 60 ml/hr 15 kg 75 ml/hr 20 kg 90 ml/hr 25 kg 98 ml/hr 30 kg 105 ml/hr 35 kg 113 ml/hr 40 kg 120 ml/hr Glucse Management (when insulin infusin has already been initiated). Mnitr patient fr falling glucse levels as described belw: If glucse < 250mg/dl Change IV fluid t D5W ½ Nrmal Saline / 20 meq f Ptassium Chlride in 1L added at rate described belw in table. If glucse cntinues t fall despite D5W ½ Nrmal Saline / 20 meq f Ptassium Chlride in 1L added at rate described belw in table Cntinue fluid Decrease insulin by 0.25 u/kg/hr Insulin Therapy If Insulin infusin HAS been initiated by sending facility, mnitr fr falling glucse levels as described belw and cntact pediatric intensivis Insulin Infusin: Start immediately after cmpletin f initial fluid blus. Mix 50 u human regular insulin in 500 ml NS (0.1 u/ml final cncentratin) Run 50 ml f slutin thrugh IV tubing t saturate binding sites n the tubing Patient > 3 years f age Infuse Insulin 0.1 u/kg/hr (1 ml/kg/hr) Patient 3 years f age Infuse Insulin 0.05u/kg/hr (0.5 ml/kg/hr) Cntinue Insulin infusin with IV maintenance fluid infusin until serum HCO3 is 18mEq/L Octber, 2015, Revised January 1, 2016, Revised June 15,

57 8.15. Pediatric Cyantic Heart Objectives: Restratin f cardiac utput t imprve tissue xygenatin and inadequate perfusin by maintaining an pen ductus arterisus and expanding intravascular vlume as apprpriate If altered mental status and BS < 80 mg/dl, refer t FRP Cntact PICU intensivist fr ptins If n imprvement in hypxia with xygen Cnsider Prstaglandin E1 (patient must be intubated prir t initiatin) 0.1 mcg/kg/min and titrate t imprved xygenatin and systemic perfusin MAX f 0.5 mcg/kg/min Mnitr patient fr hyptensin due t vasdilatry effects If signs f pulmnary vascular cngestin and/r fluid verlad are present, withhld fluid blus and administer Fursemide 1 mg/kg If n evidence f fluid verlad Nrmal Saline 20 ml/kg ver 5 10 minutes Cnsider intrpic supprt fr failed initial fluid blus Dpamine 2 20 mcg/kg/min Dbutamine 2 20 mcg/kg/min Epinephrine mcg/kg/min May repeat NS 20 ml/kg x 2 unless signs f fluid verlad present Octber, 2015, Revised January 1, 2016, Revised June 15,

58 9. OBSTETRICAL EMERGENCIES 9.1. General Cnsideratins with Pregnant Patients Assure Left Lateral psitin in a manner achieving relief f pressure n the Inferir Vena Cavae Pregnant wmen are inherently hemdiluted and fluid verladed The mst apprpriate way t manage the fetus, in-uter, is t treat the mther Delivery f an infant, in the transprt envirnment, especially the aircraft, has a gal f being a NEVER event Evaluatin, management, and cnsultatins shuld fcus n assuring that delivery during transprt is avided Identify r evaluate fr cervical dilatatin (< 4cm) Identify r evaluate fr cervical effacement Identify r evaluate fr duratin, frequency, and prgressin f uterine cntractins Identify r evaluate fr precipitus r cmplicatins with previus deliveries Cntact receiving if the fllwing signs r symptms exist Cagulpathy; (DIC) Fetal distress Excessive maternal hemrrhage Regular cntractins (active labr) Hemdynamic instability Severe abdminal pain Seizures / Neurlgical instability Pulmnary edema Severe hypertensin Advance cervical dilatatin (> 4cm) relative t gestatinal age 9.2. Vaginal bleeding asssciated with pregnancy Delay transfer if maternal r fetal distress is reprted r assessed Evaluate and treat hemrrhage as per standard LOM practice fr fluid and cllid resuscitatin Digital exams shuld be avided, unless abslutely necessary Cnsider administratin f tclytics in the presence f premature labr, FOR THE PURPOSE OF COMPLETING THE TRANSPORT ONLY, if rdered by the receiving physician Terbutaline and Ritdrine are cntraindicated in the presence f hemrrhage Octber, 2015, Revised January 1, 2016, Revised June 15,

59 9.3. Pain and/r nausea in pregnancy Evaluate and treat as per standard LOM practice Restrict narctic use t Fentanyl (Class C) mcg/kg Ondansetrn (Class B) 4mg May repeat q 20 minutes t MAX dse 16mg 9.4. Pregnancy Induced Hypertensin Identify r evaluate fr any f the fllwing Prteinuria Excessive weight gain ver 1 week Intra-cerebral hemrrhage Seizures Severe, cntinuus headache Blurred visin Persistent emesis Pulmnary edema (HELLP Syndrme) Hypertensin, Elevated Liver Enzymes, Lw Platelets Seizures Magnesium Sulfate (Blus then infusin) MIX 4g in 50mL NS, infuse at 300 ml/hr (4g ver 10 minutes) MIX 4g in 100mL NS, infuse at 50 ml/hr ***MAGnesium Txicity*** Mnitr fr absent reflexes If present, STOP magnesium infusin Mnitr fr arrhythmia, hyptensin, respiratry depressin, and if present STOP magnesium infusin Administer Calcium Glucnate 1g/100mL IV ver ten minutes Phenytin 20mg/kg IV at rate NO greater than 25mg/min Lrazepam 1 2mg every 5 minutes t a max f 20mg Hypertensin Dialgue with receiving OB/GYN regarding ptins fr Nicardipine, Hydralazine, r Labetall, Refer t FRP 4.14 Gal Systlic is usually < 160mmHg and Diastlic mmHg 9.5. Preterm Labr Cnsider NS 500mL blus prir t tclysis with histry suggesting dehydratin LOM team must achieve dialgue between referring and receiving clinicians and btain abslute clarity as t the treatment ptins, management plan, and cntingencies, prir t departure Identify r evaluate fetal lung maturity Identify r evaluate fr Grup Beta Strep, if pssible Cntact receiving fr ptins f Antibitics Sterids t facilitate lung maturity 9.6. Premature rupture f membranes Tclysis may nly be indicated as a bridge t an apprpriate facility fr sterid therapy r delivery Cnsult with receiving clinicians. Octber, 2015, Revised January 1, 2016, Revised June 15,

60 9.7. Trauma in Pregnancy Evaluate and treat as per standard LOM, PHTLS, and ATLS practice Tilting immbilizatin bard and/r patient t reduce IVC pressure is necessary If facts and circumstances f the patient's demise are such that the peri-mrtem caesarean sectin is a cnsideratin, this must be perfrmed by trained persnnel. Pssible indicatins fr peri-mrtem c-sectin are as fllws: Witnessed Arrest Effective CPR Gestatinal age > 30 weeks Unsuccessful ROSC 9.8. Unplanned deliveries As stated, transprt shuld NOT be cnsidered if delivery is imminent, r likely t ccur during transprt Cnsideratins Cervical dilatatin > 4cm with active labr and substantially effaced cervix Cntractins < 5 minutes apart Histry f precipitus delivery VERTEX presentatin Supprt the perineum. Supprt infant's head as it emerges and rtates externally. Suctin muth, nse, then evaluate neck fr wrapped umbilical crd Wait fr uterine cntractin and gently grasp the baby's head, depressing it twards the rectum. Next, raise the head t deliver the psterir shulder Keep infant belw the level f the placenta Place tw clamps, at least 8 inches frm the naval, and cut crd Dry and wrap the infant, and if bth stable, place n mther's chest. Placental delivery shuld ccur within 30 minutes, DO NOT PULL n crd Apply direct pressure t intravaginal r perineal areas f excessive bleeding Evaluate APGAR scres at 1 minute and 5 minutes f life. Treat infant as per NALS and STABLE algrithms APGAR Scre Appearance, clr Blue Acrcyansis Entirely Pink Pulse, HR Nne < 100 > 100 Grimace, reflex Nne Grimace Cugh, gag, cry Activity, attitude Flaccid Sme flexin Well-flexed, Active Respiratry effrt Nne Weak irregular Gd, crying Octber, 2015, Revised January 1, 2016, Revised June 15,

61 9.9. Cmplicatins f Delivery Breech presentatin If delivery in prgress, allw buttcks and trunk t deliver Once legs and arms are delivered, supprt the bdy in palm f hand Insert yur finger int baby's muth and bring the chin dwn t allw delivery f the head Shulder Dystcia Place patient in semi-fwlers psitin Patient's legs flexed and pulled cranially and abducted t increase AP diameter f the pelvis Suprapubic pressure can be used t attempt t push the anterir shulder under the symphysis pubis DO NOT use fundal pressure Cnsider reaching int the vagina t deliver the anterir shulder by trying t rtate it int the pelvis, extracting the psterir arm, r using a crkscrew maneuver t rtate the shulders ut f the pelvis. Delivery f the anterir shulder MUST ccur within minutes Prlapsed crd Manually displace cmpressing fetal bdy part frm the crd and maintain until in the perating rm. Place mther in trendelenburg t reduce caudal pressure Cnsider tclysis as a bridge t definite care Amnitic fluid emblus Prvide supplemental xygen and PEEP as per standard LOM prtcl Mnitr fr DIC Pst-Partum hemrrhage Fundal massage Bimanual uterine massage Evaluate and treat hemrrhage as per standard LOM practice fr fluid and cllid resuscitatin Oxytcin 20 units in 1000mL NS at 300mL/hr Laceratins Uterine Rupture Evaluate and treat hemrrhage as per standard LOM practice fr fluid and cllid resuscitatin Oxytcin 20 units IM If bleeding cntinues Oxytcin MIX 40 units/1000ml NS at 300 ml/hr Ruptured Ectpic Pregnancy Evaluate and treat hemrrhage as per standard LOM practice fr fluid and cllid resuscitatin This is a surgical emergency and ntify receiving f patient cnditin Octber, 2015, Revised January 1, 2016, Revised June 15,

62 10. Appendix A Intubatin Tips PREPARATION Fur Crnerstnes (Minimum requirements fr emergency intubatin) 1. Laryngscpe with bth straight and curved blades 2. ET tube with backup tube size 3. Suctin 4. Bugie Failed Airway Optins Minimum requirements fr emergency intubatin: Supraglttic airway (e.g. - King, LMA) Surgical airway kit HELP Psitin LARYNGOSCOPY Wide View Laryngscpy ( heads up ) Keep yur wn eyes up and away frm the patient s face. Althugh sme wuld argue that true bincular visin des nt always ccur r is nt always necessary, the heads up psitin generally prvides ptimum visin because it increases the fcal distance t the crds. The imprtance f fcal distance is illustrated when intubating patients while sitting n the flr and behind the patient s head; keeping yur wn head up and away frm the patient prvides an ptimum fcal distance and visual field fr intubatin. The ther advantage f the wide view ( heads up ) psitin is that it allws the laryngscpist t see mre than the crds in the visual field an imprtant cncept in managing mst emergency intubatins in uncntrlled cnditins. Bimanual Laryngscpy ( tw hands ) Use bth hands t find the crds. While ne hand hlds the laryngscpe, the ther shuld be kept free t pen the muth, remve teeth and freign material, help cntrl the tngue, etc. During RSI, cricid pressure is generally applied by an assistant. If the view f the crds (POGO) still needs t be imprved, that can best be dne by the laryngscpist him/herself, again as lng as the secnd hand remains free. External Laryngeal Manipulatin (ELM) can be dne by the laryngscpist t imprve the POGO scre as needed. Once ptimal POGO is btained, the assistant then takes ver cricid pressure in the new and imprved psitin. Hand ver hand is a variatin f this technique. Incremental Laryngscpy ( walk the tngue ) Emergency airway management generally invlves unscreened patients with a variety f anatmical variatins, including the ugly airway. In this technique, the laryngscpe is prgressively and carefully mved thrugh the pharynx in increments, identifying anatmical landmarks and variatins alng the way ( walking the tngue ). When the epiglttis has been identified, the tip f the blade is then placed in crrect psitin in relatin t the epiglttis. Finding anatmical landmarks and prper placement f the laryngscpe blade shuld nt be hurried, and shuld be expected t take at least 5-10 secnds in mst unscreened patients. Only after landmarks have been identified, and the blade ptimally placed in relatin t the epiglttis, shuld any significant pressure be applied t pen the airway with the laryngscpe blade. If the crds are then sufficiently visible enugh t cnfidently pass the ETT r bugie, ne f these is then passed and the intubatin is cmpleted. If landmarks are still uncertain at this pint Cnsider remving the laryngscpe blade cmpletely, and making sme adjustments befre prceeding further. In a truly difficult airway, it is generally gd practice t anticipate this kind f rientatin pass and t make these changes nw, rather than t cntinue further int unknwn territry. Pssible helpful adjustments might include ELM (see belw), changing head psitin ( sniff, ramp, and HELP), use f suctin r frceps t remve freign material, use f the rigid suctin tip as prbe, changing blade type (curved vs straight vs Hwland lck), etc. The pint is t take the necessary time t identify landmarks, and prceed carefully in increments when challenged by a truly difficult emergency airway. Bugie Tips and Perspectives Octber, 2015, Revised January 1, 2016, Revised June 15,

63 The gum elastic bugie (Eschmann, tube changer, etc.) is a practical and effective first-line device fr securing even extremely difficult airways, particularly in the presence f bld, vmitus, r anatmic defrmities. It can generally be placed by direct visin easier than a cuffed ET tube, and can ften be placed by feel f the tracheal rings even when anatmic structures are bscured. "If the ET tube cannt be quickly and cnfidently passed thrugh the crds under direct visin, it is generally best t first pass the bugie t secure tracheal placement, then pass the ET tube ver the bugie." Select the right bugie All bugies are nt equally effective. Select ne that is stiff enugh, even at the high temperatures that might be fund in an ambulance r aircraft n a ht day. Shape the bugie Bugies tend t take n the shape f their packaging. When ciled in a small pack, fr example, the bugie will need t be apprpriately shaped befre use. Nte that bugies all have shrt term memry and can be re-shaped quickly and easily. Rtate t feel rings Tracheal rings are usually easy t identify when the bugie is in the trachea, with the cude tip angled anterirly, tward the frnt f the trachea. Hwever, smetimes it is necessary t rtate the bugie tip thrugh 180 degrees t get the best feel f the rings, even when the bugie is crrectly placed. Rtate t pass bstructins Even when crrectly placed in the larynx, the bugie can still hang up n anatmical structures, such as the true vcal crds and the anterir cmmissure. When encuntering an bstructin, back the bugie a bit, and rtate gently ( back and rll ) t walk the tip past the bstructin. Trublesht with laryngscpe The laryngscpe can be used as a trubleshting tl fr a variety f situatins during intubatin. When difficulties ccur in passing the bugie thrugh the crds, particularly when passing the bugie by feel in a blind Prcedure, the laryngscpe can ften be used t help prvide sme helpful rientatin t the psitin f glttic structures and t the psitin f the bugie tip, even if the crds themselves cannt be seen. Bury the bugie The tip f the gum elastic bugie (and its plastic variatins) is generally cnsidered t be an atraumatic tip if handled gently and carefully. After the trachea is identified, place the bugie deep int the trachea. This prevents flipping the tip ut f the trachea and int the esphagus when the ET tube is guided arund the crner f the pharynx. Afterlad the tube It is generally best t afterlad the bugie with an ET tube, after it is placed and cnfirmed in the trachea. Prelading might save a few secnds, but that kind f time savings is nt generally significant. Mre imprtantly, prelading the ET tube interferes with the prper feel f the bugie tip n the tracheal rings, and als interferes with rtatin f the bugie tip. Cntrl the bugie when lading If the bugie tip were t be placed just beynd the crds, it wuld be necessary t use the secnd hand at the muth t firmly stabilize bugie in the trachea when lading the ET tube. This makes afterlading the ET tube difficult, since the prximal end f the bugie is nt well stabilized. If the patient is sedated and paralyzed during RSI, hwever, and the bugie is placed deep in the trachea ( bury the bugie ), the secnd hand can adequately stabilize the bugie at the prximal end. This makes lading the ET tube much faster and easier. Straighten the airway Once the ET tube is laded ver the bugie, it must nw be guided arund the angle f the pharynx at the base f the tngue. Straightening the airway makes this step much easier and quicker. The airway can be straightened with the secnd hand by using a laryngscpe (even withut the light), r by simply lifting the tngue and jaw with the thumb f a glved hand. Passing bstructins Even when prperly placed, the ET tube can still hang up n anatmic structures, much the same as the bugie. And as with the bugie, the tip f the ET tube can smetimes be mved back and rtated ( back and rll ) t clear the bstructin. And as with any type f cuffed tube, a gentle reciprcating actin is generally helpful, and can be cmbined with rtatin. Trublesht with laryngscpe Octber, 2015, Revised January 1, 2016, Revised June 15,

64 Just as the laryngscpe can be used as a trubleshting tl when passing the bugie, it can als be used t navigate thrugh bstructins that might be encuntered when passing the tube ver the bugie. Nt nly des it prvide sme visual rientatin, it als helps t straighten the airway. Feel the tube pass Whether r nt a bugie is used first fr placement, the passing f the ET tube cuff thrugh the larynx can generally be felt by the assistant wh is hlding cricid pressure. 11. Drug Mixing Reference Octber, 2015, Revised January 1, 2016, Revised June 15,