Omaha Fire Department Standard Operating Procedures

Transcription

1 Omaha Fire Department Standard Operating Procedures EMERGENCY MEDICAL SERVICES 4-0 PARAMEDIC TREATMENT PROTOCOL REVISION HISTORY REVISION # REVISION DESCRIPTION DATE REVISED AUTHOR REVIEWED BY APPROVED BY 1 Periodic Revision Oct 2015 Rupp 578 Mancuso 802 Hunter Ketamine, D10, Glucagon, & Epi Drip June 2016 Brown 750 Rupp 578 Hunter 723 IN EFFECT JUNE 2016 General Operations...Pages 4-15 Introductions 4 Physicians Orders 4 Transportation Codes 5 Special Transportation Considerations 6 Behavioral Emergencies 7 Physician on Scene 8 DNR Orders 9 Code 4 Patients 11 Out of Hospital Confirmation of Death 12 Refusal of Care 14

2 General Principles Pages Airway, Oxygen, and Ventilation 16 CPAP 17 IV Therapy/Medications 18 Body Substance Isolation (BSI) 19 Restraints 19 Pain Management - Adult Criteria 21 Pain Management - Pediatric Criteria 22 Cardiac Emergencies (Adult).Pages General Guidelines 22 Ventricular Fibrillation (VF) and Pulseless VT 23 Asystole 24 Pulseless Electrical Activity (PEA) 24 Return of Spontaneous Circulation (ROSC) 25 Bradycardia 26 Ventricular Tachycardia with a Pulse 27 Supraventricular Tachycardia (PSVT) 27 A-Fib and A-Flutter with Rapid Ventricular Rate 28 Ventricular Ectopy with Runs of V-Tach 29 Acute Coronary Syndrome (ACS) 29 Pulmonary Edema 30 Cardiogenic Shock 31 Acute Trauma Emergencies..Pages General Trauma Management 31 Penetrating Injuries to Head, Neck, Chest, and Abdomen 33 Head Injuries 33 Chest Injuries 33 Abdominal Injuries 34 Eye Trauma 34 Burns 34 Snakebites 35 Crush Syndrome 36 Decision Scheme for Trauma Patients 36 Trauma Center Rotation for Mass Casualty Incidents (MCI) 38 Medical Emergencies..Pages Upper Airway Obstruction 38 Altered Mental Status 39 Excited Delirium 41 Seizures 43 Difficulty Breathing 44 Exposure 45 Hypotension in the Absence of Trauma 46 Poisons 46 Nerve Agents 46 Overdose/Toxic Ingestion 47 Toxic Inhalation 47 Cyanide Poisoning 48 Stroke (TIA, CVA) 48 Behavioral Emergencies 49 Nausea and / or Vomiting 49 Page 2 of 83

3 Obstetrics Gynecology..Pages Imminent Delivery 49 Neonatal Care 49 Meconium Stained Fluid 50 Childbirth Complications 50 Postpartum Hemorrhage 51 Hypertensive Disorders of Pregnancy 51 Vaginal Bleeding 51 Pediatrics Pages General Guidelines 52 Airway Management/O2 Therapy 52 IV Therapy 53 Pediatric Cardiac Arrest 53 V-Fib/Pulseless V-Tach 53 Asystole/PEA 54 Pediatric General Cardiac Dysrhythmia 55 Bradycardia (Unstable) 55 V-Tach with a Pulse 56 SVT (Unstable) 56 Difficulty Breathing 57 Seizures 58 Altered Mental Status 59 Procedure A, B, C, D, E, F, G, H Pages A. Rapid Sequence Intubation 61 B. Cincinnati Pre-hospital Stroke Scale 64 C. Cervical Spine Immobilization Considerations 65 D. Nerve Agent/Organophosphate Mark 1 Kits / DuoDotes 67 E. 12-Lead ECG Procedures 71 F. Cyanide Poisoning Cyanokit 73 G. Trauma Scoring and GCS 76 H. Epinephrine Drip 78 Appendix A... Pages A. OFD EMS Abbreviations 79 Page 3 of 83

4 GENERAL OPERATIONS A. Introduction 1. The Omaha Fire Department has adopted the current Midlands Protocol Committee Paramedic Treatment Protocol and the State of Nebraska EMS Model Protocols as a basis for paramedic patient care guidelines. This document consists of these two protocols with modifications from the Omaha Fire Department Medical Director for Omaha Fire specific policies and procedures. 2. The Omaha Fire Department Physician Medical Director is responsible for developing and approving these protocols. This protocol, in its entirety, is considered a standing order. 3. The Omaha Fire Department will follow all EMS rules and regulations set forth by the Authority Having Jurisdiction. 4. This document utilizes current American Heart Association BLS, ACLS and PALS guidelines. In addition, current PHTLS guidelines are used when referring to trauma situations. Changes to any of these national guidelines will be adopted and implemented as they occur. 5. At least one Paramedic must be present on all runs governed by this protocol. 6. Definitions: Bypassed Patient A patient that the receiving hospital has chosen to divert to another facility or diverts a trauma patient to the trauma center. epcr (Electronic Patient Care Reporting) The OFD mechanism used for documentation of EMS patients and EMS runs (patient care report) Receiving Hospital The hospital that receives the patient. B. Physician Orders / Communications This protocol, in its entirety, is considered a standing order. Radio communications are not required prior to performing any protocol action. If at any point the paramedic determines guidance is necessary, the paramedic may contact the receiving facility or the Omaha Fire Department Medical Director or the Paramedic Shift Supervisor (PSS) for further direction or confirmation of orders whenever the patient s condition or the situation warrants. Page 4 of 83

5 C. Transport Codes and Guidelines Code 1 Code 2 Minimal or no apparent disease or injury. Patient transported for Examination. Obvious illness or injury, not a serious injury or illness but needs medical attention. Code 2 Trauma Trauma patient with an obvious injury but doesn t clearly meet the criteria for a Code 3. Enough questionable signs, symptoms or MOI exists to warrant the expertise of the Trauma Center. Code 3 Code 3 Stroke Apparent serious / life-threatening medical illness needing immediate medical attention. Patient has been identified as having a stroke (stroke alert). All stroke patients will be transported Code 3 Stroke to a hospital with stroke care capabilities. Code 3 STEMI Patient has been identified as having ST-segment elevation myocardial infarction (STEMI alert). All STEMI patients will be transported Code 3 STEMI to a hospital with cardiac catheterization lab capabilities. Code 3 Trauma Trauma patient with an actual or potential life or limb threatening injury. Code 99 Code 4 Code 5 Hospital of Choice Cardiopulmonary arrest with resuscitation in progress. Dead patient. For suspected SIDS patient, (patient meets criteria for Code 4, and transport is for the family/bystanders). CPR only (basic life support). With the exception of hemodynamically unstable patients, the patient/patient s family shall be given the choice of the receiving hospital to which they would like to be transported. Trauma Center of the Day Schedule: For patients who are hemodynamically unstable or who do not express a hospital preference, transport to: Nebraska Medicine Odd Days CHI Alegent Creighton Health Even Days MCI (Mass Casualty Incident) In the event of an MCI, the Omaha Trauma Centers will both open and receive Code 3 (RED) patients with a 4 and 4 rotation. See Trauma Center Rotation Protocol. Page 5 of 83

6 D. Special Transport Considerations Families Every effort should be made to keep injured family members together and transported to the same appropriate hospital. Transplant/Dialysis Patients If a patient is identified as a transplant or dialysis patient, they shall be taken to the hospital where they are currently receiving care. An exception is the patient who suffers a respiratory or medical cardiac arrest. In this case, the patient shall be taken to the closest hospital. Use prudent judgment if a dialysis or transplant patient is resuscitated. Go to the institution that can best care for the patient (usually the hospital where they are currently receiving care). LVAD (Left Ventricular Assist Device) Patients If a patient is identified as an LVAD patient, they shall be taken to the hospital where they are currently receiving their care. Law Enforcement - Police officers are not permitted the right to dictate the hospital that patients will be transported to by OFD medic units. Pediatric Transport Considerations A pediatric patient is a patient up to and including 15 years of age. Pediatric Medical Patients Code 3 medical pediatric patients should be transported to the closest hospital. Pediatric patients with extreme hypothermia exhibiting signs of altered mental status or cardiac dysfunction and no signs or suspicion of trauma should be transported to Children s Hospital. If the receiving hospital diverts an OFD medic unit attempting to transport a Code 3 medical (non-trauma) pediatric patient, the OFD medic unit should transport the patient based on the medic unit s actual physical location at the point of being diverted (go to closest of): If west of 60 th Street in Omaha, transport to Children s Hospital. If east of 60 th Street in Omaha, transport to CHI Alegent Creighton Health or Nebraska Medicine. Pediatric Trauma Patients All Code 2 (Level 2) pediatric trauma patients should be transported to either Children s Hospital or Nebraska Medicine (see below.) Page 6 of 83

7 The following injured children are best served by evaluation and treatment at Children s Hospital. These children must be transported to Children s Hospital: Traumatically injured children who do NOT require major immediate resuscitation Hemodynamically stable GCS greater than 9 Low risk mechanisms of injury o Victims of asphyxiation (example: drowning, hangings, smoke inhalation without burns) All Code 3 (Level 1) pediatric trauma patients will be transported to The Nebraska Medical Center. All pediatric patients with asphyxiation injuries will be transported to Children s Medical Center. Code 3 pediatric trauma patients will not be transported to Creighton. For the purposes of this protocol, a child is defined as up to and including 15 years old. This protocol applies 24/7 regardless of trauma center of the day for adult patients. The following injured children are best served by evaluation and treatment at Nebraska Medicine. These children must be transported to Nebraska Medicine: Traumatically injured children who DO require major, immediate resuscitation Code 99 (traumatic cardiac arrest except asphyxiation see below) Hemodynamic instability or poor perfusion Respiratory compromise, including need to maintain airway and intubation Neurologic compromise, GCS <9 or deteriorating status All burn patients Traumatic amputations Significant vascular injuries High risk mechanisms: i.e. ejection, GSW Unstable pelvic fractures Spinal cord injury or paralysis Code 4 Patients For safety reasons, when appropriate, certain Code 4 patients may be evacuated from the scene and transported to the appropriate hospital. E. Behavioral Emergencies (Psychiatric, Overdose and Suicidal Patients) Transport Considerations Code 1 and Code 2 psychiatric, overdose and suicidal patients and their families will be offered hospital of choice options for transports. If they do not indicate a hospital of choice, they will be transported to the catchment area hospital. Page 7 of 83

8 Patients who are rational and present no risk to OFD EMS personnel or to themselves may be transported to hospital of choice. Behavioral, psychiatric, overdose and suicidal patients that are Code 3, Code 99 or a potential risk to the safety of OFD medic unit personnel will be transported to the catchment area hospital. ALWAYS consider a medical etiology for a behavioral emergency. F. Physician on Scene There are times that a physician, not affiliated with OFD, but licensed to practice traditional medicine in the state of Nebraska will identify him/her on a scene and may wish to direct the actions of OFD EMS personnel. This protocol is intended to provide guidance to OFD EMS personnel while ensuring the best care possible for the patient. When a physician is present on the scene and desires to direct the run, OFD EMS personnel should: 1. Inform the physician that if the physician directs the run, the physician must ride along, in the rear of the medic unit with the patient to the hospital and transfer care and treatment history to the emergency room staff. 2. Inform the physician at the onset of the run that OFD paramedic personnel have strict legal guidelines and established protocols and they may not exceed those guidelines or protocols. 3. Inform the physician that any procedure outside of these legal guidelines must be carried out by the physician him/herself. 4. OFD EMS personnel have the right and obligation at any time there is gross deviation from the accepted protocol to contact the receiving hospital for further instruction. The physician on the scene should be informed if contact with the hospital is being made. 5. Only traditional medical practices will be allowed. At no time shall a physician perform non-traditional procedures. Examples of non-traditional procedures include chiropractic procedures, acupuncture or spiritual healing. 6. If at any time there is a problem or discrepancy in procedures, OFD EMS personnel may contact the receiving hospital by phone or radio and have the receiving hospital physician speak directly to the physician at the scene. Page 8 of 83

9 G. Do Not Resuscitate (DNR) Orders and Identification of CPR Only (Adopted from Nebraska EMS Model Protocols ) With the advent of individuals taking greater responsibility for their own health care, decisions made by the individuals themselves, to not prolong their own life, is recognized as valid and has become more common. Health Care Power of Attorney, Living Wills and Do Not Resuscitate (DNR) orders are encountered frequently by OFD personnel. Occasionally, a family member will call 911 even when a DNR order exists or a Living Will is present. There are also times when OFD will arrive on scene, begin resuscitation procedures and a DNR or Living Will is discovered. This protocol is designed to provide guidance for such situations. Do Not Resuscitate (DNR) A DNR is a written order by a physician stating that no cardiopulmonary resuscitation will be initiated. A DNR must be signed by a physician, dated and have the patient s name on it. OFD EMS personnel can honor a DNR. The OFD EMS provider must be identified in the patient care report. Verbal confirmation of a DNR by a family member or friend without verification of a written DNR is not sufficient to withhold resuscitation efforts. Health Care Power of Attorney (HCPA) is a legal document stating the name of the person the individual (patient) has named as the person who will make medical decisions for their care. It should be signed by the patient and the patient s attorney, and only applies to adults. Living Will This document states the patient s wishes should they require resuscitation or life support measures. The document must be signed by the patient and the patient s physician and only applies to adults. 1. OFD EMS providers will not initiate or continue cardiopulmonary resuscitation on a patient in cardiac arrest once a valid DNR order is confirmed. In the event of uncertainty, resuscitative measures should be initiated. 2. DNR does not mean that emergency medical care for any other medical condition will be changed or limited. Patients shall receive emergency medical treatment (BVM / airway management, IV therapy and pharmacology) up until the point of cardiac arrest. 3. Physicians may designate a patient as DNR by written order, verbally when the physician is physically present at the scene or by telephone consult from the paramedic on scene to the patient s physician. 4. A written DNR order must contain the patient s name and be signed by the physician or by the RN who received the order from the physician. Page 9 of 83

10 5. If a physician physically present at the scene designates the patient as a DNR, the paramedic shall ask the physician to document the DNR designation on the OFD 179 or epcr and sign it. If the physician refuses to document and sign the OFD 179 or epcr, the paramedic shall initiate resuscitative measures. 6. In a skilled care facility (nursing home), DNR orders documented in the patient s medical record are considered valid if signed by the physician or by the RN for the physician. A DNR form may be used, but is not required in the nursing home setting. The OFD EMS provider who observed the DNR order must be identified on the patient care report. 7. An OFD EMS provider can honor an effective Living Will or Health Care Power of Attorney. This must be directly observed. OFD EMS providers can presume the validity of this document if signed in Nebraska. Documents from other states in compliance with that state s laws are also valid in Nebraska. 8. If the family desires CPR and/or resuscitation in the presence of a DNR or HCPA, the family s wishes shall be honored. 9. Observation of an original or a photocopy of a living will or health care power of attorney must be documented in the patient care report. An OFD EMS provider shall not honor a living will if there is no information or evidence that a physician has determined the patient is in a terminal condition or in a persistent vegetative state. If there is information or evidence that a physician has determined the patient is in a terminal condition or in a persistent vegetative state, this information should be documented in the patient care report. The patient care report must also contain information that the patient is an adult (is 19 or older or has been married). 10. If a telephone consult with the patient s physician or the physician s designee verifies a DNR, the OFD paramedic can honor the order. Authorization shall be documented on the patient care report and include the physician s or physician designee s name, telephone number and time of the telephone call from the paramedic to the physician. 11. Once CPR has been initiated, resuscitative measures may be discontinued when any one of the following occurs: A DNR or no code order is confirmed. A Living Will or HCPA for an adult is being followed. A physician physically present at the scene or the medical director, based on information from the OFD EMS provider on scene, determines that CPR is futile or should be discontinued. An OFD EMS provider is following termination of CPR protocols that have been authorized by the OFD Physician Medical Director. Any time the scene becomes unsafe for rescuers. Page 10 of 83

11 When signs of late death or all early signs of death are identified, the OFD paramedic may discontinue CPR if previously started (see Code 4 protocol). The paramedic will document a one minute printed rhythm strip from the cardiac monitor if no signs of late death are apparent. Management of Home Hospice Patient Attempts should be made to contact the hospice representative to provide additional guidance and support to the family prior to transporting. If the family desires CPR and/or resuscitation in the presence of a DNR or HCPA, the family s wishes shall be honored. Resuscitation of a DNR Patient If inadvertently, a DNR patient is resuscitated, and in the absence of physician directives, care should be continued and the patient should be taken to the catchment area hospital. Notification to OFD Dispatch Once resuscitative measures are terminated, notify OFD dispatch and request an OPD cruiser if one has not already been dispatched. OFD personnel will remain on scene until OPD arrives. Give a brief history to the officer. Obtain the officer s name and badge number and document in the FRMS patient care report in the narrative section. H. Code 4 Patients OFD personnel may be called to a scene where biologic and clinical death is evident. In such cases, it is not necessary to begin resuscitation. Situations may also occur where CPR has been initiated on an obviously deceased patient prior to the arrival of OFD EMS personnel. This protocol is intended to assist OFD personnel in the identification of such situations. If the patient meets code 4 criteria, OFD EMS providers may discontinue CPR or may choose not to initiate CPR. A Code 4 patient is identified if he/she is described by one of the following categories: 1. Patient with obvious lethal injury trauma cardiac arrest with injuries incompatible with life (i.e. massive blood loss, displacement of brain tissue, decapitation) 2. Patient with one or more of the signs of late death: Wrinkled cornea Rigor mortis Postmortem lividity Decomposition Paramedic shall obtain and document a 1 minute ECG rhythm strip demonstrating asystole. Page 11 of 83

12 3. Patient with all the following signs of early death: Unresponsive to all stimuli No pulse No spontaneous respirations Pupils which are fixed and dilated Paramedic shall obtain and document a 1 minute ECG rhythm strip demonstrating asystole. 4. Valid DNR form 5. Physician authorization No patient will be declared Code 4 without a complete, hands-on physical evaluation including: 1. No pulse, respirations or blood pressure 2. No response to painful stimulation, no corneal reflex, and no response to a sternal rub *All of the above will be documented in the patient care report (PCR) The rhythm strip will be uploaded into the epcr or mounted and sent to the EMS office for review. The only exceptions to the above are the following: 1. Injury not compatible with life 2. Advanced whole body decomposition. Remember that smell is NOT an advanced sign of death. Anytime the exceptions are used to declare death, the state of the body should be documented in the Narrative section of the PCR. NOTE: Care should be taken to rule out hypothermia, acute alcoholic intoxication, and drug overdose. I. Out of Hospital Confirmation of Death The purpose of this protocol is to allow Paramedics to confirm / declare a patient dead based on certain criteria with permission of the base station. This does not include patients already concluded to be Code 4. Permission for declaration of death will be called to the Nebraska Medicine ER over radio, cell phone, or landline. Nebraska Medicine phone number is Only Nebraska Medicine ED physicians can authorize this protocol over the radio or cell phone. Page 12 of 83

13 CRITERIA FOR REQUESTING DECLARATION OF DEATH IN THE FIELD: Medical Code 99 patient 1. Patient found down for unknown period of time (or more than 10 minutes). 2. No CPR in progress when paramedics arrive on scene. 3. Patient assessed and found to have no signs of life. 4. Paramedic EKG evaluation is asystole. Trauma code 99 patient 1. No recent signs of life documented by bystanders or initially responding EMS personnel. 2. Patient assessed and found to have no signs of life. 3. Asystole on EKG. Field Protocol for Requesting Termination of Resuscitation Efforts 1. Paramedics who initially assess patient and meet the listed requirements should have BLS being performed on the patient. 2. Nebraska Medicine will be contacted via standard radio procedures or cell phone. 3. Paramedic will describe circumstances around the arrest, length of time patient down without CPR, and EKG findings. 4. Nebraska Medicine will either suggest continuing resuscitation and transport or give the order to terminate resuscitation attempt. 5. Paramedics should confirm that the family agrees with the termination of efforts. 6. If resuscitation is to continue, the patient will be brought to closest appropriate hospital based on protocol. 7. If patient is declared dead at scene, documentation will be completed, including the above criteria and time the patient was confirmed/pronounced dead by the Nebraska Medicine ED physician. The Coroner s Office will then be notified (in appropriate circumstances) and the patient will either be transported to County Hospital or left at the scene with the appropriate authorities (usually local law enforcement) for the Coroner s Office to collect. 8. A one minute cardiac rhythm strip will be obtained to document asystole. Page 13 of 83

14 J. Refusal of Care The patient has the right to refuse either or both care and transportation. However, OFD personnel have both a moral and legal obligation to provide adequate medical care, according to the provider s level of training and certification, until the patient is delivered to the receiving hospital. In situations in which the patient is refusing care, the following guidelines shall be followed. Adults Minors An adult is an individual 19 years old or older or who is or has been married (NEB REV STAT ). A competent adult can refuse medical services and/or transportation to a health care facility. A legal guardian can consent to or refuse medical services and/or transportation to a health care facility for an incompetent adult. A person appointed as a Health Care Power of Attorney can consent or refuse consent for medical services and/or transportation to a health care facility for the incompetent adult named in the power of attorney. A minor is an individual under 19 years of age that has never been married or emancipated. A parent or legal guardian can consent or refuse consent on behalf of a minor, for medical services and/or transportation to a health care facility. In cases of suspected abuse/neglect and refusal of care and/or transport, law enforcement shall be notified. Documentation (required) Each patient shall be given a minimal physical assessment consisting of pupil evaluation, level of consciousness, vital signs, lung sounds and/or respiratory rate and effort and a general head to toe physical exam (palpation as indicated). If a patient refuses to submit to a physical exam, the OFD EMS provider in charge of patient care shall document this refusal in the narrative of the patient care report. The narrative shall also document the following: 1. Results of the minimal physical assessment. Fill in the appropriate areas of the patient care report. 2. Visual assessment, for example: The patient is up and walking at the scene with no apparent injury. Page 14 of 83

15 3. Patient is alert, coherent and articulate, for example: alert The patient states his name, location and time of day correctly. coherent The patient is speaking in complete sentences with logical thought flow. articulate Speech is distinct. Absence of any one of these may indicate insufficient ability to make good decisions. Therefore, all efforts to convince the patient to allow treatment / transport should be attempted. NOTE: ETOH does NOT justify inaction. If after appropriate assessment, treatment is not necessary, contact OPD for transport to appropriate facility. 1. Reason for the patient s refusal, for example: Patient states he has no pain, injury or medical problem. or Patient refuses treatment / transport for religious reasons. 2. Attempt to get others involved, for example: Family members also failed in efforts to encourage patient to be transported to the hospital. 3. Consequences explained, for example: Patient informed that he may suffer serious physical harm or death as a result of not being treated / transported. 4. Alternatives explained, for example: Patient instructed to use alternate means for transport, or if condition worsens or change of mind occurs, to call Concluding statement to each incident of patient refusal shall be the following: Patient strongly advised to seek medical care as soon as possible. 6. Signature of patient and witness on OFD 179 form or epcr. A valid witness shall be any family member of legal age, a police officer, bystander, or at the very least, another OFD firefighter on the call. If the patient refuses to sign the refusal form, then the OFD firefighter documenting the run shall note this in the narrative. Complete documentation shall include all applicable portions of epcr and/or the OFD 179 form. From a legal standpoint, this documentation shall provide the basic defense that appropriate actions were taken. Any omitted patient care documentation can be challenged whether or not appropriate care was actually provided at the time of the incident. NOTE: If a patient needs treatment and/or transport to the hospital but the hospital of choice is NOT a hospital that the OFD medic unit services (i.e. Mercy Hospital, Council Bluffs or Offutt) and the patient refuses transport by OFD, the person in charge shall instruct the patient to call a private ambulance for transport. After a patient assessment, and if the patient condition warrants, Omaha Fire can remain on scene to monitor the patient and treat as necessary until the private ambulance has arrived. Contact the PSS if there is any question regarding the patient s condition. Page 15 of 83

16 GENERAL PRINCIPLES A. Airway, Oxygen and Ventilation An intact airway and adequate oxygenation and ventilation are essential for all patients with medical or traumatic conditions. Throughout this protocol it is assumed that OFD personnel will maintain a patent airway and provide appropriate supplemental oxygenation. 1. Maintain patent airway with head-tilt/chin-lift or jaw thrust maneuver and consider oral or nasal airway adjunct. 2. If ventilating adequately, apply nasal cannula at 2-6 L/min or non-rebreather mask at L/min. 3. If NOT ventilating adequately, assist ventilations with BVM and 100% oxygen advanced airway management may be required. 4. Consider assisting ventilations in those patients whose respiratory status does not improve after receiving oxygen by non-rebreather mask. 5. Adjust oxygen delivery devices to maintain a blood oxygen saturation of >94% unless contraindicated. 6. Record all vital signs (blood pressure, pulse, respirations, Oxygen saturation, CO2) - pulse oximetry is required. 7. Utilize CO2 monitoring when available (Nasal Cannula, ET, King Airway etc) 8. Consider the use of CPAP if indicated by protocol. 9. Use trauma advanced airway techniques with patients who have suspected compromised cervical spines. 10. Always confirm endotracheal tube placement by: Attaching an EtCO2 monitoring device and verifying CO2 production by colorimetric, waveform or mmhg. Observing for chest rise and fall. Verifying the presence of bilateral lung sounds at the axilla and the absence of epigastric sounds by auscultation with a stethoscope. Confirming improvement in saturations by pulse oximetry. *Confirmation of endotracheal tube placement is required with capnography and documentation in epcr. 11. Immobilize the head with a c-collar or by using tape on the head to prevent excessive head movement during transport when a patient is intubated. Commercial securing devices are recommended over tape to secure the ET tube in place. 12. If unable to intubate after two attempts; consider alternate airway management methods - BVM ventilation or King Airway, etc. Page 16 of 83

17 13. Consider RSI for patients with the following indications (also see RSI protocol): Altered mental status with airway compromise. Head injuries with signs of increased ICP (GCS < 8), but whose combativeness or gag reflex make them difficult to intubate. Conscious but unable to maintain airway. Severe respiratory distress with hypoxia / cyanosis. 14. If the adult intubated patient becomes combative, consider administering one or both of the following: Versed 1-5 mg slow IV push or 5-10 mg intranasal Morphine Sulfate 2-4 mg slow IV push 15. Required documentation. B. CPAP Indications: Reason for intubation. All vital signs prior to intubation including BP, pulse, respirations, and oxygen saturation. All medications administered and doses. Post Intubation: a) Repeat all vital signs (including oxygen saturation). b) Bilateral breath sounds. c) No sounds over stomach. d) CO2 production. e) Repeat all of above on arrival at hospital. Any adult patient presenting with respiratory distress, is awake and able to follow commands, has the ability to maintain a patent airway with adequate mask seal, and displaying findings in the medical history or assessment suggestive of any of the following conditions: COPD CHF Asthma Pulmonary Edema Pneumonia Near Drowning Carbon Monoxide poisoning Page 17 of 83

18 Contraindications Systolic blood pressure less than 90 mmhg Suspected pneumothorax Insufficient respiratory effort Tracheostomy Active vomiting Upper GI or airway bleeding Altered mental status Suspected facial fractures Special Considerations 1. CPAP is to be a continuous therapy and should only be discontinued in the case of the patient being unable to tolerate the mask or in case of progression to respiratory failure. 2. Advise the receiving hospital of your patient s CPAP therapy as soon as practical so they may prepare for continuation of therapy. 3. Observe patient for signs of gastric distention. 4. Monitor patient closely for changes in hemodynamic or respiratory status. 5. Other therapies, as described in these protocols, may be performed in conjunction with CPAP. 6. Provide patient instruction and reassurance as required. 7. Reassess mental status, hemodynamic and respiratory status continuously during CPAP therapy and record every 5minutes. 8. Discontinue CPAP therapy and consider BVM / intubation if either decreased mental status or respiratory insufficiency become present. 9. Add an in-line nebulized Duo-neb (bronchodilator) treatment when indicated. Consider Versed 1-5mg IV or 5-10mg intranasal if systolic BP is greater than 90 mmhg and patient is not tolerating CPAP mask. Assure agitation is not a result of hypoxia or that the patient needs to be intubated. C. IV Therapy / Medications 1. All IV insertions refer to peripheral IV's (extremities and external jugular vein), including saline locks and intraosseous (IO) lines. IO insertion is authorized for unstable pediatric and adult patients. All medications administered IV can also be administered IO (D50 should be diluted to D25 prior to administering via IO). 2. For trauma patients, IV s should be started enroute to the hospital, except when there is an unavoidable delay such as prolonged extrication time. 3. Large bore IV's refer to 14ga or 16ga IV catheters - infuse at rate as indicated by pulse and blood pressure (90 mmhg systolic or MAP of 70). Page 18 of 83

19 4. IV fluid refers to (NS) Normal Saline (0.9% Sodium Chloride). 5. Use micro drip (minidrip) IV tubing for all IV infusions and with all premixed and diluted medications. Establish a 2 nd IV whenever infusing medications. 6. This protocol permits 2 attempts per paramedic on the call to a maximum of 4 attempts per patient for IV insertion. If unsuccessful and the patient requires medication administration, establish IO access. Peripheral IV s should be attempted prior to IO access. 7. Pre-existing Venous Access Devices (VAD) may be used in emergency situations (Code 3 / Code 99 patients). 8. A fluid bolus refers to ml of fluid for the adult patient and 20 ml / kg of fluid for the pediatric patient. 9. Use a filtered needle or a filtered straw when drawing up any medication from a glass ampule. D. Body Substance Isolation It is protocol policy to practice body substance isolation when caring for ALL patients. This means wearing gloves and protective eyewear when administering patient care. BSI shall be observed when handling blood and body fluids or surfaces or items soiled by blood and body fluids; masks and protective eyewear during procedures likely to generate droplets of blood or body fluid; and aprons or gowns during procedures likely to generate splashes of blood or body fluid. This includes washing hands after each patient care incident even if gloves were worn or waterless soap was used. All needles and sharps shall be immediately placed in a disposable impervious container. There will be no recapping of needles. All personnel should don N-95 or HEPA masks when in contact with patients in which an airborne communicable disease is suspected or confirmed by history (e.g. tuberculosis, influenza). Personnel should also place N-95, HEPA, or surgical masks on these patients. E. Restraints Purpose OFD personnel occasionally encounter patients who require transport to a receiving hospital but who also pose a threat to themselves, others or to OFD personnel. Because of this threat of physical harm, it may be impossible to transport without restraining the patient. This protocol is intended to provide guidance in the use of restraints and a procedure to follow in such cases. Page 19 of 83

20 Note: OFD personnel/rigs are prohibited from carrying or using metal handcuffs. 1. Indications: A patient who needs to be transported for medical care, who is refusing transport of care, and who is incompetent to refuse. A person, who appears to be mentally ill and who as a result of such mental illness, appears to be an imminent danger to others (including OFD personnel) or to himself/herself or to be gravely disabled. 2. Precautions / Considerations: Do not restrain a patient in the prone position. Any attempt at restraint involves risk to the patient and to OFD personnel. The firefighter s safety must come before patient considerations. Do not attempt to restrain the patient without adequate assistance. Physical restraints are a last resort. All possible means of verbal persuasion should be attempted first. A patient who is alert, oriented, aware of his/her condition, and capable of understanding the consequences of his/her refusal is entitled to refuse treatment. He/she may not be restrained and treated against his/her will. (Review consent guidelines and confer with PSS or medical director if in doubt.) Any restrained patient may vomit, be prepared to suction and reposition as needed. Once restrained, the patient is never to be left alone. Aspiration can occur if patient is restrained on his/her back and cannot protect his/her own airway. The airway must be free and accessible for airway control. Do not restrain a patient sandwiched between backboards, scoop stretchers or other immobilization devices. Do not hog tie patients (hands restrained behind back, feet restrained together and the two restrained attached together). Check restraints as soon as applied and every 10 minutes thereafter to ensure no injury to extremities. Remove restraints only with sufficient personnel available to control the patient - generally, only in the hospital setting. Other than primary psychiatric disorders, medical causes of combativeness include hypoglycemia, hypoxia, head injury and drug ingestion. Written and verbal reports must completely document the necessity for the use of physical restraints. Record condition of extremities before applying restraints and recheck and record condition on arrival at hospital. Page 20 of 83

21 Metal handcuffs are not an authorized method of restraint for OFD personnel. The only exception to this policy is for OFD Fire Investigators whom have been specifically trained in the use of handcuffs. If a patient is already handcuffed by law enforcement, an officer must ride with the patient to the hospital. Law enforcement should be asked to remove handcuffs as soon as possible for the patient s own safety. However, if an officer deems handcuffs are necessary, place patient supine on stretcher and secure handcuffs to the base of the stretcher. Consider utilizing more personnel to restrain patient. Refer to Altered Mental Status Protocol for additional treatment considerations. F. Pain Management - Adult Criteria (Severe Pain Ranked as 6 on 0-10 Scale) 1. Systolic BP > 90 mmhg. Consider Morphine Sulfate 2-5 mg slow IV push or 2-5 mg intranasal. Reassess pain scale and vital signs. Repeat every 5 minutes as necessary if no response or pain remains severe. 2. Systolic BP = mm Hg Consider Morphine Sulfate 1-2 mg slow IV push or 1-2 mg intranasal Reassess pain scale and vital signs. Repeat every 5 minutes as necessary if no response or pain remains severe. 3. If respiratory depression occurs, begin BVM ventilations and administer Narcan mg IV push followed by a fluid bolus or mg intranasal (repeat as needed). 4. If hypotension develops, administer Narcan mg IV push followed by a fluid bolus or mg intranasal (IN) (repeat as needed) titrate to vital signs. Page 21 of 83

22 G. Pain Management - Pediatric Criteria (Severe Pain Ranked as 6 on 0-10 Scale or Wong-Baker Faces Scale) 1. Systolic BP appropriate for age. Consider Morphine Sulfate 0.1 mg / kg slow IV push or 0.1 mg / kg intranasal to a maximum of 2 mg increments (IV route preferred). Reassess pain scale and vital signs. Repeat every 5 minutes as necessary if no response or pain remains severe. 2. If respiratory depression occurs, begin BVM ventilations and administer Narcan mg IV or IN followed by a fluid bolus. 3. If hypotension develops, administer Narcan mg IV push followed by a fluid bolus or mg intranasal titrate to vital signs. CARDIAC EMERGENCIES - ADULT A. General Guidelines 1. If cardiac arrest occurs in presence of the paramedic, assess rhythm and immediately shock X 1 if indicated. 2. If patient is in cardiac arrest on arrival, start or continue basic life support (BLS) for 2 minutes. Consider Auto Pulse, if available. 3. CPR (30:2) Compression rate at least 100 / minute. Ventilations at 8 10 / minute, do not hyperventilate. ROTATE person doing compressions (compressor) every 2 minutes. 4. Reassess rhythm & pulse check after each 5 cycles (2 minutes) of CPR. 5. Limit interruptions of CPR during pulse & rhythm checks to < 10 seconds for airway management and/or medication administration. CPR should not be stopped for advanced airway placement. 6. Preferred medication administration route is IV or IO. IV / IO of NS should be established during 2 minute period of continuous CPR. Page 22 of 83

23 7. Secure ET airway during pulse & rhythm check, continue CPR immediately then secure & confirm placement by auscultation of breath sounds & epigastric sounds, followed by confirmation with capnography. NOTE: CO2 reading should be present but below normal values during CPR. If zero CO2 reading, immediately reevaluate ET tube placement. 8. If failed IV access or IO access, a final option for medication administration is via the ET tube for designated ET meds at 2 to 2.5 times IV dose. Meds for Code 99 for ET route are lidocaine, epinephrine, atropine and Narcan (LEAN). 9. If the patient regains a pulse, see the Adult Post Cardiac Arrest ROSC (Return of Spontaneous Circulation) protocol. 10. Unless otherwise noted, all defibrillations refer to: Shock # Biphasic j j 3 and on 200 j 11. If patient hypothermic from exposure, follow Hypothermia Protocol for cardiac arrest guidelines. 12. If the patient has known or highly suspected cyanide poisoning, smoke filled environment (smoke inhalation) consider Toxic Inhalation Protocol Cyanide Poisoning and Procedure F. B. Ventricular Fibrillation (VF) and Pulseless Ventricular Tachycardia (VT) 1. Follow General Guidelines for Adult Cardiac Arrest. 2. Unwitnessed arrest Perform 2 minutes (5 cycles) of CPR. Witnessed arrest go directly to confirming VF and defibrillation. 3. Assess and confirm pulseless VT / VF, then shock X 1, immediately resume CPR (no pulse check, go straight to compressions). 4. Reassess rhythm & pulse after 5 cycles (2 mins), if shockable rhythm, continue CPR while defibrillator charges, then shock X 1, immediately resume CPR. 5. During CPR, administer Epinephrine 1 mg (1:10,000) IV/IO every 3 5 minutes. 6. Reassess rhythm & pulse after 5 cycles (2 mins), if shockable rhythm, continue CPR while defibrillator charges, then shock X 1, immediately resume CPR. 7. Consider administration of anti-arrhythmic. Amiodarone 300 mg IV/IO, may repeat once in 3 5 minutes at 150 mg IV/IO OR *Lidocaine mg / kg IV/IO, may repeat in 3-5 minutes at 0.5 mg to 0.75 mg / kg IV/IO push (max dose of 3 mg / kg). Page 23 of 83

24 *Only use Lidocaine if Amiodarone is NOT available 8. Consider Mag Sulfate (50%) 1 2 gm IV/IO over 2 minutes (For Torsades de pointes). 9. Consider Sodium Bicarb 1 meq / kg IV/IO (For suspected hyperkalemia, TCA overdose or metabolic acidosis). C. Asystole 1. Follow General Guidelines for Adult Cardiac Arrest. Unwitnessed arrest Perform 2 minutes (5 cycles) of CPR. Witnessed arrest go directly to confirming the rhythm. 2. Verify / confirm true asystole in another lead. Rapid scene survey any evidence that resuscitation should not be attempted? (DNR orders, signs of death, see Code 4 Protocol). If yes, withhold resuscitation efforts. See Out of Hospital Confirmation of Death Protocol if needed for assistance. 3. Immediately resume CPR. 4. Establish IV / IO NS while providing 2 minutes of continuous CPR. 5. During CPR, administer Epinephrine 1 mg (1:10,000) IV every 3 5 minutes. 6. Secure airway during pulse & rhythm check, continue CPR immediately then secure & confirm placement by auscultation of breath sounds & epigastric sounds, followed by confirmation with capnography. 7. Provide continuous CPR, reassess rhythm & pulse after every 5 cycles (2 mins) of CPR. 8. Consider Sodium Bicarbonate 1 meq/kg IV/IO push (for suspected acidosis or hyperkalemia). 9. If pulse restored, refer to ROSC protocol. D. Pulseless Electrical Activity (PEA) 1. Follow General Guidelines for Adult Cardiac Arrest. Unwitnessed arrest Perform 2 minutes (5 cycles) of CPR. Witnessed arrest go directly to confirming the rhythm. 2. Establish IV / IO NS while providing 2 minutes of continuous CPR. 3. During CPR, administer Epinephrine 1 mg (1:10,000) IV/IO every 3 5 minutes. 4. Secure airway during pulse & rhythm check, continue CPR immediately then secure & confirm placement by auscultation of breath sounds & epigastric sounds, followed by confirmation with capnography. Page 24 of 83

25 5. Provide continuous CPR and reassess rhythm & pulse after every 5 cycles (2 minutes) of CPR. 6. Review causes for PEA. Treat per protocols if condition is present: Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyper / hypokalemia Hypothermia Hypoglycemia Toxins (overdoses) Tamponade cardiac Tension pneumothorax Thrombosis coronary Thrombosis pulmonary embolism Trauma For suspected hypovolemia - administer fluid bolus of normal saline of cc, repeating boluses up to 1 Liter of NS (especially with narrow QRS and rapid rate). For suspected TCA overdose, acidosis or hyperkalemia, administer Sodium Bicarbonate 1 meq/kg IV/IO Push. For tension pneumothorax, perform needle decompression. For hypothermia, provide warming measures. For hypoglycemia, administer D10, if not available administer D50 7. If pulse restored, refer to ROSC protocol. E. Return of Spontaneous Circulation (ROSC) If return of spontaneous circulation (ROSC) for non-trauma patients: 1. Reassess airway and breathing. Maintain ventilation rate at 8-10/min Avoid routine hyperventilation. Continuously evaluate the Capnography waveform on monitor and maintain ETCo2 of 35-45mmHg. Use the minimum flow rate of Oxygen to maintain a saturation of >94% 2. If BP < 90 systolic: Consider a fluid bolus of cc, repeating boluses up to 1 Liter of NS. Consider Epinephrine drip at 2-10 mcg / min Titrate to BP of > Obtain 12-Lead ECG, transmit to receiving facility. 4. Establish 2 nd IV. 5. Initiate hypothermic efforts by applying ice packs to the groin and axilla. Page 25 of 83

26 F. Bradycardias For heart rates below 60 beats per minute. STABLE 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start IV with NS TKO 3. Transport and OBSERVE UNSTABLE - (Verify serious signs / symptoms are due to the slow rate): 1. Airway, oxygen, monitor, obtain 12 Lead ECG 2. Start IV with NS TKO 3. Give Atropine 0.5 mg IV push, repeat every 3 to 5 minutes as needed up to maximum dose of 3 mg (0.04mg/kg). *Atropine is not effective in 2 Type II AV block, 3 heart block or Idioventricular rhythms. If these rhythms are present and patient is unstable, go directly to transcutaneous pacing (TCP). 4. If Atropine administration will be delayed or is ineffective, begin transcutaneous pacing (TCP). Preferred placement for pacing pads is anterior-posterior position. Start at a rate of beats per minute. Adjust milliamps upward as needed to achieve capture. May consider increasing rate to a maximum of 100 beats per minute to obtain a BP of > 90 systolic. Consider patient comfort as milliamps are increased. If pacing is successful (capture is established and BP improves), consider mild sedation for discomfort related to pacing. Versed 1 5 mg slow IV, or Versed 5 10 mg intra-nasal Consider Epinephrine drip at 2 10 mcg/minute titrate to blood pressure of >90 systolic (see Procedure H) Monitor vital signs every 2 5 minutes. NOTES: Do not delay TCP while waiting for IV access or for atropine to take effect if patient is unstable. Never treat the combination of 3º heart block and ventricular escape beats with amiodarone, lidocaine or any agent that suppresses ventricular escape rhythms. Atropine is not effective for denervated transplanted hearts. Page 26 of 83

27 G. Monomorphic Ventricular Tachycardia with Pulse For wide complex [> 0.12 seconds] tachydysrhythmias STABLE patient / NO serious signs and symptoms 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start IV with NS TKO. 3. Consider Medications: Adenosine 6 mg rapid IVP (over 1 second) and flush the line, may repeat once in 2 min at 12 mg. Amiodarone infusion mg in D5W 100 cc over 10 minutes. UNSTABLE patient / Displays serious signs and symptoms 1. Airway, oxygen, monitor. 2. Start IV NS TKO. 3. Consider fluid bolus cc. 4. Consider pre-medicating with: Versed 1 5 mg slow IV push, or 1 5 mg intranasal, may repeat once 5. Perform synchronized cardioversion at 100 J. IF NO RESPONSE, continue synchronized cardioversion with increasing joule settings as necessary (120J, 150J, 200J). 6. If successful and time allows, obtain and transmit a 12-Lead EKG. IF SUCCESSFUL (at any point), maintain status with anti-arrhythmic infusion (see above). NOTE: If polymorphic or Torsades de pointes, give Magnesium Sulfate 1 2 grams slow IV push (over 5 minutes). H. Supraventricular Tachycardia (SVT) For narrow complex QRS <0.12 seconds STABLE patient / NO serious signs and symptoms 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start IV with NS TKO. 3. Consider vagal maneuvers. 4. Give Adenosine 6 mg rapid IV push (over 1 second) and flush the line. IF NO RESPONSE in 2 minutes: 5. Give Adenosine 12 mg rapid IV push (over 1-2 seconds) and flush the line. Page 27 of 83

28 IF NO RESPONSE in 2 minutes: 6. Consider Adenosine 12 mg rapid IV push (over 1-2 seconds) and flush the line. UNSTABLE patient / Displays serious signs and symptoms 1. Airway, oxygen, monitor. 2. Start IV with NS TKO. 3. Consider pre-medicating with: Versed 1 5 mg slow IV push, or 1 5 mg intranasal, may repeat once. 4. Perform synchronized cardioversion at 50 J. 5. IF NO RESPONSE, continue synchronized cardioversion with increasing joule settings as necessary (75J, 100J, 120J, 150J, 200J). 6. If successful and time allows, obtain and transmit a 12-Lead ECG. I. Atrial Fibrillation and Atrial Flutter with Rapid Ventricular Rate Greater than 150 beats per minute STABLE patient / NO serious signs and symptoms 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start IV with NS TKO. 3. Observe and transport. UNSTABLE patient / Displays serious signs and symptoms 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start IV with NS TKO. 3. Prepare for immediate cardioversion, consider pre-medicating with: Versed 1 5 mg slow IV push, or 1 5 mg intranasal, may repeat once. 4. Perform synchronized cardioversion at 120J for atrial fibrillation. 5. Perform synchronized cardioversion at 50J for a-flutter. 6. IF NO RESPONSE, continue synchronized cardioversion with increasing joule settings as necessary. 7. If successful and time allows, obtain and transmit a 12-Lead EKG. NOTE: In the absence of a characteristic saw tooth pattern, the rhythm is atrial fibrillation until proven otherwise *Use caution in converting an atrial fibrillation rhythm that has an unknown duration or a known duration of greater than 48 hours. Prolonged atrial fibrillation has been documented to create clots and converting the rhythm may disseminate these clots throughout the body. Page 28 of 83

29 J. Ventricular Ectopy / Presence of Runs of V-Tach Runs of V-Tach = 3 or more PVCs in a row 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start IV with NS TKO. For couplets, multi-focal PVCs or bigeminy, continue oxygen therapy maintaining a saturation of > 94%. Follow applicable protocol based on patient presentation (signs & symptoms) i.e. Acute Coronary Syndrome (Chest Pain), Bradycardias, Dyspnea, Hypotension Protocols. For runs of V-Tach AND underlying heart rate is below 60: Administer Atropine 0.5 mg to a max of 3 mg (0.04 mg/kg) slow IV push to speed up underlying rhythm and overdrive the rhythm. For runs of V-Tach AND underlying heart rate is above 60: Consider medications - choose ONE of the following agents (Amiodarone is the preferred medication): Amiodarone infusion mg in D5W 100 cc over 10 minutes. (If successful conversion, start Amiodarone drip at 1 mg / minute). OR *Lidocaine 0.5 to 0.75 mg / kg IV push (If successful conversion, start Lidocaine infusion at 1 4 mg / minute). *Only use Lidocaine if Amiodarone is NOT available K. Acute Coronary Syndrome (ACS) (Chest Pain, Acute MI / STEMI, Suspected Cardiac Event, etc.) 1. Airway, oxygen, monitor, obtain 12-Lead ECG within 10 minutes of arrival. 2. Start IV with NS TKO. 3. Administer medications: ASA (2 to 4 baby aspirin) mg PO (chewable). Nitroglycerin 0.4 mg SL, every 5 minutes if systolic BP remains greater than 90 mmhg up to 3 doses. Repeat Nitroglycerin as needed until cardiac symptoms are relieved or patient becomes symptomatic from the medication (i.e., headache becomes the chief complaint, hypotension develops, etc) Page 29 of 83

30 *Do NOT administer Nitroglycerin if: a. The patient has used any erectile dysfunction (ED) medication (Viagra/sildenafil, Levitra/vardenafil, and Cialis/tadalafil) within the previous 48 hours. b. 12 Lead shows Inferior MI (ST Elevation in any two of the following leads II, III, avf). Morphine Sulfate 2-5 mg slow IV/IO/Intranasal for chest pain may repeat up to a maximum of 10 mg (if systolic blood pressure remains greater than 90 mmhg). Use with caution in unstable angina / non-stemi. 4. Correct perfusion-altering dysrhythmias according to protocol guidelines. 5. Transport Code 3 STEMI to closest hospital with emergency cardiac catheterization lab availability. 6. Contact receiving hospital as early as possible and notify of any S-T elevation, call a STEMI Alert. 7. Transmit 12-Lead ECG to receiving hospital. 8. Start 2 nd IV en route. L. CHF/Pulmonary Edema Dyspnea in the presence of diminished lung sounds, wheezes, rales, or frothy sputum with a BP that is hypertensive or within normal limits 1. Airway, oxygen, monitor. 2. CPAP w/ supplemental O2. 3. Upright position (45 o - 90 o ), maintain this position and treat before moving. 4. Obtain and transmit 12-Lead ECG. 5. Start IV with NS TKO. 6. Administer Medications: Nitroglycerin SL: a. If systolic BP is > 180, give 0.4 mg per dose (1 tablet, may repeat once after 3-5 minutes) b. If systolic BP is < 180, give 0.4 mg (1 tablet) c. Continue if systolic BP remains greater than 90 mmhg d. Monitor pulse and blood pressure before each dose Page 30 of 83

31 Morphine Sulfate, 2-5 mg slow IV/IO/Intranasal (to a maximum dose of 10 mg). Use with caution in patients who are elderly, have COPD history or who are hypotensive. Consider DuoNeb by nebulizer. Consider CPAP protocol. M. Cardiogenic Shock Dyspnea in the presence of diminished lung sounds, wheezes, rales, or frothy sputum with a BP that is hypotensive 1. Airway, oxygen, monitor. 2. Start IV with NS TKO. 3. Correct perfusion altering dysrhythmias according to protocol guidelines. 4. Obtain and transmit 12-Lead ECG. 5. Consider fluid bolus cc NS up to 1 Liter. 6. Administer Epinephrine Drip: (Procedure H) Begin infusion at 2 10 mcg / min Pulse and BP should be monitored every 2-5 minutes. Goal is to maintain systolic BP at > 90 mmhg. ACUTE TRAUMATIC EMERGENCIES A. General Trauma Management Priorities for Treatment 1. Provide airway management. 2. Control the cervical spine. Assume cervical spine injury is present in any patient with: Evidence of high impact with a distracting injury. Any head or neck injury. Neck pain following trauma. Altered mental status. Presence of any neurological deficit. 3. In trauma code situations (Usually PEA) attempt all mechanical interventions, i.e.: CPR, ET/King airway, IV/IO, and Needle decompression prior to administering first line cardiac drugs. REMINDER: Pain, loss of sensation or motor activity MAY NOT be present initially with cervical spine fractures. Page 31 of 83

32 Also see Spinal Injury Assessment Protocol. 4. Consider helicopter transport to the Trauma Center if: Incident is located well north of I-680 or west of 150th Street. Transportation by ground to the Trauma Center will be greater than 20 minutes. Extrication time and ground transport time to the Trauma Center will be greater than 20 minutes. Consider requesting standby status while enroute to the scene. This will be based on the incident location and information given by dispatch regarding the nature of the call. If the helicopter is not on scene when the medic unit is ready to transport, do not wait for the helicopter to arrive. Transport the patient in the medic unit to the Trauma Center unless traffic conditions warrant otherwise. See OFD SOP OPS 17-0 Helicopter Procedures for more information. 5. Helmet Removal: Remove all helmets to avoid airway management problems according to ACS and PHTLS guidelines. The exception may be football helmets with shoulder pads in place. In these cases, removal of the football helmet is an option, but removal of the face guard is required. Cervical immobilization is without the c- collar, utilizing other resources, i.e. towel rolls, commercial head immobilization devices. 6. Control external hemorrhage: Direct pressure Apply a wide band tourniquet 2 above the injury for life-threatening extremity hemorrhage, mangled extremity, or traumatic amputation that is not controlled by direct pressure. Document tourniquet application time and do not cover the tourniquet. 7. Hypovolemic shock (assume shock present when pulse greater than 120 and/or systolic BP less than 100 mmhg in a previously normotensive patient; or systolic drops mmhg in a previously hypertensive patient, especially if accompanied by pale, clammy skin and decreased level of consciousness). Apply oxygen and ventilate if necessary. Keep patient warm and dry. Start 1 or 2 large bore IV's with warm NS, fluid bolus titrating to a systolic blood pressure of 90mmHg. DO NOT delay transport for IV starts. 8. Apply ECG monitor enroute. 9. Extremity Injuries (fractures/dislocations) - General Guidelines: Check and record peripheral pulses and neurological status before and after manipulating or splinting fractures. Page 32 of 83

33 Apply gentle in-line traction to fractures with the exception of dislocations or fractures involving joints (especially the elbow). May straighten severely angulated fractures of extremities with the exception of those involving knee or elbow. For knee or elbow with neurovascular deficit, attempt once to realign extremity to restore neurovascular status. Immobilize fractures, including joint above and joint below. For suspected femur fracture (open or closed), consider traction splint. For suspected unstable pelvic fractures, tie a sheet snugly around pelvis. 10. DO NOT remove any impaled objects unless obstructing airway or interfering with CPR. 11. All life or limb-threatening injuries should be transported immediately to the Trauma Center. 12. If Quik Clot, Celox, or other similar coagulation agent has been applied for bleeding control prior to O FD arrival, leave in place. Do not remove. Follow standard bleeding control measures. 13. Place all amputated parts in NS solution and keep cool if possible B. Penetrating Injuries to Head, Neck, Chest and Abdomen 1. Airway, oxygen, monitor. 2. Consider c-collar and backboard if appropriate. 3. Start IVs enroute, NOT on scene. 4. Scene time should be < 5 minutes. C. Head Injuries 1. Maintain / manage airway and apply oxygen, monitor. Maintain oxygen saturation > 94%. 2. Consider RSI. 3. Ventilate with adequate tidal volume at normal respiratory rate for patient age. Using capnography, maintain CO2 at 35-45mmHg. 4. Start large bore IV with NS enroute and titrate to vital signs. Maintain blood pressure > 90 systolic. D. Chest Injuries 1. Airway, oxygen, monitor. 2. For tension pneumothorax WITH EVIDENCE OF SHOCK, insert 12 gauge catheter at 2nd intercostal space in mid-clavicular line. Perform bilateral needle decompression in all Code 99 patients with penetrating or blunt thoracic trauma. Page 33 of 83

34 3. Cover sucking chest wounds with occlusive dressing, remove if patient s condition deteriorates. 4. Start 1 or 2 large bore IV s with NS enroute and titrate to a systolic blood pressure of 90mmHg. E. Abdominal Injuries 1. Airway, oxygen, monitor. 2. Dress any penetrating wound with a dry sterile dressing or occlusive dressing. 3. For evisceration: DO NOT REPLACE eviscerated tissue. Cover with a moist sterile dressing. Place a dry sterile dressing over moist dressing to maintain warmth. 4. Start 1 or 2 large bore IV's with NS during transport titrating to a systolic blood pressure of 90mmHg. F. Eye Trauma 1. Chemicals - Flush with Normal Saline or water continuously enroute to the receiving hospital. Remove contacts prior to irrigation. 2. Foreign body or punctured eye - Leave foreign body in place. Apply loose protective covering over impaled eye. Patch other eye. DO NOT apply a pressure dressing. 3. Loss of eye tissue - If possible, transport tissue with patient. Keep eyes moist with NS. 4. Keep patient from rubbing eye(s). G. Burns 1. Airway, oxygen, monitor. 2. Assess for inhalation burns, consider ET intubation, RSI if indicated. 3. Protect from hypothermia. 4. Remove rings, bracelets and other constricting items in burned areas. 5. Thermal burns. Remove any clothing near area of burn wound. Apply clean, dry dressings or sheets. If an isolated burn of less than 10% BSA, consider moistening with saline (prevent hypothermia). 6. Chemical burns (wet) Flush with large volumes of fluid. Apply clean, dry dressings or sheets. 7. Chemical burns (dry) Page 34 of 83

35 Safely brush off as much of the chemical as possible. Flush with large volumes of fluid. Apply clean, dry dressings or sheets. 8. Electrical burns Apply clean, dry dressings to entrance and exit wounds. Apply ECG monitor and follow applicable protocol as indicated. 9. Consider large bore IV with NS. Titrate to vital signs. 10. Consider pain control. 11. Transport to the Trauma Center for suspected airway involvement and/or burns greater than 10% of total body surface area, circumferential burns, burns to the hands, feet, or genitalia. H. Snakebite In the event of an actual or probable snakebite: 1. Confirm that the responsible snake or snakes have been appropriately and safely contained and there is no danger of additional bites to patient or OFD personnel. 2. Keep patient calm (minimize patient movement). 3. For incidents at Henry Doorly Zoo obtain and confirm appropriate antivenom for snake involved. Quickly package patient and initiate Code 3 transport directly to Nebraska Medicine. Establish early radio contact to hospital to inform them of situation. 4. Airway, oxygen, monitor. 5. Splint any bitten extremity and maintain the extremity in a position below the level of the heart. 6. Remove any rings or jewelry on the bitten extremity. 7. Apply a blood pressure (BP) cuff, as a tourniquet, one-inch above the site of the bite on the extremity. Inflate cuff to mmhg and maintain this pressure. If no BP cuff available, may use other resources for constricting bands (tourniquet, cling, Coban, etc.). Goal is to apply just enough pressure to occlude only superficial veins and the lymphatics. A pulse should be palpable below the bite site after application. 8. Attempt IV enroute in a non-affected extremity. 9. Do not rinse bite site. 10. Do not cut or incise the bite site, or apply ice or cold packs. 11. Do not administer antivenom in the field. Page 35 of 83

36 I. Crush Syndrome This protocol is to be used for adult patients who are being rescued from being trapped by having an extremity muscle mass compressed for more than four hours or more than two hours in a cold climate, but also who have pulses distal to the compression. Preventive treatment for Crush Syndrome is secondary to primary interventions for acute traumatic injuries. The risks of Crush Syndrome are greater if the patient s extremity is hard, swollen, cold and insensitive. 1. Airway, oxygen, monitor patients should have high flow oxygen applied, especially at time of release. 2. Start two (2) large bore IVs of NS at TKO rate prior to extrication and releasing compression. 3. Adjust one of the IVs to wide open at the time muscle compression is released. 4. After the first 1000 cc of NS has been infused, mix 50 cc of Sodium Bicarbonate into the second IV bag and adjust the second IV to 500 cc per hour. 5. Continue running 1 st IV of NS wide open (change to new bag as needed). 6. Administer up to three (3) L of normal saline (clear lung sounds and no shortness of breath), over the first 90 minutes following release of compression. 7. Transport to the trauma center. J. Decision Scheme for Trauma Patients Metropolitan Omaha Triage Decision Scheme for Trauma Patients Vital Signs and Level of Consciousness Glasgow Coma Scale 13 Systolic BP 90 mmhg or less Respiratory Rate < 10 or > 29 Or need for ventilatory support (<20 in infant less than one year old) Injuries All penetrating injuries to head, neck, torso and extremities proximal to elbow and knee Chest wall instability or deformity (flail chest) Two or more proximal long bone fractures Crushed, degloved, mangled or pulseless extremity Amputation proximal to wrist or ankle Page 36 of 83

37 Suspected pelvic fracture Open or depressed skull fracture Paralysis Combination trauma and burns Suspected airway involvement and/or burns greater than 10% of total body surface Mechanism of Injury and/or Evidence of High Energy Impact Falls Adults: > 20 ft. (one story is equal to 10 ft.) Children: > 10 ft. or 2 3 times the height of the child High Risk Auto Crash Intrusion (including roof) > 12 inch occupant site and/or 18 inch any site Ejection (partial or complete) from automobile Death in same passenger compartment Vehicle telemetry data consistent with high risk injury Auto versus Pedestrian/Bicyclist Thrown, Run Over, or with Significant (> 20 mph) Impact Motorcycle Crash > 20 mph Consider transport to the Trauma Center for the following conditions/situations: Patient age of 55 years old or greater Systolic BP < 100 in patients 65 years old or older Anticoagulation and Bleeding Disorders Time Sensitive Extremity Injury End Stage Renal Disease Requiring Dialysis Pregnancy > 20 weeks EMS Provider Judgment The Trauma Center is the only hospital to contact if the above criteria are met. Trauma patients that do not meet these guidelines, and are stable, may be taken to any hospital. ANY HOSPITAL OR EMS PROVIDER HAS THE OPTION TO BYPASS TO THE TRAUMA CENTER IF IT IS FELT IT IS IN THE BEST INTEREST OF THE PATIENT Page 37 of 83

38 Trauma Center of the Day Designation (Omaha area Trauma Center days rotate at 0700 every day): Nebraska Medicine CHI Alegent Creighton Health Odd Days Even Days K. Trauma Center Rotation for Mass Casualty Incidents (MCI) In the event of an MCI, both Omaha Trauma Centers will open for trauma patients. 1. Follow Standard Operating Procedures EMS 5-0 Multi-Casualty Response. 2. The Incident Commander at the scene will notify Omaha Fire Dispatch of a MCI event along with the estimated number of victims. Dispatch will then contact the Trauma Center of the Day. 3. The ED staff at the Trauma Center of the Day will then contact the ED staff at the non-trauma Center of the Day to inform them of the situation and need for both Trauma Centers to open for trauma patients. 4. When 4 critically injured / RED patients arrive or are being transported to the open Trauma Center of the Day, the alternating Trauma Center will receive the next 4 critically injured / RED patients. This rotation of 4 and 4 will continue until all critically injured / RED patients have been transported. 5. Minor injury / GREEN patients should be transported to the other local hospitals, not to the Trauma Centers. For a large scale incident with more than 20 critically injured / RED patients, consider transporting all serious injury / YELLOW patients to the other hospitals. 6. Each Trauma Center will be responsible for informing Omaha Fire Dispatch when they are no longer able to accept any additional patients in the rotation. 7. If both Trauma Centers are overwhelmed, critically injured / RED patients should then be transported to the other local hospitals. MEDICAL EMERGENCIES A. Upper Airway Obstruction (Choking) 1. Attempt to relieve obstruction according to the American Heart Association Foreign Body Airway Obstruction (FBAO) guidelines. 2. If unsuccessful: Attempt to visualize obstruction with laryngoscope and remove with Magill Forceps. Administer oxygen, monitor. Page 38 of 83

39 If all of the above fail, consider needle cricothyrotomy. Use 12 or 14 gauge needles. Start IV with NS TKO. B. Altered Mental Status Altered Mental Status with History of Diabetes Mellitus (Hypoglycemia) 1. Airway, oxygen, monitor. 2. Check blood sugar level. 3. Start IV/IO with NS, titrate to vital signs. 4. If blood sugar is less than 70 and / or signs & symptoms are present which are consistent with hypoglycemia: Ensure patent IV with a 20ml flush of NS. Administer D10 (D10 = 25 Grams of Dextrose in 250 ml premixed bag) If D10 is not available then Administer grams (25-50 ml) of D50W IV push, followed by 10ml NS flush. Recheck blood sugar. Consider repeating if blood sugar remains less than 70. Altered Mental Status, Excluding Exposure 1. Airway, oxygen, monitor. 2. Check blood sugar level. 3. Start IV with NS, titrate to vital signs. 4. If blood sugar is less than 70 and/or signs & symptoms are present which are consistent with hypoglycemia, see Altered Mental Status, hypoglycemia protocol. 5. If narcotic overdose suspected (GCS <13, pin point pupils, and/or respiratory depression), administer Narcan, 0.4 mg to 2.0 mg IV/IM/IO/IN, repeat as indicated. 6. Note: If the patient is not an imminent safety concern consider Physical Restraint Procedures. 7. Ketamine if patient is an (Imminent safety concern) 8. RASS SCORE +2, +3, or +4 (document in your report before Ketamine administration and 5 min after administration of Ketamine, and once again upon ED arrival) Adult 250 mg IM (16 y/o and older) May repeat once (250 mg) in 5 minutes if needed (Max 500 mg) Pediatric 150 mg IM (12 y/o 16 y/o) May repeat once (150 mg) in 5 minutes if needed (Max 300 mg) Page 39 of 83

40 9. Obtain 12 Lead ECG 10. Apply O2 Nasal Cannula with CO2 monitoring (if patient is sedated) 11. If the patient is not calm after 10 minutes: Administer Versed 5 mg IM / IN Administer Versed 2 mg IV (as needed every 5 minutes x 3 doses up to 6 mg max dose) 12. If patient is sedative apply nasal cannula and monitor CO2 13. Documentation RASS SCALE: Ensure statements of self-harm, harm to others are reported to Law Enforcement and document in the patient care report. Pearls Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro Crew / responders safety is the main priority. Any patient who is handcuffed or restrained by Law Enforcement and transported by EMS must be accompanied by law enforcement in the ambulance of follow immediately behind the ambulance. Consider sedatives (Ketamine or benzodiazepine) for patients with other presumed substance abuse. While benzodiazepines may be indicated for patients with alcohol intoxication, consider that alcohol and benzodiazepines together may lead to respiratory depression Page 40 of 83

41 All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. Consider bringing extra personnel during transport. If cardiac rhythm changes, evaluate QTc interval with a 12-lead EKG. If QTc > 500ms, consider administering Magnesium Sulfate (2 grams IV / IO). If the QRS is greater than.12 seconds consider administering Sodium bicarbonate (1mEq / kg). Consult medical control if appropriate. Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) Do not irritate the patient with a prolonged exam. Do not overlook the possibility of associated domestic violence or child abuse. If patient is suspected of agitated delirium suffers cardiac arrest, consider a fluid bolus and Sodium Bicarbonate early Do not position or transport any restrained patient is such a way that could impact the patient's respiratory or circulatory status. Documentation o Ensure statements of self-harm, harm to others are reported to Law Enforcement and document in the patient care report. o Document RASS Score before Ketamine administration, 5 minutes after administration and upon ED arrival. Altered Mental Status associated with anxiety, agitation, confusion, hallucinations, bizarre behavior, combative, violent, delusional thoughts, paranoia, hyper aggression tachycardia, increased strength, hyperthermia C. Excited Delirium 1. Ketamine RASS SCORE +2, +3, or +4 (document in your report before Ketamine administration and 5 min after administration of Ketamine, and once again upon ED arrival) Adult 250 mg IM (16 y/o and above) May repeat x 1 dose in 5 minutes if needed (Max 500mg) Pediatric 150 mg (12 y/o 16 y/o) May repeat x1 dose in 5 minutes if needed (Max 300mg) 2. If patient is not calm after 10 minutes: a. Versed 5 mg IM/IN b. Versed 2 mg IV (as needed every 5 min X3 doses up to 10 mg max) Page 41 of 83

42 3. IV Access - NS 1,000 ml Bolus May repeat 500 ml bolus x2 a. Maximum 2 Liters 4. Glucose Check Refer to hypoglycemia protocol 5. Temperature measurement and cooling measures as needed 6. Apply O2 Nasal Cannula with CO2 monitoring (if patient is sedated) Lead ECG procedure a. Cardiac monitor 8. Sodium Bicarbonate 1mEq/kg IV / IO if patient has S/S of cardiac arrhythmias or presents in cardiac arrest. 9. Monitor and reassess frequently. 10. If patient is sedated apply nasal cannula and monitor CO2 11. Document RASS score before Ketamine administration, 5 minutes after administration and on ED arrival. Pearls Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro Crew / responders safety is the main priority. Page 42 of 83

43 Any patient who is handcuffed or restrained by Law Enforcement and transported by EMS must be accompanied by law enforcement in the ambulance of follow immediately behind the ambulance. Consider sedatives (Ketamine or benzodiazepine) for patients with other presumed substance abuse. While benzodiazepines may be indicated for patients with alcohol intoxication, consider that alcohol and benzodiazepines together may lead to respiratory depression All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. Consider bringing extra personnel during transport. If cardiac rhythm changes, evaluate QTc interval with a 12-lead EKG. If QTc > 500ms, consider administering Magnesium Sulfate (2 grams IV / IO). If the QRS is greater than.12 seconds consider administering Sodium bicarbonate (1mEq / kg). Consult medical control if appropriate. Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) Do not irritate the patient with a prolonged exam. Do not overlook the possibility of associated domestic violence or child abuse. If patient is suspected of agitated delirium suffers cardiac arrest, consider a fluid bolus and Sodium Bicarbonate early Do not position or transport any restrained patient is such a way that could impact the patient's respiratory or circulatory status. Excited Delirium Syndrome: o Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Potentially life-threatening and associated with use of physical control measures, including physical restraints and Tasers. Most commonly seen in male subjects with a history of serious mental illness and /or acute or chronic drug abuse, particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may also contribute to the condition. Documentation Ensure statements of self-harm, harm to others are reported to Law Enforcement and document in the patient care report. RASS Score before and after Ketamine administration. D. Seizure Disorder 1. Airway, oxygen, monitor. 2. Protect patient from further injury, DO NOT restrain or force bite block. 3. Check blood sugar level. Page 43 of 83

44 4. Start IV/IO with NS, titrate to vital signs. 5. If blood sugar is less than 70 and/or signs & symptoms are present which are consistent with hypoglycemia, see Altered Mental Status, hypoglycemia protocol. 6. For recurrent seizures, consider one of the following: Versed 2.5 mg slow IV push (may repeat once), OR 5 mg IM, OR 5 mg intranasal (may repeat in 5 minutes at half the dose). 7. If narcotic overdose suspected, consider Narcan 0.4 mg to 2.0 mg IV push or mg intranasal or other route as accessible, repeat as indicated. E. Difficulty Breathing Acute Allergic Reactions / Anaphylaxis (Difficulty Breathing in the presence of urticaria, wheezing and/or contact with a known allergen) BP <70 Systolic 1. Airway, oxygen, monitor. 2. Start IV/IO with NS, titrate to vital signs. 3. Administer Medications: BP >70 Systolic Epinephrine mg (1:10,000) IV/IO OR If intubated, mg (1:10,000) ET (Dose is doubled for ET route). Repeat every 5-10 minutes depending on vital signs and respiratory status. DuoNeb by nebulizer, may repeat as necessary. Consider BVM aerosol setup; do not wait for IV access. Benadryl 50 mg slow IV push over 1-3 minutes. 1. Airway, oxygen, monitor, intervene when needed. 2. Administer Medications: Epinephrine (1:1,000) IM. Repeat in 5 minutes as necessary. NOTE: Epinephrine has no contraindication in acute anaphylaxis. DuoNeb by nebulizer or nebulized with CPAP, may repeat as necessary. Benadryl 50 mg IM OR slow IVP over 1-3 minutes 3. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay medications while waiting for IV access. Asthma/COPD (Difficulty breathing in the presence of wheezing with history of asthma, chronic bronchitis, emphysema, or irritant exposure) 1. Airway, oxygen, monitor, intervene when needed, CPAP if BP > 90 systolic. Page 44 of 83

45 2. Administer Medications: DuoNeb by nebulizer, may repeat x1. If the nebulizer treatments are ineffective: Magnesium Sulfate 2 Grams IV/IO diluted in 10 ml NS, slow push over 10 minutes. Epinephrine mg (1:1,000) IM OR mg (1:10,000) IV (IV dose used in severe asthma with impending arrest, only.) NOTE: Do NOT administer epinephrine if the patient has chest pain, is being treated for angina, has a history of coronary artery disease, or AMI. 3. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay medications while waiting for IV access. F. Exposure Hypothermia (Lowered Skin Temperature with Altered Mental Status) 1. Remove wet clothing, protect against heat loss and wind chill. 2. Avoid rough movement and excess activity. 3. Maintain horizontal position. 4. Monitor temperature, if possible. 5. Monitor cardiac rhythm. If Pulse/Breathing Present 1. Oxygenate with warm oxygen (if available). 2. Start IV with NS TKO, use warm IV fluid (if available). If Pulse/Breathing Absent 1. Start CPR. 2. If VF/VT, defibrillate X Continue CPR if pulseless and apneic. 4. Ventilate with warm oxygen (if available). 5. Start IV with NS TKO, use warm IV fluid (if available). NOTE: Medications are not indicated in extreme hypothermia. Transport considerations: Adult patients with extreme hypothermia and no signs or suspicion of trauma, transport to catchment area hospital. Page 45 of 83

46 Pediatric patients with extreme hypothermia and no signs or suspicion of trauma, transport to Children s Hospital. Hyperthermia (Elevated Skin Temperature with Altered Mental Status) 1. Remove from environment and wrap with moist sheets. Replace moist sheets frequently. Increase airflow to improve evaporation and convection. 2. Airway, oxygen, monitor. 3. Start IV with NS, titrate to vital signs. G. Hypovolemic Shock (Hypotension in the Absence of Trauma) Shock is present when pulse greater than 120 and systolic BP less than 90 mmhg in a previously normotensive patient or systolic drops mmhg in a previously hypertensive patient, especially if accompanied by pale, clammy skin and decreased level of consciousness. 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Start 1 or 2 large bore IVs, NS and titrate to vital signs, up to 2 liters. 3. Consider Epinephrine drip at 2-10 mcg / min H. Poisons Consider calling Poison Control Center Omaha area Outside of Omaha area I. Nerve Agents See Procedure D Page 46 of 83

47 J. Overdose/Toxic Ingestion 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Check blood sugar level is less than 70, follow hypoglycemia protocol. 3. Start IV with NS, titrate to vital signs. 4. If altered mental status, respiratory depression and/or pin point pupils consider Narcan, 0.4 mg to 2.0 mg IV push or mg intranasal, repeat as necessary. 5. If patient demonstrates one of the following: Prolonged or widening of QRS ( > 120ms). Ventricular dysrhythmias. Hypotension unresponsive to fluid challenge of 500 ml NS. Seizure with no previous history of seizures. Administer 1mEq/Kg Sodium Bicarbonate slow IV push. 6. Treat dysrhythmias according to protocol guidelines. 7. Combative patients see Physical and/or Altered Mental Status Protocols K. Toxic Inhalation 1. Remove from exposure. 2. Airway, oxygen, monitor, consider CPAP. 3. If wheezing and/or signs of bronchoconstriction: DuoNeb by nebulizer or nebulized with CPAP, may repeat as necessary. 4. Start IV with NS, titrate to vital signs. 5. If CO poisoning, treat with high flow oxygen, 15LPM via non-rebreather mask. 6. If only CO poisoning is suspected and no inhalation injury, assess for the presence of any of the following and transport directly to Nebraska Medicine for possible hyperbaric chamber treatment: Chest pain. Headache in pregnant patient. Altered LOC or history of unconsciousness. Dizziness. Seizures. Unsteady gait or difficulty speaking. Page 47 of 83

48 L. Cyanide Poisoning (see Procedure F ) 1. Assess and treat Airway, Breathing, and Circulation. 2. Start (2) IV s with NS, titrate to vital signs. 3. Administer Cyanokit if known or suspected cyanide poisoning in persons exposed to smoke from a fire in closed spaces and in victims with soot around the mouth, nose, and oropharynx with a depressed mental status, systolic blood pressure < 90, seizure activity or who are unresponsive. Adult Dose (19 years and older): 5 Grams of Cyanokit (hydroxocobalamin) in 200 ml 0.9% sodium chloride IV infusion over 15 minutes 15 drop IV tubing 200 gtts/min or 3 drops / sec (nearly wide-open). Check in 7 minutes and ½ the antidote should be infused. Pediatric Dose: Contact medical control at the receiving hospital. 4. Follow ACLS guidelines if the patient in pulseless, apneic and unresponsive establish and use a second IV / IO site for all other medications. 5. Notify PSS and EMS B/C when used. **DO NOT DELAY TRANSPORT FOR CYANOKIT ADMINISTRATION **Monitor blood pressure as the patient could have significant increases. M. Stroke 1. Airway, oxygen, monitor, obtain 12-Lead ECG. 2. Check blood sugar level is less than 70 follow hypoglycemia protocol. 3. Start IV with NS en route to hospital. Do NOT delay transport. Titrate to vital signs if BP is < 90 systolic. 4. Perform, document and report results of the Cincinnati Prehospital Stroke Scale (see Procedure B) to receiving facility. 5. Obtain history if possible, determine onset time of signs and symptoms from patient and / or bystanders report to receiving facility for possible activation of hospital stroke team. 6. Code 3 Stroke Transport if: Signs/symptoms have recently developed (onset within last 3 hours). Signs/symptoms are progressing. Unstable vital signs. Page 48 of 83

49 N. Behavioral Emergencies 1. A patient with a behavioral emergency should be transported to the catchment hospital for medical clearance and psychiatric evaluation. 2. Patients who are rational and present no risk to OFD personnel or to themselves may be transported to hospital of choice. 3. Patients who pose a risk to themselves or OFD personnel (See Refer to Altered Mental Status Protocol) ALWAYS consider a medical etiology for a behavioral emergency. O. Nausea and/or Vomiting 1. Follow appropriate protocol for the patient s condition. 2. Start IV with NS, titrate to vital signs. 3. Administer Zofran (ondansetron), single dose only. For adult patients < 250 lbs., give 4 mg IV, slow push 2-5 minutes, or SL For adult patients > 250 lbs., give 8 mg IV, slow push 2-5 minutes, or SL For pediatrics age 1 or older, give 0.15 mg/kg IV, slow IV push, max of 4 mg. OBSTETRICS - GYNECOLOGY A. Imminent Delivery with History of Pregnancy, a Palpable Uterus and Contractions 1. Airway, oxygen, monitor. 2. Consider IV with NS, titrate vital signs. If possible, start IV s in forearms. 3. If not crowning (no signs & symptoms of imminent delivery), transport patient in position of comfort, usually on left side. 4. If crowning present, prepare mother for delivery. 5. Allow placenta to deliver naturally. DO NOT forcibly extract. If mother allows, put baby to breast. Massage fundus. Transport all tissue passed with patient to receiving facility. B. Neonatal Care General Care Given Newborn, Full-Term or Premature 1. Suction nose with bulb syringe. 2. Keep baby warm and dry, keep at same level as vagina. 3. Stimulate to breathe. 4. Maintain airway and apply blow-by oxygen as necessary. Page 49 of 83

50 5. Assess APGAR score at 1 minute and 5 minutes. (See Appendix) 6. Within 1-2 minutes, double clamp cord 6-12 inches from baby and cut. 7. Continue supportive care as needed. If spontaneous respirations absent or inadequate, or pulse rate below 60: Ventilate with bag-valve-mask at a rate of 40-60/minute with ROOM AIR. If pulse remains less than 60, despite positive pressure ventilation, intubate and ventilate with 5 L/min oxygen. If pulse remains less than 60 after intubation OR drops below 60 at any time, start chest compressions. Compression to ventilation ratio is: 3:1 (90 compressions and 30 ventilations per minute). If no change after this point, Administer Epinephrine: mg / kg IV / IO, (1:10,000). Repeat every 3 5 minutes. For ET administration, give 0.1 mg / kg, (1:1,000) Fluid Bolus at 10 cc / kg C. Meconium Stained Fluid 1. Use a suction catheter or infant bulb syringe to clear mouth and nose. 2. If meconium present, intubate with #3.0 ET tube, suction the tube as the tube is pulled out, re-intubate with a new tube each time until CLEAR (consider use of Meconium Aspirator). 3. Once clear, re-intubate and ventilate, maintain a patent airway and provide oxygen at no greater than 5 L/min. D. Childbirth Complications Prolapsed cord, breech presentation, limb presentation, significant hemorrhage, decreased fetal heart rate. 1. Airway, oxygen, monitor, start 1 or 2 IVs with NS and titrate to vital signs. 2. If prolapsed cord, place patient on back and elevate the hips or consider kneechest position. Place two fingers of a gloved hand in vagina to raise the presenting part of the infant off the cord. Check cord for pulsations and avoid compressing the cord. Continue during transport. Apply warm, moist sterile dressings to the exposed cord to maintain temperature. 3. If breech delivery and unable to deliver head, place gloved hand in the vagina with palm towards the infant s face. Form a V with the index and middle fingers on Page 50 of 83

51 either side of infant's mouth and nose and push the vaginal wall away from the infant s face. If necessary, continue during transport. 4. If arm or leg presentation, place patient on back and elevate hips or consider kneechest position, transport immediately. 5. If significant hemorrhage, place dressings to monitor bleeding and elevate hips. E. Postpartum Hemorrhage 1. Airway, oxygen, monitor. 2. Massage the fundus of the uterus and put baby to breast. 3. Start IV with NS and titrate to vital signs. F. Hypertensive Disorders of Pregnancy Toxemia of Pregnancy/Eclampsia - Toxemia is characterized by hypertension and diffuse edema 1. Airway, oxygen, monitor, position patient on her left side. 2. Start 2 IVs with NS TKO. 3. Consider blood sugar check if blood sugar is <70 follow hypoglycemia protocol. 4. Administer Medications if patient has eclampsia (actively seizing): Magnesium Sulfate (50%) 5 grams in 50 cc D5W with a minidrip setting. Infusion must be over a minimum of 5 minutes. If patient has pre-eclampsia (headache, confusion, visual disturbances, chest pain, dyspnea or history of recent seizure prior to medic unit arrival), consider Magnesium Sulfate at the above dose. If still seizing after 5 minutes, repeat Magnesium Sulfate at half dose. Magnesium Sulfate (50%) 2.5 grams in 50 cc D5W with a minidrip setting. Infuse over a minimum of 5 minutes. 5. For continued seizures, consider: Versed 2.5 mg slow IV push (may repeat once), OR 5 mg IM, OR 5 mg intranasal (may repeat in 5 minutes at half the dose). G. Vaginal Bleeding 1. Airway, oxygen, monitor. 2. Start IV NS and titrate to vital signs. Page 51 of 83

52 PEDIATRICS A. General Guidelines This protocol acknowledges that age limits for pediatric patients should be flexible and that the exact age of a patient is not always known. Between the ages of 13 and 16, OFD personnel should use his / her own judgment in making medical care decisions. OFD personnel always have the option of contacting medical control directly for assistance in decision making. See General Operations section (Refusal of Care) for patient consent and refusal guidelines. Parents / caregivers should be allowed to stay with children during assessment and transport, if appropriate. OFD personnel shall transport all size-appropriate pediatric patients using the Pedi Mate. OFD personnel are strongly encouraged to use current length based resuscitation tapes and guidelines for dosage and equipment recommendations for pediatric patients. If specific protocol not found in Pediatric Section, OFD personnel should follow appropriate Adult Protocol, adjusting all medications and interventions to pediatric dosages and guidelines. B. Airway Management and Oxygen Therapy OFD personnel should administer high flow oxygen by mask as needed. If patient will not tolerate mask, use high flow blow-by oxygen. Do not hyperextend the neck in newborns and infants. Avoid hyper-oxygenating newborns and infants after resuscitation. Keep O2 saturation > 94% once ROSC is achieved in a previously pulseless patient. Consider appropriately sized oral airway for all unconscious patients. When ventilation is needed, use appropriately sized bag valve mask device. Endotracheal intubation is allowed, but is not necessary when ventilations are effectively maintained with BVM. Page 52 of 83

53 C. IV Therapy For pediatric trauma patients and for all types of shock, attempt IVs enroute. Do not delay scene time to establish an IV with a code 3 pediatric trauma patient. For pediatric patients that are in critical or unstable condition, establish an intraosseous (IO) infusion if difficult or unable to establish an IV. D. Pediatric Cardiac Arrest General Guidelines 1. If respirations are absent or inadequate, begin assisted ventilations using the appropriately sized bag-valve-mask with 100% oxygen. 2. Begin chest compressions if: No pulse. Bradycardia (< 60 beats/min) is causing severe cardiorespiratory compromise as evidenced by poor perfusion, hypotension, respiratory difficulty or altered mental status. 3. Apply ECG monitor and follow standing orders as indicated using protocol guidelines or Broselow tape. 4. Use Zoll Pediatric pads for patients up to 55 pounds (25kg). 5. A patient that is over 8 years old or over 55 pounds (weight over age) should be treated as an adult with respect to electrical therapy. A patient that has signs of puberty (breast development or under arm hair) should be treated as an adult with respect to electrical therapy. 6. Consider drug overdose and/or hypoglycemia as precipitating factors in cardiopulmonary arrest. Treat confirmed hypoglycemia with glucose. Dosing guidelines based on patient age: If blood sugar is less than 70, administer D10 (1 Gram / kg) OR D50W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push). For patients three (3) years or younger, Administer Dextrose 25% 2-4 ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with NS or sterile water, which will result in D25W). 7. If BVM ventilation is effective, do not delay scene time to establish ET intubation E. Pediatric Cardiac Arrest: V-Fib / Pulseless Ventricular Tachycardia 1. UNWITNESSED arrest, perform 5 cycles (2 minutes) of CPR. WITNESSED arrest, shock X 1 at 2 joules per kilogram (2 J / kg). 2. Immediate CPR after defibrillation for 2 minutes. Page 53 of 83

54 3. Shock # 2 at 4 J / kg. 4. Immediate CPR after defibrillation for 2 minutes. 5. Repeat shocks at 4 J / kg; continue with 2 minutes of CPR between each shock. 6. Consider endotracheal intubation at any time with minimal interruption to CPR. Ventilate with BVM (15 compressions to 2 ventilations) until ET tube established, then ventilate 8 to 10 times per minute with continuous compressions. 7. Deliver chest compressions at > 100 per minute. 8. Establish IV or IO at any time without interrupting CPR. 9. Administer Medications: Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes OR 0.1 mg / kg (1:1,000) ET every 3 to 5 minutes. Amiodarone 5 mg / kg IV or IO If Torsades de Pointes: Magnesium Sulfate mg/kg to a Max of 2 Grams IV / IO slow IV push (over 5 minutes). F. Pediatric Cardiac Arrest: Asystole / PEA 1. Perform 5 cycles (2 minutes) of CPR. 2. Confirm rhythm is asystole or PEA. Ventilate with BVM (15 compressions to 2 ventilations) until ET tube established, then ventilate 8 to 10 times per minute with continuous compressions. 3. Deliver chest compressions at > 100 per minute. 4. Establish IV or IO at any time without interrupting CPR. 5. Consider endotracheal intubation at any time with minimal interruption to CPR. 6. Administer Medications: Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes OR 0.1 mg / kg (1:1,000) ET every 3 to 5 minute. 7. Consider treatable causes in the field: Hypovolemia, administer fluid boluses at 20 ml / kg. May repeat 2 more times, as needed. Page 54 of 83

55 Tension Pneumothorax, consider needle decompression. Infants up to 1 year use 18 ga needle 1 year and older use ga needle Hypothermia, provide warming measures. Acidosis or Tricyclic Overdose, administer sodium bicarbonate 1 meq / kg IV or IO. Hypoglycemia, If blood sugar is less than 70, administer D10 (1 Gram/kg) or D50 W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push). For patients three (3) years or younger, Administer Dextrose 25% 2-4 ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with NS or sterile water, which will result in D25W). G. Pediatric General Cardiac Dysrhythmia In general, pediatric patients do not have cardiac dysrhythmias due to cardiac disease. Most often, the cause of dysrhythmias in pediatrics is due to an airway/ventilation or volume condition. For pediatric patients with signs & symptoms of poor perfusion, clear & maintain the airway, provide BVM ventilations and fluid resuscitation (20 ml / kg) as needed. Most pediatric arrhythmia guidelines follow the adult protocols. OFD personnel should refer to a pediatric reference guide (length based pediatric tape) if assistance is needed with drug dosages for pediatric patients. Stable Pediatric Patient If tolerating the rhythm, monitor and provide supportive care without medications or electrical intervention. Unstable Pediatric Patient Treatments are based on the patient s condition and how rapidly a medication may be delivered versus how rapidly an electrical therapy can be performed. H. Bradycardia (HR <60 / min) Bradycardia with signs and symptoms of poor perfusion 1. Airway, oxygen and monitor. 2. Establish an IV or IO of NS. 3. If unstable (poor perfusion, hypotensive, respiratory distress, altered mental status), start chest compressions and assure airway and oxygen with BVM and/or endotracheal intubation. Page 55 of 83

56 4. Administer Medications: Epinephrine 0.01 mg / kg (1:10,000) IV or IO every 3 to 5 minutes OR 0.1 mg / kg (1:1,000) ET every 3 to 5 minutes. Atropine 0.02 mg / kg IV or IO (minimum atropine dose is 0.1 mg). Consider reversible causes (H s and T s) Administer Epinephrine Drip: Begin infusion at 0.1-1mcg / min Pulse and BP should be monitored every 2-5 minutes. Goal of resuscitation: HR > 60 (80 for neonates/infants) Systolic BP > 70 + (age in years x2) Improving mental status Improving capillary refill 5. Consider Transcutaneous Pacing (TCP) If possible, pre-medicate with Versed 0.1 mg / kg IV/IO to a maximum dose of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg I. Monomorphic Ventricular Tachycardia with a Pulse and Poor Perfusion 1. Airway, oxygen and monitor. 2. Establish an IV or IO of NS. 3. Administer Medications: If patient appears to be critically unstable go straight to Synchronized Cardioversion. Adenosine 0.1 mg / kg rapid IV or IO push followed by 10ml flush (max dose is 6 mg). May repeat once in 2 3 minutes at double the dose (max dose 12 mg). Amiodarone 5 mg / kg SLOW IV / IO over 60 minutes. 4. Consider Synchronized Cardioversion Pre-medicate if possible with Versed 0.1 mg / kg IV or IO to a maximum dose of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg Synchronized Cardioversion #1 at joule / kg Synchronized Cardioversion #2 at 2 joules / kg. J. SVT with signs and symptoms of poor perfusion 1. Airway, oxygen and monitor. If patient appears to be critically unstable, go straight to Synchronized Cardioversion. 2. Establish an IV or IO of NS. Page 56 of 83

57 3. Vagal maneuvers, if patient is old enough to understand commands. 4. Administer fluid bolus at 20 ml / kg, repeat bolus as needed, up to a total of 3 times, to increase perfusion. If patient has history of SVT, adenosine should not be delayed for multiple fluid boluses. 5. Administer Medications: Adenosine 0.1 mg / kg rapid IV or IO push followed by 10ml flush (max dose is 6 mg). May repeat once in 2 3 minutes at double the dose (max dose 12 mg). 6. Consider Synchronized Cardioversion Pre-medicate if possible with Versed 0.1 mg / kg IV or IO to a maximum dose of 2.5 mg, or 0.2 mg / kg intranasal to a max of 5 mg Synchronized Cardioversion #1 at joule / kg. Synchronized Cardioversion #2 at 2 joules / kg. K. Difficulty Breathing Asthma, Bronchiolitis (Difficulty Breathing in the presence of wheezing) 1. Airway, oxygen, monitor, maintain position of comfort. 2. If patient in respiratory arrest, begin ventilations with a BVM, consider endotracheal intubation. 3. Administer Medications: DuoNeb by nebulizer, immediately. May repeat as necessary. For patients in severe respiratory distress or the nebulizer treatment is ineffective: Epinephrine 0.01 mg / kg (1:1,000) IM to a maximum dosage of 0.3mg. Repeat Epinephrine in 5 minutes, if necessary. 4. If unconscious, consider Bag-In nebulizer setup for DuoNeb. 5. Start IV with NS TKO if not started already, titrate to vital signs. Do not delay medications while waiting for IV access. Acute Allergic Reaction/Anaphylaxis (Difficulty Breathing in the presence of urticaria, wheezing and/or contact with a known allergen) 1. Airway, oxygen, monitor. If patient in respiratory arrest, begin ventilations with a BVM, consider endotracheal intubation. 2. Administer Medications immediately: Epinephrine 0.01 mg / kg (1:1,000) IM to a maximum dosage of 0.3 mg. OR Page 57 of 83

58 0.01 mg / kg (1:10,000) IV/IO (in severe anaphylaxis w/ imminent arrest). May repeat epinephrine in 3-5 minutes if necessary and/or start epinephrine infusion at mcg/kg/min. DuoNeb by nebulizer, may repeat as necessary. Benadryl 1 mg / kg IM or slow IV/IO push (over 1-3 min), maximum dosage of 50 mg. 3. IV of NS if not started already, titrate to vital signs. Croup and Epiglottitis (Difficulty Breathing in the presence of stridor and history of illness) 1. Airway, oxygen, monitor. 2. Maintain patient in position of comfort, try to keep patient calm. 3. If unconscious, position supine and ventilate with BVM. 4. Consider early and rapid transport. 5. For suspected croup, administer medications: Nebulized Epinephrine 0.5 ml / kg of 1:1000 solution (may dilute in 3 ml saline). Maximum dose for patients < 4 years old is 2.5 ml per dose. Maximum dose for patients > 4 years old is 5.0 ml per dose. If unable to give epi nebulizer treatment, consider Epinephrine 0.01 mg/kg (1:1,000) IM (maximum of ml). 6. Consider IV of NS TKO. Choking 1. Attempt to relieve obstruction according to the American Heart Association Foreign Body Airway Obstruction (FBAO) guidelines. 2. If above maneuvers are unsuccessful, attempt to visualize obstruction with laryngoscope and remove with Magill forceps. 3. Administer oxygen, monitor. 4. If all of the above fail, consider needle cricothyrotomy, gauge for children, gauge for infants or the largest catheter that will fit into the airway / cricothyroid space. 5. Start IV with NS TKO enroute. L. Seizures - recurrent or prolonged 1. Airway, oxygen, monitor. 2. Protect patient from further injury, DO NOT restrain. Page 58 of 83

59 3. Check blood sugar level. 4. Start IV with NS and titrate to vital signs. 5. Administer Medications: If blood sugar less than 70: If blood sugar is less than 70, administer D10 (1 Gram/kg) or D50 W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push). For patients three (3) years or younger, Administer Dextrose 25% 2-4 ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with NS or sterile water, which will result in D25W). For continued seizures, consider one of the following: Versed 0.05 mg / kg slow IV/IO push up to a maximum dose of 2.5 mg, may be repeated with authorization from receiving hospital. If no IV access, Versed 0.05 mg / kg IM to a maximum dose of 2.5 mg, OR 0.2 mg / kg (max of 5 mg) intranasal (max of 1 ml per nostril). If given via nasal route, may be repeated at half-dose with authorization from receiving hospital. OR If no IV/IO access, Valium 0.5 mg / kg rectally, may repeat to a maximum dose of 10 mg. If narcotic overdose suspected: Narcan 0.1 mg / kg IV/IM/IO/IN up to 2 mg, repeat as necessary. M. Altered Mental Status 1. Airway, oxygen, monitor. 2. Check blood sugar level. 3. Start IV with NS and titrate to vital signs. 4. Administer Medications: If blood sugar less than 70: If blood sugar is less than 70, administer D10 (1 Gram / kg) OR D50W (1 Gram / kg) up to 25 grams for patients four (4) years or older if D10 not available (slow IV or IO push). For patients three (3) years or younger, Administer Dextrose 25% 2-4 ml / kg slow IV or IO push (If D25W not available, dilute D50W 1:1 with NS or sterile water, which will result in D25W). Page 59 of 83

60 If narcotic overdose suspected: 1. Narcan 0.1 mg / kg IV/IM/IO/IN up to 2 mg, repeat as necessary. Page 60 of 83

61 PROCEDURE A - RAPID SEQUENCE INTUBATION Indications 1. Altered mental status with airway compromise. 2. Head injuries with signs of increased ICP (GCS < 8), but combativeness or agitation threatens the airway, spinal cord stability, and/or patient and crew safety. 3. Conscious but unable to maintain airway. 4. Severe respiratory distress with hypoxia / cyanosis, impending respiratory failure. NOTES: High flow oxygen should be applied. If the patient has inadequate ventilations, ventilate with / minute with 100% oxygen. Maintain cricoid pressure during entire intubation until tube placement is confirmed by O2 saturations, physical exam and CO2. DO NOT PERFORM IN TRANSPORT. Stop vehicle to initiate RSI. Pre-medication Considerations 1. Administer Atropine 0.02 mg / kg IV or IO (minimum of 0.1 mg, maximum of 1mg) to the pediatric patient due to potential bradycardia (any patient under 4 years of age). 2. Sedation Versed (Midazolam) Adults: Peds: 3. Paralyzing Agent Procedure Succinylcholine Adults: Peds: 2-5 mg IV (may repeat every 5 minutes to a total dose of 10 mg) OR 5 10 mg intranasal, repeat at half-dose in 5 minutes. Max of 1 cc per nostril. 0.1 mg / kg IV or IO OR 0.4 mg / kg intranasal, max of 10 mg. Max of 1 cc per nostril. 1.5 mg / kg IV or IO 1.5 mg / kg IV or IO (DO NOT REPEAT Succinylcholine) 1. Establish IV/IO access. 2. BVM (12-16 / min for adults, / min for pediatrics) to preoxygenate the patient for approximately 2 minutes if necessary. If patient has adequate ventilations before RSI procedure, ventilations with BVM are not required prior to intubation. Page 61 of 83

62 3. Maintain cricoid pressure at all times. 4. If trauma, maintain spinal immobilization (per trauma protocol). 5. Obtain & record vital signs (BP, Pulse, Respirations, O2 saturations and ECG). 6. Prepare equipment and medications. 7. Pre-medicate with Versed. 8. Administer Atropine 0.02 mg / kg IV or IO (minimum of 0.1 mg, maximum of 1mg) to the pediatric patient due to potential bradycardia (any patient under 4 years of age). 9. Administer Succinylcholine 1.5 mg / kg rapid IV push (100 mg for 70 kg adult patient). Once fasciculations stop (approximately 30 seconds), with cricoid pressure continued, intubate. Confirm endotracheal tube placement by: Attaching the EtCO2 monitor and verify CO2 production by waveform or mmhg. Observing for chest rise and fall. Verifying the presence of bilateral lung sounds and the absence of epigastric sounds by auscultation with a stethoscope. Confirming improvement in saturations by pulse oximetry. Once ET tube confirmed, inflate the ET tube cuff. Release cricoid pressure and secure the tube in place. Apply c-collar, repeat vital signs and O2 sats. NOTE: Failed intubation should be followed by BVM ventilation, then placement of the King Airway. Contraindications (for the procedure): Inability to ventilate with BVM Examples: lodged foreign body, severe maxillofacial injury tracheo-bronchial injury (fractured larynx) Body habitus (physical exam reveals potential difficult intubation) Examples: large tongue, no neck, and morbid obesity Page 62 of 83

63 Contraindications (for succinylcholine): Known hyperkalemia (peaked T-waves), renal failure. Burns greater than 8 hours old. History of chronic paraplegia or quadriplegia History of muscular dystrophy, ALS, multiple sclerosis or myasthenia gravis. History of malignant hyperthermia or pseudo cholinesterase deficiency. Open eye injury. If patient goes into cardiac arrest after administration of Succinylcholine, defibrillate if V- FIB or pulseless V-TACH, then: Administer Sodium Bicarbonate for presumed hyperkalemia Adults: Peds: 1 meq / kg IV push 1 meq / kg IV push Follow protocol for cardiac arrest and dysrhythmia management Page 63 of 83

64 PROCEDURE B CINCINNATI PREHOSPITAL STROKE SCALE Facial Droop (have patient show teeth or smile): Normal both sides of face move equally well. Abnormal one side of face does not move as well as the other side. Arm Drift (patient closes eyes and holds both arms out): Normal both arms move the same or both arms do not move at all (other findings, such as pronator grip, may be helpful). Abnormal one arms does not move or one arms drifts down compared with the other. Speech (have the patient say you can t teach an old dog new tricks ): Normal patient uses correct words with no slurring. Abnormal patient slurs words, uses inappropriate words, or is unable to speak. Page 64 of 83

65 PROCEDURE C - PRE-HOSPITAL SPINAL INJURY ASSESSMENT AND TREATMENT (CERVICAL SPINE IMMOBILIZATION CONSIDERATIONS) NOTE: Maintain manual c-spine immobilization until evaluation is complete. Evaluate for the presence of any of the following: Multi-system trauma. Any loss of consciousness. Altered mental status. Significant injury above the clavicles (i.e. head/neck wounds). Presence of a distracting injury (i.e. fractured femur). Presence or suspicion of alcohol or drug use. Presence of language/communication barrier. Ask patient if any presence of neck pain. If negative findings to all listed above, proceed with the following focused physical exam: Test for motor/sensory function. Finger abduction/adduction. Finger/hand extension. Foot plantar flexion. Foot/great toe dorsiflexion. Light touch sensation to hands and feet. Palpate spine for tenderness. Pre-Hospital Spinal Injury Assessment and Treatment (continued): If all findings negative for potential injury, ask patient to: Flex and extend the head up and down. Rotate the head to the right and left. Tilt the head to the right and left. If the paramedic assesses any criteria above to be positive findings OR if the patient has any complaints of neck pain, pain on palpation, neurological deficit, positive mechanism of injury or is unreliable, the paramedic will immobilize patient to back board. NOTE: For patient to be reliable, he/she must be calm, cooperative, and alert and have no suspicion of alcohol or drug use. Page 65 of 83

66 If the paramedic assesses that all criteria above to be negative findings, spinal immobilization is not indicated. It is advised to document the following: Absence/presence of complaints of pain. Neck pain to direct palpation. Neck pain to motion. Injury above the clavicles. Neurologic abnormality. Obvious injury. Patient reliability. Page 66 of 83

67 PROCEDURE D NERVE AGENT / ORGANOPHOSPHATE POISONING MARK 1 / DUODOTE KITS (ADULT), VALIUM AUTO-INJECTORS (ADULT) AND ATROPEN AUTO-INJECTOR (PEDIATRIC) Purpose: To establish guidelines concerning the local EMS response to a WMD (Weapons of Mass Destruction) event and to provide local EMS providers with access to pharmaceutical resources and guidance on the use of auto-injectors (Mark I Kits, DuoDote, Diazepam and pediatric AtroPens). EMS providers are reminded to: 1. Consider scene safety and first responder safety as primary goal. 2. Consider implementing local protocol for mass casualty incidents and/or requesting the opening of the county EOC (Emergency Operations Center) in the event of a mass casualty incident to assist in assembling treatment resources and facilitating the transportation of large numbers of patients. 3. Contact the Nebraska Regional Poison Center for immediate assistance at Until the Douglas County EOC Medical Table is activated and opened, the Poison Center will serve as the point of contact for local first responders and hospitals to access the stockpiles distributed throughout the community. DuoDotes and Mark 1 Kits are available on most area rescue squads for self-administration, in small cache supplies at several local fire departments, in other local stockpiles and in federally supplied assets in the Omaha Metropolitan Medical Response System (OMMRS) area for treatment of victims of nerve agent exposures. The requesting agency will be responsible for providing the transportation of the product to the scene locally. This may often be delegated to the 911 Center by preestablished protocol. The Nebraska State Patrol may serve as the medium for movement across jurisdictions that do not already have established plans or when movement of product must come from other assets across the state. Mark I Kit: For adult patients and pediatrics over 84 lbs. (38 kg) 1. Atropine auto-injector (2 mg total dose per injection) 2. Pralidoxime chloride auto-injector (600 mg total dose per injection) DuoDote: For adult patients and pediatrics over 84 lbs. (38 kg) 1. *Atropine (2.1 mg total dose per injection) 2. *Pralidoxime chloride (600 mg total dose per injection) * DuoDote is a newer version of the Mark 1 Kit and contains the same medications and doses as the Mark 1 Kit. The only difference is the DuoDote contains both atropine and pralidoxime chloride in a single auto-injector for IM injection. Page 67 of 83

68 AtroPen: For pediatric patients up to 84 lbs. (38 kg) Atropine auto-injector (0.5 mg total dose per injection) Diazepam (Valium): For adult patients Diazepam auto-injector (10 mg total dose per injection) Nerve Agents: A classification of potential WMD chemical agents that might be used in a terrorist attack. Examples include Tabun, Sarin, Soman and VX. Organophosphates: Insecticides such as Malathion, Diazinon and Parathion Nerve Agent or Organophosphate Poisoning Signs/Symptoms by Severity: Mild Moderate Severe Constricted (pinpoint) pupils, excessive sweating, tearing, drooling, runny nose/nasal secretions, mild chest tightness, mild shortness of breath, chest tightness Severe chest tightness, wheezing, profuse airway secretions, respiratory distress, muscle weakness, vomiting, abdominal cramps and diarrhea Unconsciousness, coma, seizures, no muscle tone (flaccid paralysis), cyanosis, respiratory failure, apnea Authorization for Use The auto-injectors are authorized for use by the local Physician Medical Directors for the departments that have received them and for use by personnel who have received adequate training (by the Physician Medical Director or designee) on the recognition and treatment of nerve and/or organophosphate agent exposure in the event of a chemical release. In the case of a nerve agent incident, it would be specific to the disaster setting. Organophosphate exposure may be treated as an isolated case with the Mark 1 kits or DuoDotes. Pediatric strength atropine (AtroPen 0.5 mg) and diazepam auto-injectors are to be distributed only to paramedic staffed rescue squads. Guidelines for Use The decision to use the Mark I kit or DuoDote is based on signs and symptoms of the patient, regardless if the patient is an EMS provider, firefighter or a civilian. The goal of using the auto-injectors is directed at relieving respiratory distress and alleviating seizures. The suspicion or identified presence of a nerve agent is not sufficient reason on its own to warrant the administration of the medication. Page 68 of 83

69 EMS providers/firefighters may self-administer the Mark 1 kit or DuoDote. The premeasured doses in the auto-injectors are generally safe for most adults suffering from a nerve agent or organophosphate exposure. Paramedics are reminded to review the indications for use and to only treat victims with an auto-injector that are exhibiting signs and symptoms from a nerve agent or organophosphate exposure. Mark 1 Kit / DuoDote Dosage Guidelines for Adults Each Mark 1 Kit contains two auto-injectors: Atropine 2 mg and Pralidoxime Chloride 600 mg. Each DuoDote contains the same medications in a single auto-injector. Dosing is based on signs & symptoms. For MILD signs & symptoms, administer one Mark 1 Kit OR one DuoDote. For MODERATE signs & symptoms, administer two Mark 1 Kits OR two DuoDotes. For SEVERE signs & symptoms, administer three Mark 1 Kits OR three DuoDotes. Diazepam (Valium) Dosage Guidelines for Adults Each Valium auto-injector contains Diazepam 10 mg For SEIZURES and/or SEVERE signs & symptoms, administer one Valium auto-injector May repeat every 5 10 minutes as needed AtroPen Dosage Guidelines for Children Each AtroPen auto-injector contains Atropine 0.5 mg Dosing is weight based: 13 to 40 lbs. (6-18 kg), administer one AtroPen, repeat every 5-10 mins as needed 41 to 62 lbs. (19-28 kg), administer two AtroPens, repeat every 5-10 mins as needed 63 to 84 lbs. (29-38 kg), administer three AtroPens, repeat every 5-10 mins as needed Greater than 84 lbs. (>38 kg), administer one Mark 1 Kit OR one DuoDote, repeat every 5-10 mins as needed Mark 1 Kit Injection Procedure 1. Remove the Mark I kit from the protective foam case. Page 69 of 83

70 2. With the non-dominant hand, hold the kit so that the larger injector is on top and position the kit at eye level. 3. With the other hand, check the injection site (outer thigh or buttocks) for buttons or objects in the pocket, which may interfere with the injections. 4. Grasp the small (green tipped) injector (atropine) with your thumb and first two fingers. 5. Pull the injector out of the clip with a smooth motion. 6. Hold the injector like a pen, between your thumb and first two fingers. 7. Position the green tip of the auto injector against the injection site (thigh or buttocks). 8. Apply firm even pressure (not a jabbing motion) to the injector until it pushes the needle in to the site. Hold the injector firmly in place for at least 10 seconds. 9. Carefully remove the auto injector and place it into a sharps container. In an emergency, and no sharps container available, bend the used needle over, or blunt the end to avoid any accidental needle sticks. 10. Pull the 2-PAM auto injector (larger, black tipped one) out of the clip and inject using the same procedure outlined above. 11. Document the number of auto injectors administered on the patient care report, on the triage tag or attached the used injector(s) to the patient. DuoDote Injection Procedure 1. Remove the DuoDote from the plastic pouch. 2. Place the DuoDote in your dominant hand. Firmly grasp the center of the DuoDote with the green tip pointing down. Do not touch the green tip. 3. With your other hand, pull off the gray safety release. The DuoDote is now ready to be administered. 4. Make sure pockets at the injection site are empty. 5. Firmly push the green tip straight down against the outer thigh. Continue to firmly push until you feel the auto-injector trigger. 6. Hold the DuoDote in place for 10 seconds. 7. Remove the auto-injector from the thigh and look at the green tip. If the needle is visible, the drug has been administered. 8. If the needle is not visible, check to be sure that the gray safety release has been removed and repeat the procedure. 9. Place the auto-injector in a sharps container. 10. Document the number of auto injectors administered on the patient care report, on the triage tag or attached the used injector(s) to the patient. Page 70 of 83

71 PROCEDURE E 12 LEAD ECG Indications 1. Chest pain / discomfort (signs / symptoms suggestive of MI), any suspected cardiac event. 2. Cardiac dysrhythmias. 3. Patient presents with cardiac signs / symptoms including but not limited to: HR greater than 150. HR less than 50. Epigastric pain, unless there is other evidence indicating a GI bleed. Thoracic back pain without trauma. Diaphoresis not explained by fever or other environmental factors. Shortness of breath or dyspnea with clear lung sounds. Syncope without seizure or obvious blood loss. PVCs unchanged by oxygen and/or PVCs greater than 6 / minute. CHF / Pulmonary edema. Tricyclic overdose. All overdoses with abnormal rhythms. 4. Patients with the following chief complaints should be treated as suspected AMI: Contraindications Chest pain or pressure in a patient > 25 years old. Syncopal episode in any patient > 25 years old. Unexplained respiratory distress. Atypical upper body pain (shoulder, arm or jaw pain) in the absence of chest pain, especially with past medical history of cardiac problems, irregular pulse, diabetes, or female and elderly patients. Consider in young adult patients with a history of cocaine or methamphetamine use. 1. Treat all life-threatening conditions (A B Cs, Dysrhythmias) prior to obtaining 12- Lead. 2. Do NOT allow 12-Lead to delay transport of a critically ill patient. Page 71 of 83

72 Patient Preparation 1. Protect patient modesty. 2. Area where leads applied should be clear of items that may cause artifact (clothing, jewelry, etc.). 3. Skin should be clean and dry. 4. Shave chest hair as needed. 12 Lead ECG Placement Limb Leads: RA right arm, upper arm or upper chest near the shoulder LA left arm, upper arm or upper chest near the shoulder RL right leg or lower abdominal quadrant near the hip LL left leg or lower abdominal quadrant near the hip Chest Leads: V1 4 th intercostal space, right sternal border V2 4 th intercostal space, left sternal border V4 5 th intercostal space, left mid-clavicular line V3 placed between V2 and V4 V5 5 th intercostal space, anterior axillary line V6 5 th intercostal space, mid-axillary line Procedures 1. Acquire 12 Lead ECG when indicated per protocol. 2. Identify rhythm and treat THE PATIENT per protocol. 3. Transmit 12 Lead ECG to receiving hospital as soon as possible. 4. Transport Code 3 STEMI to receiving hospital (closest hospital with functioning Cath Lab capability). 5. Radio report to receiving hospital should include your interpretation, treatment, and notification that 12 Lead ECG has been transmitted. 6. If STEMI, inform receiving hospital that you are enroute with a STEMI Alert. Remember: A 12 Lead ECG is only a diagnostic tool. TREAT THE PATIENT, NOT THE MONITOR *An MI may present with a normal ECG, maintain a high index of suspicion, especially with diabetics, elderly, and female patients. Page 72 of 83