Combined Prehospital Care Treatment Protocols

Transcription

1 San Joaquin County EMS Agency SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES Combined Prehospital Care Treatment Protocols Version 1.0 Draft May 22, 2018 Draft Treatment Protocols May 22, 2018

2 San Joaquin County EMS Agency Table of Contents SJCEMSA TREATMENT PROTOCOLS USER GUIDE... 1 BLS TREATMENT PROTOCOLS INTRODUCTION... 2 ALS TREATMENT PROTOCOLS INTRODUCTION... 3 SECTION 1 GENERAL PATIENT CARE ROUTINE PATIENT CARE ADULT & PEDIATRIC PATIENT ASSESSMENT PRIMARY SURVEY PATIENT ASSESSMENT - SECONDARY SURVEY...10 SECTION 2 AIRWAY PROTOCOLS ADULT AIRWAY MANAGEMENT PEDIATRIC AIRWAY MANAGEMENT ADULT AIRWAY OBSTRUCTION PEDIATRIC AIRWAY OBSTRUCTION...20 SECTION 3 MEDICAL PROTOCOLS ALLERGIC REACTION/ANAPHYLAXIS - ADULT ALLERGIC REACTION/ANAPHYLAXIS - PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS ADULT ALTERED LEVEL OF CONSCIOUSNESS - PEDIATRIC BRONCHOSPASM/RESPIRATORY DISTRESS - ADULT BRONCHOSPASM/RESPIRATORY DISTRESS PEDIATRIC PULMONARY EDEMA GYNECOLOGICAL EMERGENCIES CHILDBIRTH NEONATAL RESUSCITATION ENVENOMATION/SNAKE BITES ADULT AND PEDIATRIC HYPERTHERMIA ADULT & PEDIATRIC HYPOTHERMIA ADULT & PEDIATRIC HYPOGLYCEMIA/HYPERGLYCEMIA ADULT HYPOGLYCEMIA/HYPERGLYCEMIA PEDIATRIC NAUSEA ADULT PAIN MANAGEMENT ADULT PAIN MANAGEMENT PEDIATRIC PEDIATRIC BRIEF, RESOLVED, UNEXPLAINED EVENT PEDIATRIC RESPIRATORY DISTRESS: STRIDOR POISONING/OVERDOSE ADULT...56 Draft Treatment Protocols May 22, 2018

3 San Joaquin County EMS Agency 3.22 POISONING/OVERDOSE PEDIATRIC NERVE AGENT EXPOSURE ADULT AND PEDIATRIC SEIZURES ADULT SEIZURES PEDIATRIC SHOCK NON TRAUMATIC ADULT SHOCK PEDIATRIC STROKE...71 SECTION 4 CARDIAC PROTOCOLS ADULT MEDICAL CARDIAC ARREST ASYSTOLE/PEA - ADULT ASYSTOLE/PEA - PEDIATRIC VENTRICULAR FIBRILLATION & PULSELESS V-TACH - ADULT VENTRICULAR FIBRILLATION & PULSELESS V-TACH - PEDIATRIC WIDE COMPLEX TACHYCARDIA WITH A PULSE - ADULT WIDE COMPLEX TACHYCARDIA WITH A PULSE PEDIATRIC NARROW COMPLEX TACHYCARDIA; A-FIB/A-FLUTTER SUPRAVENTRICULAR TACHYCARDIA (SVT) BRADYCARDIA - ADULT BRADYCARDIA - PEDIATRIC CARDIOGENIC SHOCK RETURN OF SPONTANEOUS CIRCULATION (ROSC) CHEST PAIN OF SUSPECTED CARDIAC ORIGIN LEFT VENTRICULAR ASSIST DEVICE (LVAD) FAILURE...97 SECTION 5 TRAUMA PROTOCOLS TRAUMA TREATMENT ADULT & PEDIATRIC BURNS ADULT AND PEDIATRIC SECTION 6 INTERFACILITY PROTOCOLS BLS INTERFACILITY TRANSPORTS MONITORING MECHANICAL VENTILATORS ALS MONITORING POTASSIUM CHLORIDE INFUSIONS - ALS MONITORING HEPARIN INFUSIONS - ALS MONITORING NITROGLYCERIN INFUSIONS - ALS SEDATION OF INTUBATED PATIENTS DURING ALS INTERFACILITY TRANSFER Draft Treatment Protocols May 22, 2018

4 SJCEMSA Treatment Protocols User Guide The San Joaquin County Emergency Medical Services Agency (SJCEMSA) Prehospital Treatment Protocols ALS BLS EMT Optional Scope Page 1 of 122

5 BLS Treatment Protocols Introduction I. The Basic Life Support (BLS) Treatment Protocols apply to all levels of certification and licensure and all prehospital personnel in San Joaquin County. The protocols contain language, instructions and treatments designed for holders of an Emergency Medical Technician (EMT) certificate. All prehospital personnel are required to operate within their respective scope of practice and must ensure that a specific procedure (e.g. AED or assisting patients with taking their own medications) is within their scope of practice II. III. IV. before proceeding. The BLS Treatment Protocols are not intended as a substitute for sound medical judgement. Initial patient presentations make it impossible to develop a protocol for every possible patient situation. All prehospital personnel are held to the following patient care standards: a. San Joaquin County Emergency Medical Services Agency (SJCEMSA) Policies and Procedures. b. American heart Association CPR, AED, and BLS airway obstruction and ventilation techniques. c. State of California EMT Course Curriculum and National Standard First Responder course Curriculum. d. OES Region IV Multi-casualty Incident Plan, Field Operations Manual 1. e. S.T.A.R.T. Triage. f. OSHA and CAL-OSHA standards for infection control. Pediatric considerations: a. SJCEMSA has not developed separate pediatric BLS treatment protocols except Neonatal Resuscitation. BLS treatment for pediatric and adult patients is the same under most conditions. However, several special considerations need to be addressed regarding pediatric patients: i. The defined age of a pediatric patient is 12 years of age and under; infants are defined as being less than 1 year of age; and neonates are defined as less than 1 months of age. ii. The Primary Survey and Secondary Survey is the same for all patients. However, the younger the patient the more EMS personnel will need to rely on family, care givers, teachers, bystanders, etc. for obtaining a patient s history. b. Establish level of consciousness using AVPU; alert, verbal, pain, unresponsive. c. Always carefully and thoroughly check a pediatric patient s airway. A majority of pediatric emergencies involve respiratory distress or airway difficulty. d. Always check the scene for evidence of poisons or chemicals in pediatric patients with an altered level of consciousness and obtain a thorough history from parents including the child s possible access to medications, including vitamins, and other chemicals. Page 2 of 122

6 ALS Treatment Protocols Introduction I. The Advanced Life Support (ALS) treatment Policies for adults and pediatrics approved by the Medical Director of the San Joaquin County emergency Medical Services Agency (SJCEMSA) directs the delivery of advanced life support (ALS) by licensed Paramedics accredited to practice within San Joaquin County. The ALS treatment Policies are the accredited paramedic s written orders authorizing the practice of ALS for specific patient conditions. All prehospital personnel are required to operate within their respective scope of practice. Accredited paramedics are expected to have a mastery of the ALS Treatment Policies, Basic Life Support (BLS) Treatment Policies and all other SJCEMSA Policies governing the delivery of emergency medical services in the field care setting. II. The ALS treatment Policies are to be used in concert with sound medical judgement. Unusual patient presentations make it impossible to develop a specific policy for every possible patient presentation. Paramedics should avail themselves of the opportunity to consult with a mobile intensive care nurse (MICN) or base hospital physician (BHP) when encountering unusual patient presentations or potential conflicts in treatment decisions. III. Base Hospital Physicians may order a deviation from any of the approved SJCEMSA treatment Policies, as long as they remain within the paramedic scope of practice. These types of orders may not be relayed by the MICN. Each order from the BHP that deviates from Policy must be documented on a Base Hospital Report Form, the prehospital patient care report, and be submitted to the SJCEMSA for review. IV. In those instances in which SJCEMSA Policy allows Paramedics to perform a procedure or provide medication only upon receipt of a Base Hospital Physician order, MICN s are allowed to relay orders from the BHP. The paramedic shall document the Physician s name on the patient care report. V. MICNs shall adhere to SJCEMSA Policies when offering advice, guidance, and direction to ALS and BLS field personnel. VI. In order to facilitate the best possible delivery of prehospital emergency medical care attending paramedics have the right to speak directly to a Base Hospital Physician during any call. VII. All prehospital personnel are held to the following patient care standards: A. San Joaquin County Emergency Medical Services Agency Policies and Procedures. B. American Heart Association CPR, AED, and BLS airway obstruction and ventilation techniques. C. State of California EMT-P Course Curriculum. D. OES Region IV Multi-Casualty Incident Plan, Field Operations Manual 1 and 2. E. S.T.A.R.T. Triage. F. OSHA and CAL-OSHA standards for infection control. Page 3 of 122

7 SECTION 1 GENERAL PATIENT CARE Page 4 of 122

8 SECTION 1 General Patient Care 1.0 Routine Patient Care Adult & Pediatric 1.0 Routine Patient Care Adult & Pediatric Definitions: A. Standard Precautions means the application of body substance isolation precautions including the use of appropriate personal protective equipment (PPE) shall apply to all patients receiving care, regardless of their diagnosis or presumed infectious status. Body substance isolation precautions apply to 1) blood; 2) all bodily fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; 3) non intact skin; and 4) mucous membranes. Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the prehospital setting. B. Adult Patient means a patient 13 years of age or older, or taller than a Broselow Tape (146.5 cm). C. Broselow Pediatric Emergency Tape means a pediatric length-based resuscitation tape used to determine drug doses, fluid volumes, defibrillation settings, and equipment sizes. The tape is designed to estimate a child s weight based on length (head to heel). The tape also includes information about abnormal vital signs. D. Pediatric Patient means a patient that is twelve (12) years of age or younger and is not taller than a Broselow Tape (146.5 cm), Note: If in doubt concerning whether to treat a patient as an adult or pediatric (i.e., obese child or smaller adult) contact the base hospital. E. Neonate/newborn means a Pediatric Patient from birth to one month of age. F. Infant means a Pediatric Patient from one month to one year of age. G. Child means a Pediatric Patient from one year to twelve years of age. I. Routine medical care is provided to all patients regardless of presenting complaint. II. Use standard precautions: A. Application of body substance isolation precautions including the use of appropriate personal protective equipment (PPE) shall apply to all patients receiving care, regardless of their diagnosis or presumed infectious status. B. Body substance isolation precautions apply to: 1. Blood; 2. All bodily fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood; 3. Non intact skin; 4. Mucous membranes. III. Perform a complete patient assessment including: A. Primary Survey. B. Secondary Survey. IV. Initiate specific treatments in accordance with San Joaquin County Emergency Medical Services Agency Treatment Protocols including, when appropriate: Page 5 of 122

9 SECTION 1 General Patient Care 1.0 Routine Patient Care Adult & Pediatric A. Monitor vital signs: 1. Initial set. 2. Repeat every 3-5 minutes for unstable patients 3. Repeat every 5-10 minutes for stable patients. B. Initiate spinal precautions. C. Administer oxygen. D. Control hemorrhage. ALS E. Monitor ECG. F. Administer IV access as indicated (may use saline lock when appropriate). G. Obtain blood glucose level, as indicated. H. Transport. Page 6 of 122

10 SECTION 1 General Patient Care 1.1 Patient Assessment - Primary Survey 1.1 Patient Assessment Primary Survey I. Scene Size Up: A. Recognize hazards, ensure safety of scene and secure a safe area for treatment. B. Apply universal body/substance isolation precautions. C. Recognize hazards to patient and protect patient from further injury. D. Identify the number of patients and initiate ICS/MCI operations if warranted: 1. Ensure an ALS ambulance response and order additional resources. 2. Consider initiating S.T.A.R.T. triage. E. Observe position of patient(s). F. Determine mechanism of injury. G. Plan strategy to protect evidence at potential crime scene. II. General Impressions: A. Check for life threatening conditions. B. Introduce self to patient. C. Determine chief complaint or mechanism of injury. III. Airway: A. Ensure open airway B. Protect spine from unnecessary movement in patients at risk for spinal injury. C. Ensuring an adequate airway supersedes spinal immobilization. D. Look and listen for evidence of upper airway problems and potential obstructions: 1. Vomit. 2. Bleeding. 3. Loose or missing teeth. 4. Dentures. 5. Facial Trauma. E. Utilize any appropriate adjuncts OPA/NPA as indicated to maintain airway. IV. Breathing: A. Look, listen, and feel in order to assess ventilation and oxygenation. B. Expose chest, if necessary, and observe for chest wall movement. C. Determine approximate rate and depth and assess character and quality. D. Reassess mental status. E. Intervene for inadequate ventilation with: 1. Pocket mask or BVM device. 2. Supplemental oxygen. F. Assess for other life threatening respiratory problems and treat as needed. V. Circulation: A. Check for pulse. B. Defibrillate as necessary. Page 7 of 122

11 SECTION 1 General Patient Care 1.1 Patient Assessment - Primary Survey C. Control life-threatening hemorrhage with direct pressure. D. Palpate radial pulse. 1. Determine absence or presence. 2. Assess general quality (strong/weak). 3. Identify rate (slow, normal, or fast). 4. Assess regularity (regular/irregular). E. Obtain baseline blood pressure. F. Assess skin for signs of hypo-perfusion/shock or hypoxia (capillary refill, cyanosis, etc.). G. Reassess mental status for signs of hypo-perfusion/shock. H. Treat hypoperfusion if appropriate. I. Obtain ECG and continually monitor cardiac rhythm as appropriate. VI. Level of consciousness: A. Determine need for spinal stabilization, Refer to EMS Policy No.5115, Cervical Spine Stabilization. B. Determine Glasgow Coma Scale (GCS) Score (see following page for GCS chart). VII. Expose, Examine & Evaluate: A. In situations with suspected life-threatening mechanism of injury, complete a Rapid Trauma Assessment. B. Expose head, trunk and extremities. C. Head to Toe for DCAP-BTLS 1. Deformity. 2. Contusion/Crepitus. 3. Abrasion. 4. Puncture. 5. Bruising/Bleeding. 6. Tenderness. 7. Laceration. 8. Swelling. Page 8 of 122

12 SECTION 1 General Patient Care 1.1 Patient Assessment - Primary Survey Adult Glasgow Coma Scale: Eye Opening Verbal Response Best Motor Response 4 = Spontaneous 5 = Oriented 6 = Obeys commands 3 = To verbal stimuli 4 = Confused 5 = Localizes stimuli 2 = To painful stimuli 3 = Inappropriate words 1 = No response 2 = Incomprehensible sounds 4 = Withdrawal from pain 3 = Abnormal Flexion 1 = No response 2 = Abnormal Extension 1 = No response VIII. Note: Always document and report GCS as a breakdown of scores (i.e. GCS = Eye 3, Verbal 3, Motor 4 for a total score of 10). Page 9 of 122

13 SECTION 2 Airway Protocols 1.2 Patient Assessment - Secondary Survey 1.2 Patient Assessment - Secondary Survey I. The secondary survey is the systematic assessment and complaint focused, relevant physical examination of the patient. The secondary survey may be done concurrently with the patient history and should be performed after the Primary Survey and the initiation of Routine Medical Care. The purpose of the secondary survey is to identify problems which, though not immediately life or limb threatening, could increase patient morbidity and mortality. Exposure of the patient for examination may be reduced or modified as indicated due to environmental factors. II. History: A. A patient s history should optimally be obtained from the patient directly. If language, culture, age, disability barriers or patient condition interferes with obtaining the history, consult with family members, significant others or scene bystanders. Check for advanced directives such as a DNR order, Medic-Alert bracelet and prescription bottles as appropriate. Be aware of the patient s environment and issues such as domestic violence, child or elder abuse or neglect and report concerns. The following information should be obtained during the history: 1. Allergies; 2. Medications; 3. Past medical history relevant to the chief complaint. 4. Have patient prioritize his or her chief complaint if complaining of multiple problems; 5. Ascertain recent medical history such as hospital admissions, surgeries, etc; 6. Mechanism of injury if appropriate; 7. In addition obtain history relevant to specific patient complaints. III. Head and Face: A. Observe and palpate skull (anterior and posterior) and face for DCAP-BTLS; B. Check eyes for equality, responsiveness of pupils, movement and size of pupils, foreign bodies, discoloration, contact lenses or prosthetic eyes; C. Check nose and ears for foreign bodies, fluid or blood; D. Recheck mouth for potential airway obstructions (swelling, dentures, bleeding, loose or avulsed teeth, vomit, absent or present gag reflex) and odors, altered voice or speech patterns and evidence of dehydration. IV. Neck: A. Observe and palpate for DCAP-BTLS, jugular vein distension, use of neck muscles for breathing, tracheal tugging, tracheal shift, stoma and medical information medallions. Page 10 of 122

14 SECTION 2 Airway Protocols 1.2 Patient Assessment - Secondary Survey V. Chest: A. Observe and palpate for DCAP-BTLS, scars, implanted devices such as pacemakers and indwelling IV/arterial catheters, medication patches, chest wall movement, asymmetry and accessory muscle use in breathing; B. Have patient take a deep breath if possible and observe and palpate for signs of discomfort, asymmetry and air leak from any wound. C. Assess lung sounds and heart tones as appropriate. VI. Abdomen: A. Observe and palpate for DCAP-BTLS, scars and distention; B. Palpation should occur in all four quadrants taking special note of tenderness, masses and rigidity. VII. Pelvis/Genital-Urinary: A. Generally, a patient s genital area should not be exposed and examined unless the assessment of this body region is required due to the patient s condition, such as trauma to the region, active labor or suspected/known bleeding. When possible have an EMT or paramedic of the same gender as the patient, perform evaluations of the pelvis/genital area. B. Observe and palpate for DCAP-BTLS, asymmetry, sacral edema and as indicated for other abnormalities; C. Palpate and gently compress lateral pelvic rims and symphysis pubis for tenderness, crepitus or instability; D. Palpate for bilateral femoral masses, if warranted. VIII. Shoulder and Upper Extremities: A. Observe and palpate for DCAP-BTLS, asymmetry, skin color, capillary refill, edema, medical information bracelet, and equality of distal pulses; B. Assess sensory and motor function as indicated. IX. Lower Extremities: A. Observe and palpate for DCAP-BTLS, asymmetry, skin color, capillary refill, edema and equality of distal pulses; B. Assess sensory and motor function as indicated. X. Back: A. Observe and palpate for DCAP-BTLS, asymmetry and sacral edema. XI. Precautions and Comments: A. Observation and palpation can be done while gathering a patient s history. B. A systematic approach will enable the rescuer to be rapid and thorough and not miss subtle findings that may become life threatening. C. Minimize scene times, especially with trauma patients and pediatrics, by packaging/preparing the patient for immediate transport upon ambulance or air ambulance arrival (spinal stabilization, pediatric immobilization device, ensuring rapid ingress/egress for BLS personnel and equipment). Page 11 of 122

15 SECTION 2 Airway Protocols 1.2 Patient Assessment - Secondary Survey D. The secondary survey should ONLY be interrupted if the patient experiences airway, breathing or circulation deterioration requiring immediate intervention. Complete the examination before threating the other identified non-life threatening problems. E. Reassessment of vital signs and other observations are necessary, particularly in critical or rapidly changing patients. Vital signs should be taken approximately every 5 minutes. Changes and trends observed in the field are essential data to be documented and communicated to the transport personnel or receiving facility. As stated in the Primary Survey DCAP-BTLS is a mnemonic that stands for: 1. Deformity; 2. Contusion/Crepitus; 3. Abrasion; 4. Puncture; 5. Bruising/Bleeding; 6. Tenderness; 7. Laceration; 8. Swelling. Page 12 of 122

16 SECTION 2 Airway Protocols SECTION 2 AIRWAY PROTOCOLS Page 13 of 122

17 SECTION 2 Airway Protocols 2.1 Adult Airway Management 2.1 Adult Airway Management Definitions: A. Oral Tracheal Intubation (OTI) Attempt means the introduction of an Endotracheal Tube Inducer (ETTI) or Endotracheal Tube past the patient s teeth. B. Difficult Airway means an airway that has been predicted to be difficult based on assessment of the patient or upon an attempt to visualize the cords and the patient has a Cormack-Lehane grade of three (3) of four (4). C. Successful OTI Attempt means a verified placement and securing of the endotracheal tube into the patient s trachea. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. ALS II. The approved airway management procedure for the unconscious adult patient consists of the following: providing BLS airway management skills; correctly assessing the need for an advanced airway; and successfully inserting either an endotracheal tube via oral tracheal intubation, or a I-Gel Airway. III. Paramedics placing advanced airways shall follow the procedures specified in EMS Policies No. 2545, 2552, and IV. Do not delay transport to establish an advanced airway in trauma patients except in the case of complete airway obstruction, as evidenced by a complete inability to ventilate the patient using an Oral Pharyngeal Airway (OPA) and BVM device. V. If unable to establish an airway due to complete airway obstruction not relieved using an OPA and BVM maneuvers, begin red lights and siren (RLS) transport to closest receiving hospital. During transport consider insertion of a I-Gel Airway, or a needle cricothyrotomy (EMS Policy No. 2549). VI. INDICATIONS FOR INTUBATION: A. Inability of the patient to protect their airway (coma, decreased level of consciousness with non-intact gag reflex). B. Inability to adequately ventilate or oxygenate the patient using an OPA and BVM device. C. Cardiac arrest. Adhere to sequence as specified in EMS Protocol No. 4.1 Adult Medical Cardiac Arrest. D. Failing respirations (irregular and shallow), respiratory arrest. VII. CONFIRMATION OF TUBE PLACEMENT: A. Paramedics shall ensure that all intubations are confirmed by end tidal CO2 device (colorimetric or capnography) and/or esophageal detection device (EDD) (EDD not used for I-Gel Airway). B. Paramedics shall immediately confirm tube placement by auscultating Page 14 of 122

18 SECTION 2 Airway Protocols 2.1 Adult Airway Management bilateral lung fields for breath sounds, observe for chest rise and fall with ventilations, and listen for air flow into the epigastric area after placement of an endotracheal tube or I-Gel Airway. C. Paramedics shall continually monitor capnography readings on all patients who have an endotracheal tube or I-Gel Airway in place. Monitoring shall commence with transport and shall continue through to patient transfer at the emergency department. D. Paramedics shall attach a copy of the capnography strip and document the readings on the patient care record. E. Paramedics shall reconfirm ET Tube placement prior to transferring patient care. F. Paramedics shall visualize the pharynx and vocal cords with the laryngoscope, if there is any doubt as to proper placement of the endotracheal tube. VIII. INDICATIONS FOR I-Gel AIRWAY A. Select I-Gel Airway directly upon assessing a Cormack-Lehane grade of 3 or 4,or; B. Select a I-Gel Airway directly in response to other physical or physiological impediments to the successful insertion of an endotracheal tube, or; C. Select a I-Gel Airway after two unsuccessful attempts to insert an endotracheal tube. IX. APPROVED ADVANCED AIRWAY PROCEDURE: A. Prepare equipment and position patient with the intent to provide an airway via either an Endotracheal Tube or via a I-Gel Airway B. Upon a determination that the patient has a Cormack-Lehane grade of one (1) or two (2), attempt to insert an endotracheal tube as described in EMS Policy No. 2545, Endotracheal Intubation Adult. 1. If SPO2 is less than 96% prior to attempt, ventilate patient using BVM to increase SPO2 above 96%. 2. After two (2) unsuccessful attempt at endotracheal intubation, insert a I- Gel Airway as described in EMS Policy No. 2552, I-Gel Airway. 3. An endotracheal tube introducer (ETTI) shall be used on all attempts. 4. Each attempt should last no longer than thirty (30) seconds. If during any attempt patient desaturates below 90%, immediately cease and ventilate to increase saturation. 5. Ventilate with 100% oxygen for one (1) minute prior to attempting to intubate, unless transitioning to an advanced airway per EMS Policy No. 5710, ALS Medical Cardiac Arrest. 6. Monitor pulse oximetry continuously. C. Upon a determination the patient has a Cormack-Lehan grade of three (3) or four (4), continue providing BLS resuscitation, and provide a I-Gel Airway as described in EMS Policy No I-Gel Airway. 1. A patient with a Cormack-Lehane grade of three (3) or four (4) (epiglottis is not or is barely visible) will be considered to have a difficult airway. Page 15 of 122

19 SECTION 2 Airway Protocols 2.1 Adult Airway Management The I-Gel Airway shall be utilized on the first attempts for difficult airways in adult patients. Cormack and Lehan Classification (Grades) of Difficult Laryngoscopy Grade I Most of glottis is seen Grade II Only posterior portion of glottis can be seen Grade III Only epiglottis may be seen (none of glottis seen) Grade IV Neither epiglottis nor glottis can be seen D. Only I-Gel Airway sizes three (3), four (4), and five (5) are authorized for use. E. The I-Gel Airway is not authorized for use in adults < 4 feet tall. Authorized I-Gel Airway Sizes Size Height in Feet Color Feet Yellow Feet Red 5 > 6 Feet Purple F. Use a laryngoscope to facilitate placement. G. Do not exceed manufacture s recommended pressures. H. Remove and replace the I-Gel Airway if resistance is met upon initial insertion. I. After two (2) unsuccessful attempts, place a BLS an airway and transport code 3 to the closest receiving hospital. J. If patient is entrapped preventing OTI procedure paramedic may proceed directly to I-Gel Airway Page 16 of 122

20 SECTION 2 Airway Protocols 2.2 Pediatric Airway Management 2.2 Pediatric Airway Management I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. The approved airway management procedure for the unconscious pediatric patient consists of the following the simplest method of BLS interventions to maintain oxygen saturation >94%. A. If gag present and BVM alone insufficient, place NPA B. If gag is not present and BVM insufficient, place OPA C. If unable to ventilate with BVM and airway adjunct, may place additional (i.e. both NPA and OPA). ALS D. If airway obstruction is suspected, may use Mac/Miller to visualize airway to remove FB with Magill forceps. E. If no airway obstruction, continue ventilation using simplest method of BLS interventions to maintain oxygen saturation >94%. F. If unable to ventilate using BLS interventions and no obstruction: 1. Child fits on a Broselow tape a) Place I-Gel (supraglottic airway) and ventilate at rate of 1 ventilation every 3 seconds. b) Monitor capnography 2. Child is larger than Broselow tape: a) If Cormack-Lehane grade of one (1) or two (2), attempt to insert an endotracheal tube. (1) If SPO2 is less than 96% prior to attempt, ventilate patient using BVM to increase SPO2 above 96%. (2) After two (2) unsuccessful attempt at endotracheal intubation, insert i-gel. (3) An endotracheal tube introducer (ETTI) shall be used on all attempts. (4) Each attempt should last no longer than thirty (30) seconds. If during any attempt patient desaturates below 90%, immediately cease and ventilate to increase saturation. (5) Ventilate with 100% oxygen for one (1) minute prior to attempting to intubate. (6) Monitor pulse oximetry continuously. b) If Cormack-Lehan grade of three (3) or four (4), continue providing BLS resuscitation, and provide a i-gel Airway. (1) A patient with a Cormack-Lehane grade of three (3) or four (4) (epiglottis is not or is barely visible) will be considered to Page 17 of 122

21 SECTION 2 Airway Protocols 2.2 Pediatric Airway Management have a difficult airway. The I-Gel shall be utilized on the first attempts for difficult airways in adult patients. Cormack and Lehan Classification (Grades) of Difficult Laryngoscopy Grade I Most of glottis is seen Grade II Only posterior portion of glottis can be seen Grade III Only epiglottis may be seen (none of glottis seen) Grade IV Neither epiglottis nor glottis can be seen G. Monitor capnography. Page 18 of 122

22 SECTION 2 Airway Protocols 2.3 Adult Airway Obstruction 2.3 Adult Airway Obstruction Definitions: A. Severe obstruction means signs of severe obstruction include poor air exchange, increased breathing difficulty, silent cough, cyanosis, and/or inability to speak or breathe. I. Perform routine ALS/BLS medical care as directed in Protocol 1.0. II. Treatment A. If no signs of severe obstruction present, maintain airway and apply oxygen. B. If patient has signs of severe obstruction and/or is unconscious: 1. Initiate abdominal and chest thrusts. ALS 2. If conscious and foreign body can be seen when patient opens mouth use Magill forceps to remove foreign body. 3. If unconscious use direct laryngoscopy and Magill forceps to remove foreign body. 4. Assist ventilations with BVM. 5. If unsuccessful, attempt endotracheal intubation. 6. If unsuccessful and unable to ventilate adequately with BVM, Perform needle Cricothyrotomy. Refer to EMS Policy No Needle Cricothyrotomy. 7. Initiate transport and make early receiving hospital notification for unresolved obstruction. Page 19 of 122

23 SECTION 3 Medical Protocols 2.4 Pediatric Airway Obstruction I. Perform routine ALS/BLS medical care as directed in Protocol 1.0. II. Treatment A. Attempt to clear the airway using BLS maneuvers. 1. For infants administer back blows and chest thrusts. 2. For children > 1 year of age, administer abdominal thrusts. ALS B. If unable to clear foreign body and patient unconscious visualize the larynx and remove the foreign body with Magill forceps. 1. Assist ventilation with BVM and 100% oxygen. C. If unsuccessful, and patient fits on a Broselow assist ventilation with BVM and 100% oxygen. D. If Unsuccessful, and taller than a Broselow tape attempt to insert an endotracheal tube. E. If patient has a complete airway obstruction (unable to ventilate) and you are unable to clear foreign body using BLS maneuvers and direct visualization, transport to the closet facility. F. Initiate abdominal and chest thrusts. Page 20 of 122

24 SECTION 3 Medical Protocols SECTION 3 MEDICAL PROTOCOLS Page 21 of 122

25 SECTION 3 Medical Protocols 3.1 Allergic Reaction/Anaphylaxis - Adult 3.1 Allergic Reaction/Anaphylaxis - Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information Needed: History of exposure to allergen, bee/wasp stings, drugs or medication, nuts, seafood, new food consumed (especially infants), prior allergic reactions. III. Objective findings: A. Mild: Hives, rash, itching, anxiety. B. Moderate: Hives, rash, bronchospasm, wheezing nausea. C. Severe: Respiratory distress, chest tightness, difficulty swallowing, altered mental status, signs of shock. IV. Treatment Mild Reaction: A. Remove allergen if possible 1. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. ALS B. Mild Reaction (urticaria only): 1. Administer diphenhydramine 50mg PO V. Treatment Moderate to severe reaction (urticaria with one or more of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps, nausea, vomiting). BLS 1. Assist patient with taking their own prescribed anaphylaxis medications (e.g. Epi-Pen, rescue inhaler, bee sting kit). 2. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. 3. Secondary survey and routine medical care. 4. Treat for shock as appropriate. EMT Optional Scope 5. ** EMT Optional Skill: Administer epinephrine auto-injector: a) Adult dose (greater than 33 kg/66 lbs) Epi-Pen auto injector 0.3 mg. Page 22 of 122

26 SECTION 3 Medical Protocols 3.1 Allergic Reaction/Anaphylaxis - Adult b) Pediatric dose (less than 33 kg/66 lbs) Epi-Pen Jr auto injector 0.15 mg. ALS 6. Epinephrine 1: mg IM in lateral thigh. 7. If wheezing, initiate hand held nebulizer dose of Albuterol 5 mg in normal saline (NS) 6 ml. May repeat as needed. 8. Consider IV NS TKO or saline lock. B. Administer diphenhydramine 50mg IM/IV/IO. C. Anaphylactic shock 1. Oxygen liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct 2. Administer epinephrine 1: mg IM in lateral thigh. 3. Establish large bore IV/IO NS and administer 500 ml fluid boluses for goal of systolic BP > 90 mmhg. 4. If wheezing, initiate hand held nebulizer dose of Albuterol 5 mg in normal saline (NS) 6 ml. May repeat as needed. 5. Administer Diphenhydramine 50mg IV/IO. 6. Consider CPAP if wheezing continues. 7. If patient is unresponsive but still has a palpable pulses initiate epinephrine drip infusion 5µg/min IV/IO. Epinephrine Drip Chart for Adults For a Concentration of 4µg of Epinephrine per milliliter of solution Add 1mg of 1:000 to 250ml NS Dosage = µg/minute 1µg 2µg 3µg 4µg 5µg 6µg 7µg 8µg 9µg 10µg Drops/Min *Based on 60gtts/1ml drip set ** Procedure may only be performed by a San Joaquin County Emergency Medical Services Agency optional skill EMT working on duty with an approved optional skill BLS provider. Page 23 of 122

27 SECTION 3 Medical Protocols 3.2 Allergic Reaction/Anaphylaxis - Pediatric 3.2 Allergic Reaction/Anaphylaxis - Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Treatment: A. Remove allergen if possible. ALS B. Mild reaction (urticaria only): 1. Consider diphenhydramine 1 mg/kg IM/IV (maximum dose of 50 mg). C. Moderate to severe reaction (Urticaria with one or more of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps). 1. Epinephrine 1:1,000, 0.01mg/kg IM (maximum dose 0.3mg). DOSE SHOULD BE GIVEN IN LATERAL THIGH 2. Administer diphenhydramine 1 mg/kg IM/IV (maximum dose of 50 mg). 3. If wheezing, initiate hand-held nebulizer dose of Albuterol 2.5mg in 3 ml NS. May repeat as needed. 4. If stridor present, nebulize 0.5mL of 2% Racemic Epinephrine in 4mL of NS 5. Initiate transport. 6. Establish IV normal saline TKO or saline lock. D. Anaphylaxis (Urticaria and signs of shock with any or all of the following: swelling of mucous membranes, dyspnea, wheezing, chest or throat tightness, abdominal cramps). 1. Epinephrine 1:1,000, 0.01mg/kg IM (maximum dose 0.3mg). DOSE SHOULD BE GIVEN IN LATERAL THIGH. 2. Establish IV/IO access and administer normal saline fluid bolus of 20 ml/kg. May repeat 10mL/kg twice as indicated. 3. Administer diphenhydramine 1 mg/kg IM/IV/IO (maximum dose of 50 mg). 4. If wheezing, administer Albuterol 2.5mg in 3 ml normal saline. May repeat as needed. 5. If stridor present, nebulize 0.5mL of 2% Racemic Epinephrine in 4mL of NS. 6. If patient is unresponsive with no palpable pulses, administer epinephrine (1:10,000) 0.01mg/kg to max dose of 0.5mg IVP/IO and diphenhydramine 1mg/kg to maximum dose of 50mg IM or IVP/IO. 7. Manage airway as needed per EMS Protocol No. 2.2 Pediatric Airway Management. 8. Initiate transport to closest facility. 9. Consult Base Hospital Physician for further orders. Page 24 of 122

28 SECTION 3 Medical Protocols 3.3 Altered Level of Consciousness - Adult 3.3 Altered Level of Consciousness Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information Needed: A. Surroundings: syringes, blood glucose monitoring supplies, insulin. B. Changes in mental status: Baseline status, onset and progression of altered state, symptoms prior to altered state such as headache, seizures, confusion, and trauma. C. Medical History: Diabetes, epilepsy, substance abuse, mental health, medications, allergies. D. Identify and document neurological deficits and consider possible stroke, overdose / intoxication. III. Considerations: A. Potential treatable causes (hypoglycemia, stroke, neurological injury, syncope, overdose, and sepsis) and refer to appropriate protocol. B. Consider indications for spinal stabilization precautions per EMS Policy No. 5115, Spinal Motion Restriction. IV. Objective Findings: A. Level of consciousness (AVPU) and neurological assessment. B. Signs of trauma. C. Breath odor. D. Pupil size and reactivity. E. Needle tracks. F. Medical information tags, bracelets, or medallions. V. Treatment: A. Reassure patient and place in position of comfort or supine if hypotensive. B. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. C. Suction as needed. D. Check blood glucose level. E. If patient s blood glucose is less than 70mg/dl administer or if unable to determine blood glucose level and patient has signs and symptoms of hypoglycemia administer 1 tube of oral glucose paste slowly. F. Suspected opioid overdose and respiratory rate less than 12 per min: G. Remove any transdermal opioid patches. Page 25 of 122

29 SECTION 3 Medical Protocols 3.3 Altered Level of Consciousness - Adult EMT Optional Scope H. ** Optional Skill EMT: Administer naloxone intranasal with mucosal atomizer device: I. Adult dose (weighing greater than 20 kg / 44 lbs) 2 mg intranasal. May repeat once in 2-3 minutes for a maximum dose of 4 mg. J. Pediatric dose: 0.1 mg/kg intranasal. ALS K. Establish IV/IO of normal saline (NS) L. Perform ECG M. Perform 12 Lead ECG. If STEMI see Protocol No. 4.14, Chest Pain of Suspected Cardiac Origin. N. Check blood glucose. If abnormal see Protocol No. 3.14, Hypoglycemia/Hyperglycemia Adult. O. Establish IV/IO Ns TKO Page 26 of 122

30 SECTION 3 Medical Protocols 3.4 Altered Level of Consciousness - Pediatric 3.4 Altered Level of Consciousness - Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Treatment: A. Initiate appropriate airway management. ALS B. Place on monitor, obtain HR, BP, pulse oximetry and cap refill C. Establish IV/IO of normal saline. D. Evaluate blood glucose level. If blood glucose level is less than 60 mg/dl, see Protocol No. 3.15, Hypo/Hyperglycemia - Pediatric. E. If mental status and respiratory effort are depressed, see Protocol No. 3.21, Poisonings and Overdose. F. For Hypotension, give 20mL/kg IV bolus followed by additional bolus 10ml/kg x 2 as needed for persistent hypotension. Pediatric Glasgow Coma Scale <1 year 1 4 years >4 years EYE Opening 4 Open Open Open 3 To voice To voice To voice 2 To pain To pain To pain 1 No response No response No response Verbal response 5 Coos & babbles Oriented, speaks, interacts Alert & oriented socially 4 Irritable cry Confused speech, Disoriented disoriented, consolable 3 Cries to pain Inappropriate words, Inappropriate words inconsolable 2 Moans to pain Incomprehensible agitated Incomprehensible sounds 1 No response No response No response Best Motor Response 6 Normal, spontaneous Obeys commands Obeys commands movement 5 Withdraws to touch Localizes stimuli Localizes stimuli 4 Withdraws from pain Withdraws from pain Withdraws from pain 3 Abnormal flexion Abnormal flexion Abnormal flexion 2 Abnormal Extension Abnormal Extension Abnormal extension 1 No response No response No response Note: Always document and report GCS as a breakdown of scores (i.e. GCS = Eye 3, Verbal 3, Motor 4 for a total score of 10). Page 27 of 122

31 SECTION 3 Medical Protocols 3.5 Bronchospasm/Respiratory Distress - Adult 3.5 Bronchospasm/Respiratory Distress - Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. A. Information Needed: Patient History: Fever, sputum production, asthma, COPD, exposures (allergen, toxins, fire/smoke), trauma (blunt/penetrating). B. Symptoms: Chest pain, shortness of breath, cough, inability to speak in full sentences. II. Objective findings: A. Respiratory rate <10 or > 30 per minute, rhythm (abnormal pattern, shallow), effort (labored); B. Lung sounds (wheezing, stridor), cough, fever, spitting/coughing up blood or pink froth, barking; C. Rash, urticaria; D. Heart rate, blood pressure, skin signs, mental status, anxiety and restlessness; E. Evidence of trauma. III. Treatment: A. Reassure patient and place in position of comfort or supine if hypotensive. B. ABCs C. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. D. Suction as needed. E. Assist patient in using their own prescribed respiratory inhaler medications (EMT only). F. Routine medical care. 1. Upper airway obstruction: Relieve obstruction by positioning, suction, abdominal thrusts; infants use back blows and chest thrusts instead of abdominal thrusts. 2. Chest would: Cover open chest wound with occlusive dressing taped on three sides. ALS G. Mild to moderate bronchospasm: 1. Initiate an nebulizer treatment with Albuterol 2.5mg in 3 ml normal saline (NS) and Atrovent 0.5 mg in 2.5 ml NS. 2. Repeat Albuterol as needed. H. Severe bronchospasm: 1. Administer magnesium sulfate 2 grams IV/IO drip over 5-10 minutes. 2. Assist ventilations with 100% oxygen and initiate an inline nebulizer Page 28 of 122

32 SECTION 3 Medical Protocols 3.5 Bronchospasm/Respiratory Distress - Adult treatment with Albuterol 2.5mg in 3 ml normal saline (NS) and Atrovent 0.5 mg in 2.5 ml NS. 3. Continue Albuterol 2.5 mg nebulizer/bag-valve-mask (BVM). 4. Epinephrine 0.3mg IM. 5. Consider CPAP. 6. Ensure early receiving hospital notification. Note: Breath actuated nebulizer should only be utilized with patients who have adequate spontaneous respirations. Patients that require ventilator support should have nebulized medications administered via standard nebulizer equipment. Page 29 of 122

33 SECTION 3 Medical Protocols 3.6 Bronchospasm/Respiratory Distress - Pediatric 3.6 Bronchospasm/Respiratory Distress Pediatric Definitions: A. Mild Respiratory Distress means mild wheezing, shortness of breath and/or cough, and ability to speak full sentences. B. Moderate Respiratory Distress means spontaneous breathing and adequate tidal volume with significant wheezing/sob accompanied by any of the following signs: accessory muscle use, nasal flaring, grunting, and/or inability to speak full sentences. C. Severe Respiratory Distress means ineffective ventilations and/or inadequate tidal volume, which may be accompanied by any of the following signs: accessory muscle use, cyanosis, inability to speak, gasping respirations, and/or decreased level of consciousness. I. Perform routine ALS/BLS medical care as directed in Protocol 1.0. II. Treatment A. Place patient in position of comfort. B. Administer oxygen, allow parent to administer if appropriate. ALS C. Treat according to severity: 1. Mild Distress: a) Monitor heart rate, respiratory rate, and pulse oximetry. b) Administer Albuterol 2.5mg in 3 ml NS via nebulizer. May repeat as needed 2. Moderate Distress: a) Monitor heart rate, respiratory rate, and pulse oximetry. b) Administer Albuterol 2.5mg in 3 ml NS by nebulizer with Atrovent 0.5mg in 2.5 ml NS (1) Add Atrovent 0.5mg if history of asthma and age >2 years old. Use only one dose. All additional doses should be albuterol only. c) May repeat Albuterol as needed (do not give more than 20mg/hr) d) If significant wheeze or shortness of breath continues after 10mg of albuterol, may give Magnesium 25 mg/kg IV/IO(max dose 2g) over 10 minutes. 3. Severe Distress: a) Administer Albuterol 2.5mg in 3 ml NS and Atrovent 0.5mg in 2.5 ml NS by nebulizer/bvm/ett. May repeat Albuterol as indicated (not to exceed 20mg per hour). b) If significant wheeze or shortness of breath continues after 10mg of albuterol, may give Magnesium 50mg/kg IV(max dose 2g) over 10 minutes. c) Assist ventilations with BVM and 100% oxygen with inline neb if Page 30 of 122

34 SECTION 3 Medical Protocols 3.6 Bronchospasm/Respiratory Distress - Pediatric needed. If unable to adequately oxygenate and ventilate patient, follow EMS Protocol No. 2.2, Pediatric Airway Management. Consider epinephrine 0.01 mg/kg SQ (Maximum dose is 0.5mg). Page 31 of 122

35 SECTION 3 Medical Protocols 3.7 Pulmonary Edema 3.7 Pulmonary Edema Definitions A. Acute pulmonary Edema means an acute onset of respiratory difficulty with systolic blood pressure over 120 mmhg. May have a history of cardiac disease, rales or occasional wheezes. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Treatment: A. Oxygen liters per minute via non-rebreather mask. ALS B. Initiate IV/IO access. C. Perform 12 Lead EKG. D. Nitroglycerine 0.4mg spray of tablets, repeat every 5 minutes if systolic blood pressure remains > 100mmHg. E. If patient is in severe respiratory distress, consider CPAP. Refer to EMS Policy No. 2554, Continuous Positive Airway Pressure. Page 32 of 122

36 SECTION 3 Medical Protocols 3.8 Gynecological Emergencies 3.8 Gynecological Emergencies Definitions B. Severe Pre-eclampsia means a third trimester pregnancy with hypertension (systolic blood pressure greater than 160 mmhg, diastolic great than 110 mmhg), mental status changes, visual disturbances and/or peripheral edema. C. Eclampsia means third trimester pregnancy with hypertension (systolic blood pressure greater than 160 mmhg, diastolic great than 110 mmhg) mental status changes, visual disturbances, peripheral edema seizures and/or coma. D. High risk obstetrical means a pregnancy is one in which some condition puts the mother, the developing fetus, or both at higher-than-normal risk for complications during or after the pregnancy and birth. III. Perform routine ALS/BLS medical care is directed in Protocol 1.0. IV. Information needed: A. Last menstrual period and possibility of pregnancy B. Duration and amount of any bleeding C. If pregnant weeks of pregnancy, estimated due date, any anticipated problems (e.g. pre-eclampsia, lack of prenatal care, expected multiple births) D. Presence of contractions, cramps, or discomfort E. Pertinent past medical history V. Objective findings: A. Estimated blood loss B. Low blood pressure or high blood pressure C. Spontaneous abortion passage of products of conception, fetus <20 weeks gestation D. Headaches, blurred vision E. Severe abdominal cramps or sharp abdominal pain BLS VI. Treatment: A. Place patient in Trendelenburg position. If pregnant place in left lateral recumbent position. B. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. C. Do not visualize genital region except for known or suspected active bleeding, severe trauma to region or active labor. D. For active bleeding, place bulky dressing externally to absorb blood flow. Page 33 of 122

37 SECTION 3 Medical Protocols 3.8 Gynecological Emergencies ALS E. Without shock: 1. Non-pregnant patient: a) Establish IV of normal saline (NS) TKO. b) If post-partum and placenta has delivered, perform fundal massage and put infant to breast (as appropriate). 2. Pregnant patient: a) Place patient in left lateral position. b) If any bleeding in third trimester, establish two (2) large bore IVs of NS TKO. c) Consult base hospital F. With Shock: 1. Non-pregnant patient: a) Establish a large bore IV of NS. Administer a fluid challenge of NS 10ml/kg. Recheck vital signs after each infusion of NS 250 ml. b) Consider second large bore IV of NS. c) If post-partum and placenta has delivered, perform fundal massage and put infant to breast (as appropriate). 2. Pregnant patient: a) Position in left lateral position if concern for spinal injury is not present. If concern is present, keep in spinal precaution and manually attempt movement of uterus towards the left side with gentle traction. b) Establish a large bore IV of NS. Administer a fluid challenge of NS 10ml/kg. Recheck vital signs after each infusion of NS 250 ml. c) Consider second IV of NS. G. Pre-eclampsia / Eclampsia: 1. Position patient on left side. Transport quickly in a quiet environment (No siren). 2. Establish IV of NS TKO, while enroute to hospital. 3. Treat seizures according to EMS Protocol No. 3.24, Seizures Adult. 4. Consult base hospital physician to obtain order for magnesium sulfate 2 grams slow IV/IO of 3-5 minutes. H. High Risk Obstetrical: I. High risk obstetrical patients are patients that are pregnant who have signs and symptoms of active labor or vaginal bleeding with one or both of the following condition: 1. No history of prenatal care. 2. Estimated gestational age from weeks. Note: 1. Do not pack vagina with any material, use external dressings only. 2. When possible have a care giver of same gender as the patient perform evaluations of the pelvis/genital area. Page 34 of 122

38 SECTION 3 Medical Protocols 3.9 Childbirth 3.9 Childbirth Definitions A. Imminent delivery means regular contractions, bloody show, low back pain, feels like bearing down, crowning. B. Breech presentation means presentation of buttocks or both feet. C. Limb presentation means presentation of a single extremity. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Estimated due date, weeks of pregnancy, any anticipated problems (e.g. preeclampsia, lack of prenatal care, expected multiple births). B. Onset of regular contractions, current frequency of contractions, rupture of membranes. C. Urge to bear down, number of previous pregnancies and live births. III. Objective findings: A. Observe perineal area for fluid, bleeding, crowning during contraction, and abnormal presentation (e.g. breech, extremity, cord) IV. Treatment: A. ABCs B. Open OB Kit. C. Oxygen 6 liters per minute via nasal cannula or liters per minute via non-rebreather mask for respiratory distress. ALS D. IV Normal Saline TKO. E. If birth not imminent place patient in left lateral recumbent position during transport. F. Normal Delivery: 1. Assist mother with delivery, clean, preferably sterile technique. 2. Control and guide delivery of neonate s head and body. 3. Check for cord around neck, gently slide over head if possible, if tight clamp and cut to unwind and deliver neonate as quickly as possible. 4. Suction neonate s mouth then nose with bulb syringe. 5. Clamp and cut umbilical cord. 6. Dry and wrap neonate for warmth, especially the head; if possible allow infant to breast feed or place on mother s chest. 7. Note time of delivery and assess respirations, pulse rate and strength of Page 35 of 122

39 SECTION 3 Medical Protocols 3.9 Childbirth ALS crying. 8. Perform neonatal resuscitation if needed. 9. Evaluate mother post-delivery for evidence of shock due to excessive bleeding. 10. Deliver placenta, and place in biohazard bag; transport to hospital. 11. Perform fundal massage to help stop post-partum bleeding. G. Complicated Delivery: 1. Apply high flow oxygen 2. Establish IV of NS TKO. 3. Rapid transport to a neonate/high risk pregnancy receiving hospital and early base hospital contact. 4. Prepare for neonatal resuscitation. 5. Breech Delivery: a) Assist with and continue delivery if possible. b) Provide airway for neonate with gloved hand if unable to continue delivery. c) If unable to deliver, place mother in shock position. d) Rapid transport. 6. Prolapsed Cord: a) Place mother in Trendelenburg position, elevate hips with pillows, if possible place mother in knee position. b) If cord is present, assess cord for palpable pulse. c) If strong regular pulse is absent, gently insert gloved hand into vagina to relieve pressure on cord. d) Cover exposed cord with saline soaked gauze dressing. e) Rapid transport. 7. High Risk Delivery: any newborn who meets one of more of the following conditions shall be transported to a designated neonatal intensive care center in accordance with EMS Policy No. 5201, Medical Patient Destination. a) Significant anoxia either prior to or during transport. b) Estimated gestational age <33 weeks. 8. Neonatal patients who are in cardiac arrest/respiratory arrest should be treated in accordance with EMS Policy No. 5201, Medical Patient Destination and be transported to the closest receiving hospital. Notes: 1. First priority in childbirth is assisting mother with delivery of child. 2. The primary enemy of the newborn is hypothermia which can occur in minutes. 3. Ensure newborn is warm and dry. 4. Ensure newborn has a clear airway, suction with bulb syringe as needed. 5. Keep baby at or below the level of the mother s heart until cord is clamped. 6. Do not pull on the umbilical cord. Page 36 of 122

40 SECTION 3 Medical Protocols 3.10 Neonatal Resuscitation 3.10 Neonatal Resuscitation Definitions: A. Neonate means an infant that is less than 24 hours old. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Initiate resuscitation on all premature infants who weigh 1 pound and are reported to be over 20 weeks gestation. III. Objective Findings A. Patients less than 24 hours of age B. Number of weeks gestation C. Pertinent history prior to birth of neonate (multiple births, preterm, medical treatment, drug use, presence of meconium. D. Heart rate. IV. Treatment: A. Position airway and suction mouth and nose with bulb syringe. B. Warm/Dry neonate and keep warm with thermal blankets or dry towel. C. Stimulate neonate by drying vigorously including head and back. D. Assess/evaluate breathing and heart rate (APGAR). 1. Mild distress - Administer blow by oxygen. 2. Respiratory depression, failure, or gasping respirations Assist ventilations with 100% oxygen at a rate of breaths/min. E. Check heart rate at cord. F. Ensure transport ambulance enroute. G. Clamp and cut cord. ALS H. If narcotic induced respiratory depression is suspected administer Naloxone 0.1mg/kg via IV/IO/IM. Heart Rate <60 beats per minute: A. Assist ventilations with 100% oxygen via neonatal BVM at breaths per minute. B. Start CPR 120 compressions per minute. C. Reassess heart rate and respirations every seconds. Page 37 of 122

41 SECTION 3 Medical Protocols 3.10 Neonatal Resuscitation ALS D. If no improvement in 1 minute, establish vascular access and administer epinephrine 0.01 mg/kg (1:10,000) IV/IO. E. If no improvement in 30 seconds, perform endotracheal intubation. F. Reassess heart rate and respiratory rate while en route to the hospital. If heart rate is above 80/minute, stop chest compressions and continue assisting ventilations. Heart Rate beats per minute: A. Continue to assist ventilations with 100% oxygen. B. If no improvement after 30 seconds of assisted ventilations, begin chest compressions. C. Reassess heart rate and respiratory rate while en route to the hospital. If heart rate is above 80/minute, stop chest compressions and continue assisting ventilations. Heart Rate beats per minute and rising: A. Oxygen 100% via mask or blow by B. Stimulate and reassess heart rate and respirations after seconds. C. If heart rate is less than 100/minute, begin assisted ventilations with 100% oxygen. D. Reassess if heart rate <100 after 30 seconds of oxygen and stimulation, begin assisted ventilation with 100% oxygen via neonatal BVM at breaths per minute. E. Reassess heart rate and respirations every seconds. Heart Rate >100 beats per minute: A. Assess skin color. If peripheral cyanosis (blue skin) is present administer 100% oxygen via blow by. B. Reassess heart rate and respiratory rate every seconds and while enroute to the hospital. Page 38 of 122

42 SECTION 3 Medical Protocols 3.11 Envenomation/Snake Bite 3.11 Envenomation/Snake Bites Adult and Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Type of animal, insect or snake or snake s appearance (shape of pupil, color, stripes or rattles). B. Time of exposure, sting or bite and type of bite (fang punctures or row of teeth marks). C. History of previous exposures, allergic reactions, known specific allergen. D. Prior first aid by patient or by-standers. III. Objective findings: A. Local reaction: rash, hives; localized redness and swelling; skin at wound area hot to touch; decreased pain or sense of touch. B. Systemic reaction: any or all localized findings; respiratory distress; wheezing, stridor; diaphoresis; decreased blood pressure; tachycardia; rapid respirations. C. Mild or non-envenomation: No discoloration around puncture marks; minor pain or no pain after a few minutes. D. Serious envenomation: Dark discoloration around punctures; swelling at and around puncture site; severe pain; altered mental status; abnormal motor movements; low blood pressure; tachycardia; metallic taste; active bleeding from site, possible blistering. IV. Treatment: A. Ensure personal safety ensure transport ambulance response. B. ABCs. Animal Bite: A. Dress wounds with gauze as needed. B. Cold packs may be applied for pain (avoid placing ice directly on skin). Insect Bite: C. Scrape away stinger if appropriate; do not squeeze venom sac. D. Observe for allergic reaction and/or anaphylaxis. Treat according to EMS Protocols 3.1 or 3.2, Allergic Reaction/Anaphylaxis. BLS E. Assist patient with taking their own allergic reaction medication such as bee sting kit (epinephrine, diphenhydramine, antihistamine) or beta-2 inhaler. F. Apply cold packs for pain management. Page 39 of 122

43 SECTION 3 Medical Protocols 3.11 Envenomation/Snake Bite Snake Bite: A. Remove rings, watches, and other jewelry which might constrict circulation. B. Do not apply ice. C. Consider pain management. Serious Envenomation: D. Avoid movement of extremity (splint) and keep at or below level of the heart. E. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. F. Circle swelling around puncture site with ink pen and note time. G. Monitor distal pulses. Notes: A. Do not apply loose constricting band or (tourniquet) B. Do not incise snake bites. C. All patients need to be transported to a hospital for evaluation and possible antibiotic or anti-venom therapy. D. If dead or captured have animal control transport snake for identification. E. Notify animal control and law enforcement for all animal bits. F. If safe, package insect or spider for transport and positive identification. G. All bites (dog, cat, human, etc.) need to be transported for further evaluation at a hospital for further cleansing and potential antibiotic therapy. H. Time since envenomation is important as anaphylaxis rarely occurs more than 60 minutes after inoculation. Page 40 of 122

44 SECTION 3 Medical Protocols 3.12 Hyperthermia Adult & Pediatric 3.12 Hyperthermia Adult & Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information Needed: A. Patient age, activity level, medications; B. Associated symptoms headache, chest pain, cramps, nausea, weakness, temperature; C. Air temperature and humidity; presence or absence of clothing III. Objective findings: A. Heat cramps and heat exhaustion: temperature normal to slightly elevated; mental status alert to slightly confused; skin signs diaphoresis, warm or hot to touch; muscle cramps and weakness. B. Heat stroke: High core temperature usually above 104F; altered mental status; skin hot to touch and flushed; possible seizure activity; low blood pressure; tachycardia. IV. Treatment: A. Note patient s temperature if possible. B. Move patient to cool environment. C. Remove excess clothing. D. Spray or sprinkle patient s face with cool (not cold) water and use fan to evaporate. E. Initiate micro-circulation cooling by applying ice packs to palms of hands and soles of feet. F. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. G. For heat cramps/heat exhaustion may give patient cool/cold liquids by mouth. H. May stretch cramped muscles to relieve pain. ALS V. Specific Heat Cramps/Heat Exhaustion Treatment: A. Initiate passive cooling measures. B. Administer up to 2 liters of normal saline IV. If patient has history of CHF or lungs are not clear, give fluid challenges in boluses of 250 ml and reassess. VI. Specific Heat Stroke Treatment: A. Begin cooling measures. B. Note patient s temperature if possible. Page 41 of 122

45 SECTION 3 Medical Protocols 3.12 Hyperthermia Adult & Pediatric C. Move patient to cool environment. D. Remove excess clothing. E. Spray or sprinkle patient s face with cool (not cold) water and use fan to evaporate. F. Initiate micro-circulation cooling by applying ice packs to palms of hands and soles of feet. G. Administer up to 2 liters of normal saline IV. If patient has history of CHF or lungs are not clear, give fluid challenges in boluses of 250 ml and reassess. Note: Persons at greatest risk of hyperthermia are the elderly, athletes, and persons on medications which impair the body s ability to regulate heat. Page 42 of 122

46 SECTION 3 Medical Protocols 3.13 Hypothermia - Adult & Pediatric 3.13 Hypothermia Adult & Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information Needed: A. Length and history of exposure. B. Air temperature, water temperature, wind velocity, was patient wet or dry. C. History and time of mental status changes. D. Medical history trauma, alcohol consumption, medications, pre-existing medical problems. III. Objective findings: A. Altered mental status B. Patient s body temperature C. Exposure to cold environment D. Evidence of local cold injury blanching, red or wax looking skin especially ears, nose and fingers, burning or numbness in affected areas. IV. Treatment: A. Consider the need for cervical spine precautions. B. Gently move patient to warm environment. C. Remove wet clothing and cover with warm blankets. D. Move to sheltered area minimizing patient s physical exertion or movement. Remove patient s wet clothing and cover with warm, dry sheets or blankets. E. Heat packs with less than 110F may be applied to patient s groin/axillary for warmth. F. Oxygen liters per minute via non-rebreather mask. Patient s with ineffective respirations: support ventilations with BVM and airway. G. Do not attempt to thaw out frost bitten areas or apply heat packs to frostbite sites. ALS H. Establish IV of normal saline (NS). If lungs are clear, consider warm 250ml NS fluid challenges. 1. Consult with Base hospital for fluid challenges to pediatric patients. 2. Recheck vital signs following each infusion. I. Severe hypothermia: (stuporous or comatose, dilated pupils, hypotensive or pulseless, slowed or absent respirations) 1. Prepare to support ventilations using appropriate airway adjuncts with BVM. Do not attempt intubation if patient has intact gag reflex. 2. Ventilate using warm, humidified oxygen if available. Avoid hyperventilating the patient. Page 43 of 122

47 SECTION 3 Medical Protocols 3.13 Hypothermia - Adult & Pediatric 3. Observe for organized rhythm and pulses for one (1) minute. If organized rhythm present, move quickly, but gently to warm environment (ambulance) and provide appropriate treatment for cardiac dysrhythmia. J. Provide Receiving facility with early notification. Page 44 of 122

48 SECTION 3 Medical Protocols 3.14 Hypoglycemia/Hyperglycemia - Adult 3.14 Hypoglycemia/Hyperglycemia Adult Definitions: A. Hypoglycemia- Classified as a finger stick blood sugar below 60 mg/dl. a. Signs and Symptoms ALOC, Hunger, Pale, Diaphoretic. B. Hyperglycemia - Classified as a finger stick blood sugar between mg/dl a. Signs and Symptoms May be asymptomatic. May have Polyuria, polydipsia. C. Diabetic Ketone acidosis (DKA) - Classified as a finger stick blood sugar above 300mg/dl. a. Signs and Symptoms Polyuria, Polydipsia, Polyphagia, ALOC, Fruity odor on breath. D. Hyperglycemic Hyperosmolar Nonketotic (HHNK) Coma- Classified as a finger stick blood sugar above 300 mg/dl with the absence of Ketones. a. Signs and Symptoms Polyuria, Polydipsia, Polyphagia, ALOC. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information Needed: A. History and time of mental status changes. B. Medical history trauma, alcohol consumption, medications, pre-existing medical problems. III. Objective findings: A. Altered mental status IV. Treatment: A. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. B. Glucose paste may be administered if the patient is a known diabetic, can hold head upright, can self-administer medication, and has an intact gag reflex. ALS C. ECG, Consider 12 -lead ECG in female and patients over 40 years-old. D. Check Blood Sugar 1. Hypoglycemia- FSBS <60mg/dl a) IV/IO NS TKO b) Dextrose 50% 25 Gms IVP; or Dextrose 10% 50 ml IV/IO bolus, repeated every minute until GCS is 15. Maximum dose of Dextrose 10% is 10 ml/kg. Page 45 of 122

49 SECTION 3 Medical Protocols 3.14 Hypoglycemia/Hyperglycemia - Adult 2. Hyperglycemia- FSBS mg/dl a) IV NS TKO 3. Diabetic Ketone acidosis (DKA)/ Hyperglycemic Hyperosmolar Nonketotic (HHNK) Coma- FSBS >300 Mg/dl a) IV (IO only if ALOC) NS TKO b) Administer a NS fluid challenge of up to 500ml while rechecking vital signs and lung sounds after every 250 mls. If patient s lungs are not clear, discontinue the fluid challenge and consult the base hospital physician. Page 46 of 122

50 SECTION 3 Medical Protocols 3.15 Hypoglycemia/Hyperglycemia - Pediatric 3.15 Hypoglycemia/Hyperglycemia Pediatric Definitions: A. Hypoglycemia- Classified as a finger stick blood sugar below 60 mg/dl. a. Signs and Symptoms ALOC, Hunger, Pale, Diaphoretic. B. Hyperglycemia - Classified as a finger stick blood sugar between mg/dl a. Signs and Symptoms May be asymptomatic. May have Polyuria, polydipsia. C. Diabetic Ketone acidosis (DKA) - Classified as a finger stick blood sugar above 300mg/dl. a. Signs and Symptoms Polyuria, Polydipsia, Polyphagia, ALOC, Fruity odor on breath. D. Hyperglycemic Hyperosmolar Nonketotic (HHNK) Coma- Classified as a finger stick blood sugar above 300 mg/dl with the absence of Ketones. a. Signs and Symptoms Polyuria, Polydipsia, Polyphagia, ALOC. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information Needed: A. History and time of mental status changes. B. Medical history trauma, alcohol consumption, medications, pre-existing medical problems. III. Objective findings: A. Altered mental status IV. Treatment: A. Initiate appropriate airway management. B. Obtain HR, BP, pulse oximetry and cap refill ALS C. Place on ECG D. Establish IV/IO of normal saline. E. Evaluate blood glucose level. If blood glucose level is less than 60 mg/dl, administer dextrose: 1. Child older than two years of age Dextrose 50% 1 ml/kg IV/IO or Dextrose 10% 5 ml/kg IV/IO. 2. Child less than two years of age Dextrose 50% 0.5 ml/kg IV/IO or Dextrose 10% 5 ml/kg IV/IO. Use D50 only if D10 not available 3. Neonate Dextrose 10% 5ml/kg IV/IO. F. If blood glucose level is greater than 300 mg/dl 1. 20ml/kg NS IV or IO if unconscious. No repeat. Page 47 of 122

51 SECTION 3 Medical Protocols 3.16 Nausea - Adult 3.16 Nausea Adult Definitions: A. Nausea may be due to a viral illness (such as gastroenteritis), motion sickness, or medication side effects. However, it is important to remember that serious medical conditions also produce nausea or vomiting such as stroke, head injuries, toxic ingestions, bowel obstruction, appendicitis and acute coronary syndrome. Generally, benign causes of nausea or vomiting do not have any associated pain complaints, or alterations in level of consciousness (LOC). I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Patient history: III. Treatment: A. For patients greater than 55 years of age perform 12-lead ECG. B. Standing Order: Adult patients exhibiting persistent nausea may be treated with Ondansetron (Zofran). 1. Dosage and Route: a) IV/IO Administration - 4 mg slow push (over 1 minute); or b) IM Administration 4 mg; or c) Oral Disintegrating Tablet (ODT) 4 mg. d) May repeat administration of 4 mg (IV/IO, IM, ODT) if nausea persists 15 minutes following first administration. e) Maximum single dose is 4 mg repeated once for a maximum total dose of 8 mg. f) Contraindications: Known sensitivity to Ondansetron or other 5- HT-3 antagonists e.g.: Granisetron (Kytril), Dolasetron (Anzamet), Palonosetron (Aloxi). g) Treatment Considerations: (1) Rapid administration of Ondansetron has been associated with syncope. (2) Rare side effects include headache, dizziness, tachycardia, sedation, or hypotension. Page 48 of 122

52 SECTION 3 Medical Protocols 3.17 Pain Management - Adult 3.17 Pain Management Adult This protocol is intended for the treatment of pain associated with traumatic injuries, burns, cardiac and other non-cardiac medical conditions. Definitions: A. Pain is a significantly unpleasant sensation, occurring in varying degrees of severity, which results because of injury, disease, or emotional disorder. ALS I. Fentanyl or morphine may be administered as pain management for patients with: A. Moderate to severe pain from traumatic injuries. B. Moderate to severe pain from burns. C. Moderate to severe pain from cardiac and other non-cardiac medical condition associated with severe patient discomfort or pain that interferes with patient movement. II. In the presence of any finding listed below, a base hospital physician order is required prior to administering fentanyl or morphine: A. Allergy or sensitivity to the medication being administered. B. Systolic blood pressure less than 90 mmhg. C. Respiratory rate less than 12. D. History of loss of consciousness. E. Decreased mental status. F. Pregnancy greater than 20 weeks. III. Procedure: A. Perform routine ALS/BLS medical care is directed in Protocol 1.0. B. Employ non-invasive pain management techniques as appropriate, e.g. ice, splinting, positioning. ALS C. Establish IV access. (IV NS or NS lock as appropriate). D. Obtain full set of vital signs and determine pain scale. E. Administer fentanyl or morphine according to dosing chart. Pain medications shall be titrated to relief, not to exceed maximum dose. F. Reassess vital signs and pain scale after 5 minutes. G. Continually monitor and reassess patient. Document patient pain scale prior to and following each administration. The use of morphine to manage moderate to severe pain is an advanced life support procedure that is indicated for patients who are complaining of moderate to severe pain in the presence of adequate vital signs and level of consciousness. Page 49 of 122

53 SECTION 3 Medical Protocols 3.17 Pain Management - Adult ALS Pain Management Dosage Chart Fentanyl Cardiac* A. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. B. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. Burn* A. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 3 mcg/kg. B. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 3 mcg/kg. Trauma* A. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. B. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. Other* A. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. B. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. *NOTE for all categories above: Maximum single does shall not exceed 100 mcg. Morphine Cardiac A. 2-4 mg slow IV/IO push (initial dose). May repeat 2 mg slow IV/IO push every 5 minutes to a maximum cumulative dose not to exceed 20 mg. Burn A. 2-4 mg slow IV/IO push (initial dose). May repeat 2 mg slow IV/IO push every 5 minutes to a maximum cumulative dose not to exceed 20 mg. B. If unable to secure IV access, administer 5-10 mg IM. May repeat one dose in 30 minutes. Trauma A. 2-4 mg slow IV/IO push (initial dose). May repeat 2 mg slow IV/IO push every 5 minutes to a maximum cumulative dose not to exceed 20 mg. B. If unable to secure IV access, administer 5-10 mg IM. May repeat one dose in 30 minutes. Other A. 2-4 mg slow IV/IO push (initial dose). May repeat 2 mg slow IV/IO push every 5 minutes to a maximum cumulative dose not to exceed 20 mg. B. If unable to secure IV access, administer 5-10 mg IM. May repeat one dose in 30 minutes. *NOTE for all categories above: Maximum single does shall not exceed 6 mg. Page 50 of 122

54 SECTION 3 Medical Protocols 3.18 Pain Management - Pediatric 3.18 Pain Management Pediatric This protocol is intended for the treatment of pain associated with traumatic injuries, burns, cardiac and other non-cardiac medical conditions. Definitions: A. Pain is a significantly unpleasant sensation, occurring in varying degrees of severity, which results because of injury, disease, or emotional disorder. ALS I. Fentanyl or morphine may be administered as pain management for patients with: A. Moderate to severe pain from traumatic injuries. B. Moderate to severe pain from burns. C. Moderate to severe pain from other medical conditions associated severe patient discomfort or pain that interferes with patient movement. II. In the presence of any finding listed below, a base hospital physician order is required prior to administering fentanyl or morphine: A. Allergy or sensitivity to the medication being administered; B. Systolic blood pressure less than age appropriate range; C. Respiratory rate less than 12; D. History of loss of consciousness; E. Decreased mental status. III. Procedure: B. Perform routine ALS/BLS medical care is directed in Protocol 1.0. H. Employ non-invasive pain management techniques as appropriate, e.g. ice, splinting, positioning. Monitor patient closely. ALS I. Establish IV/IO access (IV NS or NS lock as appropriate). J. Prior to analgesia obtain full set of vital signs. K. Document pain scale before and after medication administration. L. For children under the age of 3, use the behavioral or the FACES scale. M. For children over the age of 3, use the FACES or the visual analog scale. N. Administer fentanyl or morphine according to dosing chart. Pain medications shall be titrated to relief, not to exceed maximum dose. O. Reassess vitals and pain scale after 5 minutes. P. Continually monitor and reassess patient. Document patient pain scale prior to and following each administration. Page 51 of 122

55 SECTION 3 Medical Protocols 3.18 Pain Management - Pediatric Pediatric ALS Pain Management Dosage Chart Fentanyl Burn* C. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 3 mcg/kg. D. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 3 mcg/kg. Trauma* C. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. D. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. Other* C. 1 mcg/kg slow IV/IO push every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. D. 1 mcg/kg IN (0.5 mcg/kg per nostril) every 5 minutes. Maximum cumulative dose shall not exceed 2 mcg/kg. Morphine Burn C. 0.1 mg/kg slow IV/IO push. May repeat once in 5 minutes. D. If unable to secure IV access, administer 0.1 mg/kg IM. May repeat one dose in 30 minutes. Trauma A. 0.1 mg/kg slow IV/IO push. May repeat once in 5 minutes. B. If unable to secure IV access, administer 0.1 mg/kg IM. May repeat one dose in 30 minutes. Other A. 0.1 mg/kg slow IV/IO push. May repeat once in 5 minutes. B. If unable to secure IV access, administer 0.1 mg/kg IM. May repeat one dose in 30 minutes. *NOTE for all categories above: Maximum single does shall not exceed 50 mcg. *NOTE for all categories above: Maximum single does shall not exceed 4 mg. Page 52 of 122

56 SECTION 3 Medical Protocols 3.18 Pain Management - Pediatric IV. Pain Scales: A. Behavioral Pain Scale - Select the most appropriate description for each row and total the numbers. Face 0 No expression or smile Legs 0 Normal or relaxed position Activity 0 Lying quietly, normal position, moves easily Cry 0 No cry (awake or asleep) Consolability 0 Content, relaxed B. Wong-Baker FACES Scale 1 Occasional grimace, withdrawn, frown 1 Uneasy, restless, tense 1 Squirming, tense, shifting back and forth 1 Moans or whimpers, occasional complaint 1 Reassured by voice, hugging. Distractible. 2 Frequent frown, clenched jaw, quivering chin 2 Kicking or legs drawn up 2 Arched, rigid, or jerking 2 Cries steadily, screams, sobs, frequent complaints 2 Difficult to console or comfort C. Visual Analog Scale No Worst Pain Pain Ever Page 53 of 122

57 SECTION 3 Medical Protocols 3.19 Pediatric Brief, Resolved, Unexplained Event 3.19 Pediatric Brief, Resolved, Unexplained Event Definitions: A. Brief, Resolved, Unexplained Event (BRUE) indicates an episode that is frightening to the observer (may think the infant has died). Occurs in a child younger than 1 year of age and lasts less than 1 minute. Must have resolved and patient back to baseline and has one or more of the following: a. Central Cyanosis or Pallor (discoloration of face, gums and/or trunk) b. Absent, Decreased or Irregular Breathing c. Marked change in tone (hypertonia or hypotonia) d. Altered level of responsiveness. Note: These events usually occur in infants < 12 months old, however, any child less than 2 years old who exhibits the symptoms listed above should still be evaluated for BRUE. I. Treatment: A. Assume the history given is accurate. B. Determine the severity, nature and duration of the episode. C. Obtain a medical history. D. Perform a complete physical exam that includes the general appearance of the child, skin color, extent of interaction with environment, and evidence of trauma. E. If hypoglycemia suspected or ALOC, obtain glucose level. F. Consider and treat any identifiable causes. G. Transport patient to the hospital. Page 54 of 122

58 SECTION 3 Medical Protocols 3.20 Pediatric Respiratory Distress: Stridor 3.20 Pediatric Respiratory Distress: Stridor I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. For suspected airway obstruction refer to EMS Protocol No. 2.4, Pediatric Airway Obstruction. III. For suspected allergic reaction refer to EMS Protocol No. 3.2, Allergic Reaction - Pediatric. IV. Treatment: A. Place patient in position of comfort. ALS B. If suspected croup, 1. Nebulize 0.5mL of 2% Racemic Epinephrine in 4mL of NS. Hold for heart rate greater than 200bpm C. If suspected epiglottis, do not attempt to visual airway. 1. Consider saline nebulizer treatment if it does not cause stress/crying to child 2. Administer oxygen, allow parent to administer if appropriate. If patient deteriorates, or becomes completely obstructed, attempt to ventilate via BVM with airway adjunct as tolerated 3. Place I-gel (supraglottic airway) only if BVM ventilation is unsuccessful or impossible and without gag reflex Page 55 of 122

59 SECTION 3 Medical Protocols 3.21Poisoning/Overdose - Adult 3.21 Poisoning/Overdose Adult Definitions: A. Poisoning / Overdose means ingestion and/or exposure to one or more toxic substances, including alcohol. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Surroundings and safety check: syringes, containers, flammables, gas cylinders, weapons, unusual odors. B. Identify substance. Bring any containers, labels or a sample if safe to do so into the hospital with the patient. Determine type, amount, and time of the exposure. C. For drug ingestion note: drugs(s) taken, dosage, number of pills remaining in bottle, date prescription filled. D. For toxic ingestion or exposure note: identifying information, warning labels, placards, MSDS. Check for commercial antidote kits (e.g. cyanide kits) in occupational settings. E. Duration of illness: onset and progression of present state, symptoms prior to exposure such as headache, seizures, confusion, difficulty breathing. F. History of event: ingested substance, drugs, alcohol, toxic exposure, work environment, possible suicide. G. Past medical history: behavioral emergencies, psychiatric care, allergic reactions, neurological disorders; confirm information with family member or bystander if possible. III. Objective Findings: A. Breath odor, track marks, drug paraphernalia, prescription opioid pain medication, vital signs, pupil assessment, skin signs, lung sounds and airway secretions. IV. Treatment: A. Remove patient from contact with hazardous material or environment. B. Confirm transport ambulance en route. C. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. D. Suction if needed. E. Check blood glucose level. F. Secondary survey and routine medical care. G. Suspected opioid overdose and respiratory rate less than 12: 1. Remove and transdermal opioid patches. Page 56 of 122

60 SECTION 3 Medical Protocols 3.21Poisoning/Overdose - Adult EMT Optional Scope 2. ** Optional Skill EMT: Administer naloxone intranasal with mucosal atomizer device: 3. Adult dose (weighing greater than 20 kg / 44 lbs) 2 mg intranasal. May repeat once in 2-3 minutes for a maximum dose of 4 mg. 4. Pediatric dose: 0.1 mg/kg intranasal. *Procedure may only be performed by a San Joaquin county Emergency Medical Services Agency optional skill EMT working on duty with an approved optional skill BLS provider. ALS H. Establish IV/IO of normal saline TKO or saline lock if indicated. I. Initiate early transport and receiving hospital notification. V. Substance Specific Treatment: A. Opiates: 1. Administer naloxone (Narcan) titrated to maintain adequate ventilation and airway control. Initial dose if 0.4 mg 2 mg IVP; maximum dose of 4 mg. May administer intranasal (IN) or sublingual (SL) if unable to start an IV. **Note Naloxone is NOT titrated based on level of consciousness, the goal is to increase respirations and avoid hypoxemia B. Cocaine / Amphetamines: 1. Consider activated charcoal 1 gm/kg PO, not to exceed 50 grams given orally if within the first sixty (60) minutes of ingestion. 2. Monitor for seizure and/or dysrhythmias and treat accordingly. 3. For immediate control over psychomotor agitation, consult base hospital physician for sedative order. C. Insecticides (organophosphates, carbonates): 1. Avoid contamination of prehospital personnel. 2. Skin exposure: decontaminate patient as soon as possible (remove clothes, wash skin). Page 57 of 122

61 SECTION 3 Medical Protocols 3.21Poisoning/Overdose - Adult 3. Assess for SLUDGE (salivation, lacrimation, urination, diaphoresis/diarrhea, gastric hyper motility and emesis/eye [small pupils and/or blurry vision]). ALS 4. If indicated, administer atropine 2 mg slow IVP. If no tachycardia or pupil dilation, give second dose of atropine 2 mg IVP. Note: atropine does not reverse muscle weakness that leads to respiratory failure. 5. Atropine can be toxic and orders for repeated doses above 4 mg should be given by the base hospital physician only. D. Cyclic antidepressants: 1. Anticipate rapid deterioration of condition. 2. In the presence of life-threatening dysrhythmias: a) Hyperventilate if assisting ventilation. b) Administer sodium bicarbonate 1 meq/kg IVP. 3. For seizure, see EMS Protocol No. 3.24, Seizures. 4. For signs of shock, see EMS Protocol No. 3.26, Shock. E. Beta Blockers: 1. Consider activated charcoal 1 gm/kg PO, not to exceed 50 grams given orally if within the first 60 minutes of ingestion. 2. Obtain blood glucose level. F. Calcium Channel blockers: 1. Consider activated charcoal 1 gm/kg PO, not to exceed 50 grams given orally if within the first 60 minutes of ingestion. 2. If bradycardic and/or hypotensive, consult base hospital physician for order to administer calcium chloride 500 mg slow IVP over five (5) minutes. May repeat one time in ten (10) minutes. G. Phenothiazine Reactions: 1. Administer diphenhydramine 1 mg/kg IV/IO to a maximum of 50 mg. If unable to establish IV access, administer IM. H. Other Non-Caustic Drugs: 1. If patient is awake and alert consider activated charcoal 1 gm/kg PO, not to exceed 50 grams if within the first 60 minutes of ingestion. 2. Consider contacting the Poison Control Center. I. Hydrocarbons (kerosene, gasoline, lighter fluid, turpentine, furniture polish, etc): 1. Do not induce vomiting. 2. Transport immediately. J. Caustic Substances (acid/alkalis): 1. Do not induce vomiting. Page 58 of 122

62 SECTION 3 Medical Protocols 3.22 Poisoning/Overdose - Pediatric 3.22 Poisoning/Overdose Pediatric Definitions: A. Poisoning / Overdose means ingestion and/or exposure to one or more toxic substances, including alcohol. I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Surroundings and safety check: syringes, containers, flammables, gas cylinders, weapons, unusual odors. B. Identify substance. Bring any containers, labels or a sample if safe to do so into the hospital with the patient. Determine type, amount, and time of the exposure. C. For drug ingestion note: drugs(s) taken, dosage, number of pills remaining in bottle, date prescription filled. D. For toxic ingestion or exposure note: identifying information, warning labels, placards, MSDS. Check for commercial antidote kits (e.g. cyanide kits) in occupational settings. E. Duration of illness: onset and progression of present state, symptoms prior to exposure such as headache, seizures, confusion, difficulty breathing. F. History of event: ingested substance, drugs, alcohol, toxic exposure, work environment, possible suicide. G. Past medical history: behavioral emergencies, psychiatric care, allergic reactions, neurological disorders; confirm information with family member or bystander if possible. III. Objective Findings: A. Breath odor, track marks, drug paraphernalia, prescription opioid pain medication, vital signs, pupil assessment, skin signs, lung sounds and airway secretions. IV. Identify substance. Bring any containers, labels or a sample (if safe) into the hospital with the patient. Determine type, amount and time of the exposure. V. Substance Specific Treatment: A. Opiates: 1. Manage airway and ensure adequate oxygenation and ventilation. EMT Optional Scope 2. ** Optional Skill EMT: If mental status and respiratory effort are Page 59 of 122

63 SECTION 3 Medical Protocols 3.22 Poisoning/Overdose - Pediatric depressed administer naloxone intranasal with mucosal atomizer device with 0.1 mg/kg intranasal. *Procedure may only be performed by a San Joaquin county Emergency Medical Services Agency optional skill EMT working on duty with an approved optional skill BLS provider. ALS 3. If mental status and respiratory effort are depressed administer Narcan: a) 0.1 mg/kg IN, (half dose in each nostril) or; b) 0.4 mg - 2 mg IVP/IO. Titrate in small increments to maintain adequate ventilation and airway control to a total initial dose of 2 mg. May administer IM, SL or SQ if unable to start IV. B. Insecticides (organophosphates, carbonates): ALS 1. Decontaminate patient as soon as possible (remove clothes, wash skin). 2. Avoid contamination of prehospital personnel. 3. Assess for SLUDGE (salivation, lacrimation, urination, diaphoresis/diarrhea, gastric hypermotility, and emesis/eye [small pupils and/or blurry vision]). 4. If indicated, administer Atropine 0.05 mg/kg IVP/IO slowly. May give second dose of Atropine 0.05 mg/kg in 5 minutes if indicated to a maximum dose of 4 mg. 5. If further doses of Atropine are required, consult the base hospital physician. C. Cyclic Antidepressants: 1. Anticipate rapid deterioration of condition. 2. Consider activated charcoal 1gm/kg PO ONLY IF AWAKE AND ALERT, not to exceed 50 gms given orally if within the first 60 minutes of ingestion. 3. In the presence of life-threatening dysrhythmias or rapid deterioration: Hyperventilate if assisting ventilation If unable to ventilate adequately with OPA/NPA (or both), place SGA as outlined in Protocol No. 2.2, Page 60 of 122

64 SECTION 3 Medical Protocols 3.22 Poisoning/Overdose - Pediatric Pediatric Airway Management. a) Administer Sodium Bicarbonate 1 meq/kg IVP. b) Emergent transport to closest hospital 4. For seizures, see EMS Protocol No. 3.2, Seizures - Pediatric. D. Beta Blockers: 1. Consider activated charcoal 1 gm/kg PO ONLY IF AWAKE AND ALERT, not to exceed 50 gms given orally if within the first 60 minutes of ingestion. 2. Obtain blood glucose level. 3. if hypotensive, give 20ml/kg bolus followed by 10mL/kg x2 bolus as needed 4. If hypotensive and/or bradycardic, emergent transport to closest hospital and consult base hospital physician E. Calcium Channel Blockers: 1. Consider activated charcoal 1gm/kg PO ONLY IF AWAKE AND ALERT, not to exceed 50gms given orally (if within the first 60 minutes of ingestion). 2. Calcium Chloride 10% mg/kg IVP over 3 5 minutes. 3. if hypotensive, give 20ml/kg bolus followed by 10mL/kg x2 bolus as needed 4. If bradycardic and/or hypotensive, consult base hospital physician. With emergent transport to closest hospital F. Phenothiazine Reactions: 1. Administer Diphenhydramine 1 mg/kg slow IVP to a maximum of 50 mg. If unable to establish IV access, administer IM. G. Other Non-Caustic Drugs: 1. If patient is awake and alert consider activated charcoal orally 1 gm/kg PO, not to exceed 50gms if within the first 60 minutes of ingestion. 2. Consider contacting Poison Control Center. H. Hydrocarbons (kerosene, gasoline, lighter fluid, turpentine, etc): 1. Do not induce vomiting. 2. Transport without delay. I. Caustic Substances (acids/alkalis): 1. Do not induce vomiting. 2. Consider diluting by having the patient drink 1-2 glasses of milk or water. 3. Transport without delay. Page 61 of 122

65 SECTION 3 Medical Protocols 3.23 Nerve Agency Exposure Adult and Pediatric 3.23 Nerve Agent Exposure Adult and Pediatric Definitions: A. Chempack means a voluntary component of the Federal Strategic National Stockpile Program (SNS) operated by the Centers for Disease Control and Prevention (CDC) for the benefit of the US civilian population. The Chempack program s mission is to provide state and local governments a sustainable nerve agent antidote cache that increases their capability to respond quickly to a nerve agent event such as a terrorist attack. B. Nerve agents mean an extremely toxic organophosphate type chemicals, including GA (tabun), GB (sarin), GD, (soman), GF (cyclosarin) and VX, which attack the nervous system and interfere with chemicals that control nerves, muscles, and glands. They are odorless and invisible and can be inhaled, absorbed through the skin, or swallowed. C. Nerve agent antidotes means to counteract the effects of a nerve agent be decreasing symptoms and regenerating an enzyme that is wiped out by nerve agents. Nerve agent antidotes are among the five (5) actions taken after exposure to nerve agent, as follows: DOES THIS MAKE SENSE? WHAT DOES C MEAN IN REFERENCE TO THE FOLLOWING? a. Terminate the exposure; b. Stop breathing and move quickly to good air; c. Decontaminate victims and emergency medical staff within minutes of exposure; d. Don personal protective equipment; e. Ventilate pre-hospital and hospital treatment areas. f. Support ventilation. g. Provide atropine therapy. h. Provide oxime therapy. i. Provide antiseizure therapy. j. Document treatment on the triage tag. I. Procedure A. As soon as the scene is identified as hazardous materials incident, secure, isolate and deny entry, ensure appropriate resources are responding, and notify the base hospital. B. Decontamination should precede any treatment by EMS personnel. C. All providers will ensure personal safety by assuring adequate decontamination of victims is conducted and all response personnel will utilize appropriate personal protective equipment (PPE). Medical procedures within the exclusion zone (hot zone / contaminated area) will only be performed by personnel who have specific training to allow them to function in that area. Under no circumstances should responding personnel at any level of Page 62 of 122

66 SECTION 3 Medical Protocols 3.23 Nerve Agency Exposure Adult and Pediatric expertise use PPE or assist in patient decontamination without completing the required training. D. EMTs and paramedics that have been trained and equipped may utilize the nerve agent protocol to self-administer EMS Chempack auto injectors when they have been exposed to nerve agents and are symptomatic. E. Once the EMS Chempack is deployed to an active incident, the Medical Group Supervisor (MGS) may contact the base hospital and request that all paramedics on that incident operate under standing orders. II. Treatment: A. Perform routine ALS/BLS medical care is directed in Protocol 1.0. B. Position the patient on their side (recovery position). C. Monitor respiratory status closely. Use airway adjuncts, administer high flow oxygen, suction, ventilate, and advanced airways as indicated. ALS D. Establish IV and normal saline (NS). Titrate to maintain systolic blood pressure >90 mmhg. E. Nerve agent medications should never be given prophylactically. F. The auto-injectors included in EMS Chempack Nerve Agent Antidote Kits will be used only by those paramedics that have been trained in their use. Paramedics may administer atropine IM/IV in situations where EMS Chempack Nerve Agent Antidote Kids are not available. G. Administer antidotes as outlined below. H. Seizure: After atropine administration: 1. Diazepam (Valium): a) Adults titrate 2.5 mg 10 mg slow IVP to effect. If unable to obtain IV access, administer 10 mg deep IM slowly. If recurrent or persistent seizure, repeat once IV/IM to a maximum of 20 mg. b) Pediatric (less than 40 kg or 9 years of age) 0.05 mg 0.3 mg IV over 2-3 minutes every minutes, titrated to effect; maximum 10 mg. Page 63 of 122

67 SECTION 3 Medical Protocols 3.23 Nerve Agency Exposure Adult and Pediatric Page 64 of 122

68 SECTION 3 Medical Protocols 3.24 Seizures - Adult 3.24 Seizures Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Patient History: recent infection, fever, trauma, environment (heat/cold), epilepsy. B. Current Seizure History: Onset, duration, frequency, description of seizure. C. Change in mental status: Baseline status, onset and progression of altered state, symptoms prior to altered state such as headache, seizures, confusion, and trauma. III. Objective Findings: A. Level of consciousness (AVPU) and neurological assessment. B. Evidence of trauma. C. High temperature (febrile state). D. Current seizure activity. E. Medical information tags, bracelets, or medallions. IV. Treatment: A. Protect patient from further injury move furniture and ensure safe area for treatment. B. Spinal stabilization as indicated. C. Ensure transporting ambulance response. D. Check blood glucose level. E. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. F. Institute appropriate cooling measures if indicated by history and findings (temperature 104F). G. Continually assess neurological status. H. Be prepared for recurrent seizure activity. Do not forcibly restrain patient during seizure activity. I. Initiate cooling measures if febrile patient ALS J. If witnessed by prehospital personnel to be seizing for >2minutes or patient has two (2) seizures without regaining consciousness; 1. Establish IV/IO of normal saline (NS) TKO. 2. Administer midazolam 2 mg slow IV/IO or 4 mg IM. 3. May be repeat if necessary every five (5) minutes to a maximum dose of 10 mg. Page 65 of 122

69 SECTION 3 Medical Protocols 3.24 Seizures - Adult 4. For pregnant patients with continued seizure activity after the first administration of midazolam administer magnesium sulfate 2 grams IV/IO slow over 3-5 minutes. 5. Obtain blood glucose level. Refer to Protocol No. 3.1, Hypoglycemia / Hyperglycemia Adult. 6. If narcotic overdose is suspected refer to Protocol No. 3.21, Poisoning/Overdose Adult. V. Continued seizure activity: A. Be prepared to assist ventilations. B. Make base contact if seizures continue after maximum dose of midazolam. Page 66 of 122

70 SECTION 3 Medical Protocols 3.25 Seizures - Pediatric 3.25 Seizures Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Patient History: recent infection, fever, trauma, environment (heat/cold), epilepsy. B. Current Seizure History: Onset, duration, frequency, description of seizure. C. Change in mental status: baseline status, onset and progression of altered state, symptoms prior to altered state such as headache, seizures, confusion, and trauma. III. Objective Findings: A. Level of consciousness (AVPU) and neurological assessment B. Evidence of trauma C. High temperature (febrile state) D. Current seizure activity E. Medical information tags, bracelets, or medallions. IV. Treatment: A. Protect from injury, do not restrain. B. Place nasal cannula or NRB, suction secretions as needed. ALS C. If two (2) or more generalized seizures occur without regaining consciousness or the paramedic observes seizure activity that lasts for two (2) or more minutes: 1. Establish IV/IO normal saline TKO. a) Evaluate blood glucose level. If blood glucose level is less than 60 mg/dl refer to EMS Protocol No. 3.1, Hypoglycemia/ Hyperglycemia - Pediatric. b) Obtain O2 saturation. c) Manage airway as needed to maintain O2 saturation >92% per EMS Protocol No. 2.2, Pediatric Airway Management. 2. If continued seizure activity, administer Midazolam: a) 0.2 mg/kg IN (half dose in each nostril) to a maximum dose of 5 mg or b) 0.1mg/kg IVP/IO/IM to a maximum dose of 5 mg. 3. Initiate transport. a) If reports of trauma, proceed to trauma center. 4. For continued seizure activity not controlled by the initial dose of Page 67 of 122

71 SECTION 3 Medical Protocols 3.25 Seizures - Pediatric Midazolam, consult Base Hospital Physician for consideration of further Midazolam orders. Page 68 of 122

72 SECTION 3 Medical Protocols 3.27 Shock Pediatric 3.26 Shock Non Traumatic Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Patient History: Onset of symptoms and duration, fluid loss (nausea, emesis, diarrhea, diuretics), fever, infection, trauma, medication or substance ingestions, allergic reaction, past history of cardiac disease, abnormal EKG or internal bleeding disorder. III. Objective Findings: A. Compensating patients: Anxiety, agitation, restlessness, tachycardia, normal blood pressure, normal or delayed capillary refill, signs and symptoms of mild or moderate anaphylaxis. B. Decompensating patients: Decreased level of consciousness, bradycardia or decreasing heart rate, hypotension, cyanosis, delayed capillary refill, inequality of central and distal pulses. IV. Treatment: A. Place patient in shock position face up with legs elevated inches. Modify position if necessary due to respiratory distress. B. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. C. Give patient nothing by mouth. D. Maintain patient warmth. ALS E. Establish an IV/IO and administer 500ml NS. Reassessing after 250ml. Page 69 of 122

73 SECTION 3 Medical Protocols 3.28 Stroke 3.27 Shock Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. For suspected allergic reaction refer to EMS Protocol No. 3.2, Allergic Reaction/Anaphylaxis Pediatric. III. Treatment: A. Assure adequate oxygenation and ventilation. ALS B. Establish IV/IO of normal saline TKO. C. Administer rapid fluid bolus of normal saline 20 ml/kg. May repeat 10mL/kg x2 as indicated. D. If suspected Cardiogenic Shock, consult with Base Hospital Physician for Dopamine orders. 1. Do not give initial 20mL/kg bolus. Instead, give 10mL/kg boluses up to 4 times assess lung sounds and pulse oximetry between each. Give only enough fluid to maintain blood pressure. Page 70 of 122

74 SECTION 3 Medical Protocols 3.28 Stroke 3.28 Stroke I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Information needed: A. Patient History: III. Objective Findings: A. Level of consciousness (AVPU) and neurological assessment ALS IV. Procedure: A. Assess patient using the Cincinnati Prehospital Stroke Scale (CPSS)* and document findings. If any of the tested signs/symptoms is abnormal the patient is considered to be experiencing a stroke. 1. Determine the patient s Last Known Well Time (LKWT) and if patient is on anticoagulation therapy. B. Assess patient using the Rapid Arterial Occlusion Evaluation (RACE)* Scale and document findings. A RACE of greater than 5 is indicative of an ischemic stroke with a large vessel occlusion. C. If RACE score greater than 5 initiate IV NS in antecubital or external jugular TKO. D. Initiate transport to Primary Stroke Center without delay. E. Provide stroke alert to PSC as early as possible after initiation of transport. F. Provide supportive care according to EMS Protocol No. 3.3, ALS Altered Level of Consciousness - Adult. G. Transport without delay if progressive neurologic deficit is evident or unable to maintain effective airway. * Aphasia: Ask the patient to "Close your eyes" & "Make a fist". ** Agnosia: Ask the patient and evaluate recognition of deficit: 1. While showing the paretic arm, "Whose arm is this?" 2. Ask the patient: "Can you lift both arms and clap?" Page 71 of 122

75 SECTION 4 Cardiac Protocols SECTION 4 CARDIAC PROTOCOLS Page 72 of 122

76 SECTION 4 Cardiac Protocols 4.1 Adult Medical Cardiac Arrest 4.1 Adult Medical Cardiac Arrest Definitions: A. EMS Agency means the San Joaquin County Emergency Medical Services (EMS) Agency. B. MICR means minimally interrupted cardiac resuscitation that focuses upon maintaining high quality chest compressions with both depth and rate. C. MICR Algorithm means a representation of correct treatment choices in response to a patient s cardiac rhythm. D. MICR Round means the time required to complete compressions (approx. two minutes), analyze the patient s rhythm and provide a shock (If indicated). E. Passive Oxygen Insufflation (POI) is the method of providing oxygen to a patient during the first eight (8) minutes of resuscitation with an oral pharyngeal airway (OPA), high flow oxygen via non-rebreather mask, and no ventilations. Fundamental Concepts of Medical Cardiac Arrest Protocol I. The goal of cardiac resuscitation is to preserve cerebral and coronary function through meticulous attention to procedure and achieving return of spontaneous circulation (ROSC). A. Focus resuscitative efforts on accompanying the following in rank order of importance: 1. Provide high quality chest compressions with minimal interruption. 2. Apply ECG or AED for analysis and defibrillation. B. Use a team approach. II. Maintain a chest compression rate of 100 compressions per minute and alternate chest compression duties between team members each MICR Round. Each MICR Round consists of between 200 and 230 chest compressions and will vary based upon AED analysis and shock pattern limitations. Set and use metronome to assist in maintaining compression rate. III. The starting point to measure the beginning of MICR Rounds is the time that the first EMS personnel on scene initiates the MICR procedure (compressions), IV. Perform routine ALS/BLS medical care is directed in Protocol 1.0. V. Obtain patient history and document the following: A. Estimated down time. B. Quickly assess for obvious signs of death. 1. Decapitation 2. Decomposition 3. Burnt beyond recognition 4. Lividity 5. Rigor Mortis Page 73 of 122

77 SECTION 4 Cardiac Protocols 4.1 Adult Medical Cardiac Arrest C. Circumstances surrounding the arrest: 1. Onset (witnessed or unwitnessed). 2. Preceding symptoms. 3. Bystander CPR. 4. Duration of CPR. 5. Medications. 6. Environmental factors (hypothermia, inhalation, and asphyxiation). D. Contraindications for use of MICR include: 1. Traumatic arrest. See EMS Protocol No. 5.1, Trauma Treatment. 2. Pediatric arrest. See EMS Protocol No. 4.3 Asystole/PEA Pediatric, and No. 4.5 Ventricular Fibrillation and Pulseless B-Tach Pediatric. 3. Respiratory arrest due to known respiratory problem (e.g. asthma). Proceed Directly to Protocol No. 3.5, Bronchospasm/Respiratory Arrest - Adult. 4. Drowning. Proceed Directly to Protocol No. 4.2 Asystole/PEA Adult, and No. 4.4 Ventricular Fibrillation and Pulseless B-Tach Adult. 5. Obstructed Airway (including partial obstruction due to vomitus). Proceed directly to EMS Protocol No. 4.3, Ventricular Fibrillation - Adult or 4.2, Asystole/PEA - Adult. 6. Left Ventricular Assist Device See Protocol No LVAD. a) If confirmed no Audible sounds from LAVAD. (1) Initiate continuous CPR at 100 compressions per min (2) Secure Airway with I-Gel Tube (3) Transport to SRC (4) Establish IV/IO (5) Epinephrine 1:10,000 IV/IO every 3-5 Min. VI. Treatment: A. Follow the MICR Algorithm as described below for the first 4 rounds (8 Minutes): 1. First MICR Round: While providing a minimum of 200 chest compressions (two minutes), apply ECG or AED on manual mode. Ensure that the airway is secure with an OPA and institute Passive Oxygen Insuflation (POI) with high flow oxygen non-rebreather mask. If ALS is available start IV/IO. a) Approach to airway complications for BLS and ALS personnel: (1) If BLS personnel determine that vomitus has compromised the patient s airway, the BLS crews should suction the airway prior to applying an AED or POI. (2) If ALS personnel determine that vomitus has compromised the airway, the ALS crew should suction the airway and apply either endotracheal intubation (ETI) or igel Supraglottic Airway (SGA) and transition to treatment described below. Page 74 of 122

78 SECTION 4 Cardiac Protocols 4.1 Adult Medical Cardiac Arrest ALS 2. Subsequent MICR Rounds: Following the first MICR Round (200+ chest compressions and approximately two minutes), stop compressions to quickly check for a pulse and for ECG analysis. a) For non-shockable rhythms Administer epinephrine 1 mg 1:10,000 IV/IO once every two (2) MICR Rounds (e.g. once every 4 minutes). (1) Continue chest compressions immediately after Identifying Non shockable rhythm or if AED advises no shock. (2) Alternate chest compression duties between crew members every MICR Round. ALGORITHM FOR NON-SHOCKABLE RHYTHM b) For shockable rhythms (V-Fib/V-Tach) defibrillate at 200 joules (biphasic); or 360 joules (monophasic) after each 2 min of Chest compression. (1) Interruptions for defibrillation must be kept to a minimum. (2) Continue chest compressions immediately upon performing defibrillation. (3) Do not stop chest compressions to wait for an ECG analysis following defibrillation and do not interrupt chest compressions to perform airway procedures. Page 75 of 122

79 SECTION 4 Cardiac Protocols 4.1 Adult Medical Cardiac Arrest (4) Alternate chest compression duties between crew members every MICR Round. (5) Administer Lidocaine 1mg/kg IV/IO after 3 rd shock. (6) If at any point shockable rhythm is identified as Polymorphic Ventricular Tachycardia (Torsades De Pointes) Administer 2 Gms of Magnesium Sulfate Slow IVP. ALGORITHM FOR SHOCKABLE RHYTHM If during any rhythm analysis polymorphic V-Tach is identified administer 2g Magnesium Sulfate B. For return of spontaneous circulation (ROSC) treat the patient in accordance with EMS Protocol No. 4.13, Return of Spontaneous Circulation. C. If Asystole or PEA after 4 rounds of MICR (eight (8) minutes); (Non Shockable Rhythm) 1. Place OPA/NPA 2. Ventilate using BVM and 100% Oxygen at a ventilation ratio of 2:30 compressions. 3. Begin monitoring capnography 4. Continue performing high quality, compressions (> 100 per minute). 5. Administer epinephrine 1 mg 1:10,000 once every two (2) MICR Rounds (e.g. once every 4 minutes). 6. Follow EMS Protocol No. 4.2, Asystole/PEA - Adult. D. If V-Fib / V Tac after 4 rounds of MICR (eight (8) minutes); (Shockable Rhythm) 1. Administer epinephrine 1 mg 1:10,000 once every two (2) MICR Rounds (e.g. once every 4 minutes). Page 76 of 122

80 SECTION 4 Cardiac Protocols 4.1 Adult Medical Cardiac Arrest 2. Place either a igel (SGA) or an oral tracheal tube and secure it with a commercial tube restraint. While oral tracheal intubation will usually interfere with continuous chest compressions, endeavor to not interrupt compressions for longer than fifteen (15) seconds. 3. Continue performing high quality, uninterrupted compressions (> 100 per minute). 4. Use waveform capnography from the time of tube placement through the duration of the resuscitation attempt. Both numerical value (capnometry) and wave form morphology MUST be obtained and documented every five (5) minutes. 5. Once an advanced airway is in place, compressions are given continuously and ventilate at a rate of eight to ten (8-10) per minute. DO NOT HYPERVENTILATE. 6. Initiate Transport to STEMI receiving facility. 7. Follow EMS Protocol No. 4.4, Ventricular Fibrillation & Pulseless V-Tach Adult. Page 77 of 122

81 SECTION 4 Cardiac Protocols 4.2 Asystole/PEA - Adult 4.2 Asystole/PEA - Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Perform treatment for Cardiac Arrest in EMS Protocol 4.1 Adult Medical Cardiac Arrest. ALS III. After completing Rounds (8) rounds of MICR per EMS Protocol 4.1, confirm pulselessness and rhythm. IV. Treatment: A. Continue administering continuous chest compressions and ventilate the patient 8-10 times per minute. DO NOT HYPERVENTILATE. B. Establish an advanced airway and administer 100% oxygen via BVM. C. Establish IV/IO of normal saline (NS) TKO. 1. PEA- Administer rapid infusion of normal saline (NS) until systolic blood pressure is greater than 90 mmhg or 2 liters has been infused; then reduce the infusion rate to TKO. D. Consider reversible causes and treat as indicated: 1. Hypovolemia Start two (2) large bore IV/IO lines and administer rapid 2 liter volume infusion of NS, then 250 ml boluses until systolic blood pressure is >90 mmhg. 2. Hypoglycemia If blood sugar is less than 60 mg/dl, administer either Dextrose 50% 25 Gms IVP; or Dextrose 10% 50 ml IV/IO bolus, repeated every minute until GCS is 15. Maximum dose of Dextrose 10% is 10 ml/kg 3. Hypoxia Administer 100% oxygen. 4. Tension pneumothorax Perform needle decompression. 5. IDDM and Dialysis (Acidosis) Administer Sodium Bicarbonate 1 meq/kg IVP/IO. 6. Cardiac tamponade Continue CPR. 7. Drug overdose Administer reversal agent as indicated. 8. Hypothermia Initiate rewarming activities. 9. Renal Failure / Dialysis (Hyperkalemia) Administer Calcium Chloride10% 500 mg and Sodium Bicarbonate 1 meq/kg IVP/IO. E. Administer epinephrine 1 mg 1:10,000 IVP/IO every 3-5 minutes followed by 200 compressions. F. If ROSC at any time refer to Protocol No. 4.13, Return of Spontaneous Circulation. Page 78 of 122

82 SECTION 4 Cardiac Protocols 4.2 Asystole/PEA - Adult 1. Initiate transport to closest receiving hospital. G. Make Determination of Death without base hospital contact if no ROSC After 30 Minutes when all of the following are true: 1. No ROSC at anytime 2. No shocks at anytime (due to no shockable rhythm) 3. Successful insertion of an advanced airway such as I-Gel Tube or oral tracheal tube with ETCO2 Less than 10mmHg 4. Arrest not witnessed by EMS personnel 5. Discontinue resuscitation and determine death without base hospital contact. 6. Contact base hospital for determination of death if none of the criteria listed in IV. G. are met. Page 79 of 122

83 SECTION 4 Cardiac Protocols 4.3 Asystole/PEA - Pediatric 4.3 Asystole/PEA - Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. while confirming pulselessness and appropriate (non shockable) rhythm on the cardiac monitor. II. Treatment: A. Continue administering continuous chest compressions and ventilate the patient 8-10 times per minute. DO NOT HYPERVENTILATE. B. Perform immediate, effective CPR for 15 minutes before transport C. Continue CPR, maintain patent airway with 100% oxygen via BVM. D. Provide appropriate airway management with simplest most effective airway adjunct. See Pediatric Airway Protocol No ALS E. Establish IV/IO of normal saline TKO and obtain capnography.. F. Administer Epinephrine 0.01 mg/kg (1:10,000) IVP/IO, max of 1 mg. Repeat every 6-8 minutes G. Obtain blood glucose H. Consider reversible causes and treat as indicated. 1. Special pediatric populations a) Dialysis patient consider sodium bicarbonate 1mEq/kg max 50mEq per dose and Calcium chloride 20 mg/kg max 1grqm per dose. May repeat once b) Known Diabetic patient or blood sugar reading high consider sodium bicarbonate 1mEq/kg max 50mEq per dose. May repeat 3 times. c) Metabolic disease if possible, obtain emergency treatment card with patient or family and follow any special instructions. 2. Continue CPR for 5 cycles/2 minutes and recheck pulse/rhythm. I. Prepare for emergent transport upon ROSC. Transport to STEMI center if greater than 10 years old or has a cardiac history. J. Initiate transport to closest hospital after 15 minutes of high quality CPR if ROSC not achieved. Note: In cases where transport is not available or practical an order to terminate resuscitation efforts may be given by the Base Hospital Physician for patients in Asystole or PEA for greater than 30 min with capnography less than 20mmHg that are unresponsive to treatment (See EMS Policy No. 5103, Determination of Death). Page 80 of 122

84 SECTION 4 Cardiac Protocols 4.4 Ventricular Fibrillation & Pulseless V-Tach - Adult 4.4 Ventricular Fibrillation & Pulseless V-Tach - Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. ALS II. If ALS personnel witness a change in patient condition to ventricular fibrillation or pulseless VTach, immediately defibrillate the patient one time using manufacturer recommended dose of energy. III. After completing four (4) rounds of MICR (8 Minutes), confirm pulselessness and rhythm and proceed with treatment as described below. IV. Treatment: A. Consider reversible Causes and treat as indicated 1. Suspected hyperkalemia in renal dialysis patients Consider administration of Calcium Chloride 10% 500mg IVP/IO and Sodium Bicarbonate 1 meq/kg, and consult Base Hospital Physician to discuss further management. 2. Hypoglycemia If blood sugar is less than 60 mg/dl, administer either Dextrose 50% 25 Gms IVP; or Dextrose 10% 50 ml IV/IO bolus, repeated every minute until GCS is 15. Maximum dose of Dextrose 10% is 10 ml/kg 3. If Torsades, immediately give Magnesium 2g IVP/IO 4. Hypovolemia Start two (2) large bore IV/IO lines and administer rapid 2 liter volume infusion of NS, then 250 ml boluses until systolic blood pressure is >90 mmhg. 5. Hypoxia Administer 100% oxygen. 6. Tension pneumothorax Perform needle decompression. 7. IDDM and Dialysis (Acidosis) Administer Sodium Bicarbonate 1 meq/kg IVP/IO. 8. Cardiac tamponade Continue CPR. 9. Drug overdose Administer reversal agent as indicated. 10. Hypothermia Initiate rewarming activities. 11. Renal Failure / Dialysis (Hyperkalemia) Administer Calcium Chloride10% 500 mg and Sodium Bicarbonate 1 meq/kg IVP/IO. B. Administer epinephrine 1 mg 1:10,000 IVP/IO every 3-5 minutes C. Defibrillate one (1) time at joules (biphasic); or one (1) time at 360 joules (monophasic); immediately resume compressions without waiting for a rhythm check. D. Administer Lidocaine 1 mg/kg IVP/IO. May repeat one in 3-5 minutes V. Patient Transport: A. For a patient with a ROSC at any time See ROSC Protocol No. 4.13, Return of Spontaneous Circulation. 1. Perform 12 lead ECG, Page 81 of 122

85 SECTION 4 Cardiac Protocols 4.4 Ventricular Fibrillation & Pulseless V-Tach - Adult 2. Initiate transport to STEMI center. 3. If patient loses ROSC during transport alter destination to closest receiving hospital. B. For patients in refractory v-fib/v-tach (No ROSC) VI. Initiate transport to closest receiving hospital after placement of advanced airway or 16 Min (8 Rounds MICR). Page 82 of 122

86 SECTION 4 Cardiac Protocols 4.5 Ventricular Fibrillation & Pulseless V-Tach - Pediatric 4.5 Ventricular Fibrillation & Pulseless V-Tach - Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0., while confirming pulselessness and appropriate (non-shockable) rhythm on the cardiac monitor. II. Treatment A. Perform immediate, effective CPR for 15 minutes before transport B. Continue CPR, maintain patent airway with 100% oxygen via BVM. C. Provide appropriate airway management with simplest most effective airway adjunct. See Pediatric Airway Management Protocol No ALS D. Defibrillate patient one (1) time at 2J/kg and then resume CPR immediately for 5 cycles/2 minutes (do not check rhythm or pulse after shock). E. Establish IV/IO of normal saline TKO and obtain capnography.. F. Check rhythm/pulse. If shockable rhythm, defibrillate 1 4J/kg and resume CPR immediately after the shock. G. Administer Epinephrine 0.01 mg/kg (1:10,000) IVP/IO, max of 1 mg. Repeat every 6-8 minutes H. Continue CPR for 5 cycles/2 minutes while performing appropriate airway management. I. After 2 minutes of CPR, check rhythm and if appropriate defibrillate at 4J/kg. J. Continue CPR for 2 minutes K. If patient continues to be in shockable rhythm, defibrillate again at 4 J/kg and administer Lidocaine 1 mg/kg IVP/IO (may repeat x1 in 3-5 minutes). L. If non shockable rhythm present, treat according to appropriate protocol. M. Continue CPR for 5 cycles/2 minutes and recheck pulse/rhythm. N. Prepare for emergent transport upon ROSC. Transport to STEMI center if greater than years old or has a cardiac history. O. Initiate transport to closest hospital after 15 minutes of high quality CPR if ROSC not achieved. Page 83 of 122

87 SECTION 4 Cardiac Protocols 4.6 Wide Complex Tachycardia with a Pulse - Adult 4.6 Wide Complex Tachycardia with a Pulse - Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Unconscious Patient: ALS A liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. B. ECG and 12 Lead C. Establish an IV/IO of normal saline (NS) TKO. D. Cardioversion: 1. Synchronized cardioversion at 100 joules (biphasic). 2. If no response: repeat synchronized cardioversion at 150 joules (biphasic). 3. If no response: repeat synchronized cardioversion at 200 joules (biphasic). 4. If rhythm does not convert with cardioversion administer lidocaine 1 mg/kg IVP. May repeat one (1) time in 3-5 minutes. E. Initiate transport. F. Consult with Base Hospital Physician for further interventions. III. Conscious and Unstable (unstable chest pain, systolic blood pressure less 90 mmhg, decreased level of consciousness, shortness of breath, signs of shock): A. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. ALS B. Initiate transport. C. Place on 12 Lead ECG if chest pain is present. D. Establish an IV/IO of NS TKO. Page 84 of 122

88 SECTION 4 Cardiac Protocols 4.6 Wide Complex Tachycardia with a Pulse - Adult E. In the presence of continuous chest pain, administer lidocaine 1 mg/kg IVP. May repeat every 5-10 minutes at ½ the initial dose up to a total of 3 mg/kg. F. Lidocaine drip: 1 gram in 250ml NS. Utilizing a dial-a-flow and extension tubing, administer 2-4 mg/min to decrease of eliminate ventricular ectopy. G. If wide complex tachycardia persists consult base hospital physician about sedation and synchronized cardioversion. IV. Conscious Stable Patient (No chest Pain, No Shortness of breath or ALOC, systolic blood pressure above 90 mmhg). ALS A. Oxygen 2-6 liters per minute via nasal cannula or liters per minute via non- rebreather mask. B. Place on 12 Lead ECG if chest pain is present C. Transport D. IV/IO of NS TKO E. Lidocaine1 mg/kg IVP. May repeat every 5-10 minutes at ½ the initial dose up to a total of 3 mg/kg. V. **Do not administer nitroglycerine for chest patient. Page 85 of 122

89 SECTION 4 Cardiac Protocols 4.7 Wide Complex Tachycardia with a Pulse - Adult 4.7 Wide Complex Tachycardia with a Pulse Pediatric Definitions: A. Sinus Tachycardia indicates a rapid heart rate with a narrow QRS (less than or equal to 0.08 sec.) that is less than 220/min. in an infant or less than 180/min. in a child. B. Supraventricular Tachycardia indicates a rapid heart rate with a narrow QRS (less than or equal to 0.08 sec.) that is greater than 220/min. in an infant or greater than 180/min. in a child. C. Ventricular Tachycardia indicates a rapid heart rate with a wide QRS (greater than 0.08 sec.). I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Treatment: A. Consider pediatric normal values for heart rate. Infants may have heart rates as high as 220/minute and children may have heart rates as high as 180/minute in the presence of fever, anxiety, and/or pain. B. Manage airway and ventilations as indicated. ALS C. Establish IV/IO of normal saline TKO. D. Treat according to rhythm: 1. Sinus Tachycardia: a) Consider and treat underlying cause (fever, pain, trauma, hypovolemia). b) Consider fluid bolus of normal saline 20 ml/kg IVP/IO. May repeat 10mL/kg x2 as indicated c) Recheck vital signs after each bolus. d) If suspected trauma, refer to EMS Protocol No. 5.1, Trauma Treatment Adult and Pediatric. 2. Supraventricular Tachycardia: a) Conscious: (1) Attempt vagal maneuver. (2) If unsuccessful, administer Adenosine 0.1mg/kg rapid IVP/IO push to a maximum dose of 6 mg followed by rapid 20ml flush of normal saline. (3) If unsuccessful, administer Adenosine 0.2mg/kg rapid IVP/IO push (to a maximum dose of 12 m) followed by rapid 20ml flush of normal saline. Page 86 of 122

90 SECTION 4 Cardiac Protocols 4.7 Wide Complex Tachycardia with a Pulse - Adult (4) If unsuccessful and hypotensive, give fluid bolts and contact Base Hospital for further orders b) Unconscious: (1) Transport without delay. (2) Administer Adenosine 0.1mg/kg rapid IVP/IO push, to a maximum dose of 6mg followed by rapid 20ml flush of normal saline while setting up to perform cardioversion. (3) Perform synchronized cardioversion at 1 J/kg. (a) If no response at 1 J/kg, perform synchronized cardioversion at 2 J/kg. (b) If no response, perform synchronized cardioversion at 4 J/kg. (4) If cardioversion is successful, consult with Base Hospital Physician for post cardioversion medication orders. (5) If pain after cardioversion may give Fentanyl per Protocol No Pain Management Pediatric. Page 87 of 122

91 SECTION 4 Cardiac Protocols 4.8 Narrow Complex Tachycardia; A-Fib/A-flutter 4.8 Narrow Complex Tachycardia; A-Fib/A-flutter I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. ALS II. Unstable systolic BP less than 90 mmhg, altered level of consciousness, signs of shock: A. Place on 12 Lead ECG. B. Establish an IV of NS TKO. C. Initiate transport. Make early notification of receiving hospital. D. 500 ml fluid bolus of normal saline. Repeat up to 4 times with a goal of achieving a systolic BP of greater than 110 mmhg. Reassess after each administration for signs of fluid overload. E. Do not administer any medication without consulting base hospital physician. III. Stable: A. Place on 12 Lead ECG. B. Establish an IV of NS TKO. C. Initiate transport. D. Do not administer any medication without consulting base hospital physician. E liters per minute via non- rebreather mask for patients with signs of respiratory distress. Patient s with ineffective respirations: support ventilations with BVM and appropriate airway adjunct. Page 88 of 122

92 SECTION 4 Cardiac Protocols 4.9 Supraventricular Tachycardia (SVT) 4.9 Supraventricular Tachycardia (SVT) I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. ALS II. Unstable (systolic blood pressure less 90 mmhg, decreased level of consciousness, shortness of breath, signs of shock): A. Perform 12 Lead ECG. B. Establish an IV (AC or higher) of normal saline (NS) TKO. C. Initiate transport. D. Administer Adenosine 6 mg rapid IVP immediately followed by 20 ml of NS. E. Administer 500 ml fluid bolus of normal saline. F. Consult with Base Hospital Physician about cardioversion: 1. Synchronized cardioversion at 100 joules (monophasic energy dose of equivalent biphasic energy dose). 2. If no response: repeat synchronized cardioversion at 200 joules. (monophasic energy dose of equivalent biphasic energy dose). 3. If no response: repeat synchronized cardioversion at 300 joules (monophasic energy dose of equivalent biphasic energy dose). 4. If no response: repeat synchronized cardioversion at 360 joules (monophasic energy dose of equivalent biphasic energy dose). III. Stable: A. Perform 12 Lead ECG B. Consider reversible causes of tachycardia including hypoxia and hypovolemia and treat accordingly. C. Perform Valsalva s maneuver. D. Establish an IV (AC or higher) of NS TKO. E. Administer Adenosine 6 mg rapid IVP immediately followed by 20 ml of NS. F. If no response after two (2) minutes: administer Adenosine 12 mg rapid IVP followed by 20 ml of NS. G. If no response after two (2) minutes: administer Adenosine 12 mg rapid IVP followed by 20 ml of NS. H. Initiate transport. Page 89 of 122

93 SECTION 4 Cardiac Protocols 4.10 Bradycardia - Adult 4.10 Bradycardia - Adult I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. ALS II. Stable Patients: A. Monitor patient and transport. B. Consult Base Hospital Physician as needed. C. Do not administer Nitroglycerine. III. Unstable Patients (Systolic blood pressure, 90 mmhg, signs of shock, decreased level of consciousness, and shortness of breath): A. Perform 12 lead ECG. B. If sinus bradycardia: 1. Establish IV/IO of normal saline (NS) TKO. 2. Administer fluid challenge of 250 ml NS. Recheck vital signs after every 250 ml. 3. Administer atropine in increments of 0.5 mg IVP every five (5) minutes to a maximum of 1.5 mg. Reassess after each administration. a) If heart rate increases following initial 1.5 mg of atropine and patient the patient remains unstable then administer additional doses of atropine in increments of 0.5 mg IVP every (5) minutes to a maximum of 3 mg. Goal is to achieve systolic BP greater than 90 mmhg. C. If complete heart block prepare to initiate transcutaneous pacing, and sedation. D. Consult Base Hospital Physician. 1. Initiate transcutaneous pacing. 2. Provide sedation with midazolam 1-2 mg and/or morphine sulfate 1-2 mg slow IVP. Titrate to effect. 3. If capture is maintained, but patient remains symptomatic, consider fluid challenges of 250 ml NS. Recheck vital signs after every 250 ml or more frequently as needed. 4. If inadequate response to atropine and pacing, consider dopamine 400 mg/250 ml premix. Using a dial-a-flow start at 10 mcg/kg/min and titrate to systolic blood pressure 90 mmhg. (See next page for dopamine dosage chart). Page 90 of 122

94 SECTION 4 Cardiac Protocols 4.10 Bradycardia - Adult E. For renal failure / dialysis (suspected hyperkalemia): consult with Base Hospital Physician to obtain order for administration of Calcium Chloride 10% 500 mg and Sodium Bicarbonate 1 meq/kg IVP/IO. Page 91 of 122

95 SECTION 4 Cardiac Protocols 4.11 Bradycardia - Pediatric 4.11 Bradycardia - Pediatric I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Treatment A. Assure adequate oxygenation and ventilation. Most bradycardia in children is due to hypoxia. See Protocol No. 2.2, Pediatric Airway Management. ALS B. Check blood glucose. C. Check temperature and begin warming if hypothermic. D. Normal Perfusion: 1. Establish IV/IO of normal saline TKO. 2. Obtain 12 lead EKG E. Decreased Perfusion and/or Respiratory Distress (I.e. hypotension, delayed capillary refill, acute altered level of consciousness): 1. fluid bolus of 20ml/kg.may repeat with 10 ml/kg x2use caution in history of heart failure or dialysis.. These patients give 10mL/kg per bolts up to four times. Reassess lung sounds and oxygen data between boluses 2. Recheck vital signs. 3. If patient remains bradycardic despite adequate oxygenation and ventilation, administer Epinephrine 0.01mg/kg 1:10,000IVP/IO to a maximum dose of 1mg. May repeat epinephrine dose every 3-5 minutes as indicated. 4. If increased vagal tone or AV block present, administer Atropine 0.02mg/kg IVP/IO, minimum dose 0.1mg and maximum dose 1mg. May repeat once. 5. If HR <60/min with poor perfusion despite 02 and Ventilation Begin CPR. 6. If bradycardia remains, consult with Base Hospital Physician. Page 92 of 122

96 SECTION 4 Cardiac Protocols 4.12 Cardiogenic Shock 4.12 Cardiogenic Shock I. Perform routine ALS/BLS medical care is directed in Protocol 1.0. II. Treatment: A. Apply oxygen at 10 to 15 liters per minute via non-rebreather mask. ALS B. Obtain 12 Lead ECG and transport to an SRC if indicated. C. Treat significant arrhythmias. D. Establish IV of normal saline (NS) TKO. E. For hypotension administer NS IV fluid in 250 ml increments up to 2 liters. Check oxygen saturations and lung sounds after each administration. If patient s lungs are not clear when assessed after bolus, discontinue the fluid challenge and proceed to dopamine infusion. F. If systolic blood pressure remains <90 mmhg following the fluid challenges, initiate infusion of dopamine titrated at 10 mcg/kg/min to a systolic blood pressure of 90 mmhg using a dial-a-flow with extension tubing. G. Initiate transport. H. Consider CPAP if lung sounds are not clear and patient has signs and symptoms of respiratory distress. Page 93 of 122