TABLE OF CONTENTS. Contra Costa County Prehospital Care Manual January 2010 Page 57. General Treatment Guidelines (All Patients)

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1 TABLE OF CONTENTS Adult Treatment Guidelines A1 Adult Patient Care A2 Chest Pain / Suspected ACS A3 Cardiac Arrest Initial Care and CPR A4 Ventricular Fibrillation / V. Tachycardia A5 PEA / Asystole A6 Symptomatic Bradycardia A7 Ventricular Tachycardia with Pulses A8 Supraventricular Tachycardia A9 Other Dysrhythmias A10 Shock General Treatment Guidelines (All Patients) G1 Allergy and Anaphylaxis G2 Altered Level of Consciousness G3 Behavioral Emergency G4 Burns G5 Childbirth G6 Dystonic Reaction G7 Envenomation G8 Heat Illness / Hyperthermia G9 Hypothermia G10 Pain Management G11 Poisoning / Overdose G12 Respiratory Depression or Apnea G13 Respiratory Distress G14 Seizure G15 Stroke G16 Trauma Pediatric Treatment Guidelines P1 Pediatric Patient Care P2 Cardiac Arrest Initial Care and CPR P3 Neonatal Resuscitation P4 Ventricular Fibrillation / V. Tachycardia P5 PEA / Asystole P6 Symptomatic Bradycardia P7 Tachycardia P8 Shock Procedures and Patient Care References Spinal Immobilization Vascular Access 12-Lead ECG and STEMI Key Paramedic Procedures Pediatric Assessment Pediatric Vital Signs and GCS Scoring ABC Maneuvers for Adults, Children and Infants Policy Summaries / Hospital References Base Hospital and Receiving Facilities Destination Determination Destination and Obstetric Patients Trauma Triage Criteria Trauma Base Call-In Criteria Helicopter Transport Criteria Rule of Nines (Burn Surface Area) Burn Patient Destination Burn Centers Declining Medical Care or Transport (AMA) Determination of Death Restraints Drug References Adult Drug Reference Dopamine Drip Chart Pediatric Drug Reference Pediatric Drug Dosage Charts Contra Costa County Prehospital Care Manual January 2010 Page 57

2 INSTRUCTIONS FOR USE This field manual is intended to provide Contra Costa EMS prehospital personnel with quick reference to treatment guidelines and other critical reference materials for patient treatment. The Contra Costa Prehospital Care Manual includes the contents of this field manual as well as additional reference materials not in this manual. The entire Prehospital Care Manual can be accessed at Updates and corrections to this manual may also be posted at this website. Treatment Guidelines are divided into three main groupings: Adult, Pediatric, and General Guidelines. The General Guidelines include treatment guidelines that pertain to both adult and pediatric treatments. Treatment Guidelines A1 (Adult General Care) and P1 (Pediatric General Care) address basic concepts of care that are pertinent to all patients. This information is not repeated in other treatment guidelines. Policy summaries reflect critical information for field personnel. For full policies, please refer to Page 58 Contra Costa County Prehospital Care Manual January 2010

3 A1 ADULT ADULT PATIENT CARE These basic concepts should be addressed for all adult patients (age 15 and over) Scene Safety Body Substance Use universal blood and body fluid precautions at all times Isolation Systematic Assessment Determine Primary Impression Base Contact Assure open and adequate airway. Management of ABC s is a priority. Place patient in position of comfort unless condition mandates other position (e.g. shock, coma) spinal immobilization if history or possibility of traumatic injury exists Apply appropriate field treatment guideline(s) Explain procedures to patient and family as appropriate Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines are considered Use SBAR to communicate with base Transport Document Minimize scene time in critical trauma, STEMI, stroke, shock, and respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR Document patient assessment and care per policy Contra Costa County Prehospital Care Manual January 2010 Page 59

4 A2 ADULT CHEST PAIN SUSPECTED ACUTE CORONARY SYNDROME OXYGEN Low flow Caution: Do not administer or allow patient to take Nitroglycerin if patient has taken PRECAUTION erectile dysfunction meds Viagra or Levitra within 24 hrs or Cialis within 36 hrs. In these situations, severe hypotension may occur as a result of NTG administration. Nitroglycerin BLS Personnel: Allow patient to take own if BP greater than 90 CARDIAC MONITOR STEMI Alert if appropriate. Perform right-sided lead (V4R) if inferior MI noted. 12 LEAD ECG Repeat ECGs are encouraged. 325 mg po to be chewed by patient DO NOT administer if patient has allergies to ASPIRIN aspirin or salicylates or has apparent active gastrointestinal bleeding IV TKO 0.4 mg sl if systolic BP above 90. May repeat every 5 minutes until pain subsides, NITROGLYCERIN maximum 6 doses or BP less than 90 systolic. Do not administer Nitroglycerin if Right Ventricular MI suspected 2-20 mg IV in 2-4 mg increments for pain relief if BP greater than 90 and NTG not effective. earlier administration to patients in severe distress from pain. Titrate to pain relief, systolic BP greater than 90, and adequate respiratory MORPHINE effort. SULFATE If persistent pain, continue NITROGLYCERIN to maximum of 6 doses. Do not administer Morphine Sulfate if Right Ventricular MI suspected 250 ml NS if BP less than 90, lungs clear and unresponsive to positioning. May repeat X 1. Patients with Right Ventricular MI may require multiple fluid FLUID BOLUS boluses. Key Treatment ations Classic symptoms: Substernal pain, discomfort or tightness with radiation to jaw, left shoulder or arm, nausea, diaphoresis, dyspnea, anxiety Diabetic, female or elderly patients frequently present atypically Atypical symptoms can include syncope, weakness or sudden onset fatigue Rapid identification of STEMI to speed intervention is the goal of 12-lead ECG 12-lead ECG should be acquired as soon as possible after arrival (ideally within 5 minutes) 12-lead ECG should be acquired before initial NTG administration Minimize scene time in STEMI patients If STEMI noted and ST elevation is noted in inferior distribution (leads II, III, and avf), the possibility for right ventricular MI (RVMI) exists o Perform ECG with right-sided lead (V4R) mirrored in the same orientation as V4. RVMI should be suspected if ST elevation of 1 mm or greater in V4R. o Patients with RVMI may present with shock or poor perfusion in the presence of clear lungs and may have JVD. o Nitroglycerin and Morphine should not be administered in the setting of RVMI. Trendelenburg positioning and fluid bolus is appropriate treatment for shock in this setting. If STEMI noted and ST elevation is noted in anterior distribution (V1-V4), patient is at higher risk for pump failure and CHF on presentation Many STEMI s evolve during prehospital period and are not noted during first ECG, so repeat 12-lead ECGs are encouraged (avoid artifact by patient or vehicle movement) IV placement prior to NTG recommended in patients who have not taken NTG previously Page 60 Contra Costa County Prehospital Care Manual January 2010

5 AIRWAY A3 ADULT VENTILATIONS COMPRESSIONS CARDIAC ARREST INITIAL CARE AND CPR Open airway and utilize BLS airway for initial management If ResQPOD available, King Airway should be used as soon as possible but should not interfere with compressions - keep interruption less than 10 seconds Ventilations: Give 2 breaths initially Administer each breath over 1 second and observe for chest rise CPR for 2 minutes or 5 cycles before rhythm analysis if: Witnessed arrests with 5 minutes or more time elapsed without CPR Unwitnessed arrests CPR until defibrillator available for rhythm analysis for all other witnessed arrests Compressions: Depth inches in adults allow full recoil of chest Rate - 100/minute Compression/ventilation ratio - 30:2 Rotate compressors every 2 minutes if manual compression used Apply mechanical compression device (if available) after first 2-minute cycle of CPR CARDIAC MONITOR IV / IO ACCESS ADVANCED AIRWAY TREATMENT ON SCENE To minimize CPR interruptions: Perform CPR during charging of defibrillator Resume CPR immediately after shock (do not stop for pulse or rhythm check) Determine cardiac rhythm and follow specific treatment guideline Preferred IV site - antecubital vein If antecubital access not apparent or if unsuccessful, use IO access IO access is preferable to external jugular Hand veins and other smaller veins should be avoided in cardiac arrest Advanced airway management is not essential early in resuscitation and should not interfere with resuscitation in the first 2-3 CPR cycles (two minutes per cycle) Exception: If ResQPOD used, early use of King Airway is appropriate King Airway may be inserted more rapidly and causes less CPR interruption than endotracheal intubation efforts Placement of King Airway or endotracheal tube should not interrupt compressions for more than 10 seconds For endotracheal intubation, position and visualize airway prior to cessation of compressions for tube passage Ventilation rate with advanced airway 8-10 breaths/minute Provide initial and continuous confirmation of tube placement with end-tidal carbon dioxide monitoring Movement of a patient may interrupt CPR or prevent adequate depth and rate of compressions, which may be detrimental to patient outcome Provide resuscitative efforts on scene up to 30 minutes to maximize chances of return of spontaneous circulation (ROSC) If resuscitation efforts do not attain ROSC, consider cessation of efforts per policy Contra Costa County Prehospital Care Manual January 2010 Page 61

6 A4 ADULT INITIAL CARE DEFIBRILLATION CPR VENTILATION/AIRWAY VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA See Cardiac Arrest Initial Care and CPR (A3) 200 joules (low energy 120 joules) For 2 minutes or 5 cycles between rhythm check and shock If ResQPOD available, utilize King Airway early If no ResQPOD available, use BLS airway in first 2-3 cycles of CPR o Defer advanced airway unless BLS airway inadequate TKO. Should not delay shock or interrupt CPR 300 joules (low energy 150 joules) 1:10,000-1 mg IV or IO every 3-5 minutes For 2 minutes or 5 cycles between rhythm check and shock 360 joules (low energy 200 joules) 300 mg IV or IO For 2 minutes or 5 cycles between rhythm check and shock 360 joules (low energy 200 joules) as indicated after every CPR cycle Should not interfere with first 2-3 CPR cycles minimize interruptions IV or IO DEFIBRILLATION EPINEPHRINE CPR DEFIBRILLATION AMIODARONE CPR DEFIBRILLATION ADVANCED AIRWAY repeat If rhythm persists, 150 mg IV or IO, 3-5 minutes after initial dose AMIODARONE TRANSPORT If indicated SODIUM 1 meq/kg IV or IO for suspected hyperkalemia, profound acidosis or prolonged BICARBONATE down time with return of circulation If Return of Spontaneous Circulation, see Symptomatic Bradycardia (A6), Shock (A10) if treatment indicated Key Treatment ations Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second. If advanced airway placed, perform CPR continuously without pauses for ventilation If available, ResQPOD impedance threshold device may be used Place King Airway to utilize ResQPOD early in CPR If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage. Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement and continuously monitor Prepare drugs before rhythm check and administer during CPR Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) Follow each drug with 20 ml NS flush Sodium bicarbonate should only be given for listed indications, and should not be given if ventilation ineffective Page 62 Contra Costa County Prehospital Care Manual January 2010

7 A5 ADULT PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE INITIAL CARE See Cardiac Arrest Initial Care and CPR (A3) If ResQPOD available, utilize King Airway early VENTILATION/AIRWAY If no ResQPOD available, use BLS airway in first 2-3 cycles of CPR o Defer advanced airway unless BLS airway inadequate IV or IO TKO EPINEPHRINE 1:10,000 1 mg IV or IO every 3-5 minutes Asystole or PEA with rate less than 60: 1 mg IV or IO. ATROPINE Repeat every 3-5 minutes to total dose of 3 mg treatable causes treat if applicable: 500 ml NS IV or IO for hypovolemia FLUID BOLUS VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia. SODIUM BICARBONATE CALCIUM CHLORIDE WARMING MEASURES 1 meq/kg IV or IO for hydrogen ion (acidosis), tricyclic antidepressant or aspirin overdose, or hyperkalemia 500 mg IV or IO may repeat in 5-10 minutes for hyperkalemia or calcium channel blocker overdose For hypothermia NEEDLE For tension pneumothorax THORACOSTOMY If Return of Spontaneous Circulation, see Symptomatic Bradycardia (A6), Shock (A10) if treatment indicated Key Treatment ations Uninterrupted CPR is the key to successful resuscitation. Its performance takes precedence over advanced airway management and administration of medications. Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second If advanced airway placed, perform CPR continuously without pauses for ventilation If available, ResQPOD impedance threshold device may be used Place King Airway to utilize ResQPOD early in CPR If utilizing Endotracheal Tube, minimize CPR interruptions by positioning airway and laryngoscope, and performing airway visualization prior to cessation of CPR for tube passage. Immediately resume CPR after passage. Confirm placement of advanced airway (King Airway or ET tube) with end-tidal carbon dioxide measurement and continuously monitor Prepare drugs before rhythm check and administer during CPR Follow each drug with 20 ml NS flush Acidosis or hyperkalemia should be suspected in patients with renal failure or dialysis or if suspected diabetic ketoacidosis Contra Costa County Prehospital Care Manual January 2010 Page 63

8 A6 ADULT SYMPTOMATIC BRADYCARDIA - Heart rate less than 60 with signs or symptoms of poor perfusion (e.g., acute altered mental status, hypotension, other signs of shock) OXYGEN High flow. Be prepared to support ventilation as needed CARDIAC MONITOR 12-LEAD ECG pre- and post-treatment if condition permits TKO. If not promptly available, proceed to external cardiac pacing. IO IV ACCESS if patient in extremis and unconscious or not responsive to painful stimuli. TRANSCUTANEOUS Set rate at 80 PACING Start at 10 ma, and increase in 10 ma increments until capture is achieved If pacing urgently needed, sedate after pacing initiated. MIDAZOLAM - initial dose 1 mg IV or IO, titrated in 1-2 mg increments SEDATION (maximum dose 5 mg), and/or MORPHINE SULFATE 1-5 mg IV or IO in 1 mg increments for pain relief if BP 90 systolic or greater ATROPINE 0.5 mg IV or IO if availability of pacing delayed or pacing ineffective repeat 0.5 mg IV or IO every 3-5 minutes to maximum of 3 mg Use with caution in patients with suspected ongoing cardiac ischemia. Atropine should not be used in wide-qrs second- and third-degree blocks. TRANSPORT ml NS if clear lung sounds and no respiratory distress FLUID BOLUS DOPAMINE Begin infusion at 5 mcg/kg/min if not responsive to pacing or atropine (see table) Key Treatment ations Sinus bradycardia in the absence of key symptoms requires no specific treatment (monitor / observe) Sedation prior to starting pacing is not required. Patients with urgent need should be paced first. The objective of sedation in pacing is to decrease discomfort, not to decrease level of consciousness. Patients who are in need of pacing are unstable and sedation should be done with great caution. Monitor respiratory status closely and support ventilation as needed Atropine is not effective for bradycardia in heart-transplant patients (no vagus nerve innervation in these patients) Patients with wide-qrs second- and third-degree blocks will not have a response to atropine because these heart rates are not based on vagal tone. An increase in ventricular arrhythmias may occur. Page 64 Contra Costa County Prehospital Care Manual January 2010

9 A7 ADULT VENTRICULAR TACHYCARDIA WITH PULSES Widened QRS Complex (greater than or equal to 0.12 sec) generally regular rhythm INITIAL THERAPY OXYGEN High flow. Be prepared to support ventilation as needed. CARDIAC MONITOR 12-LEAD ECG pre- and post treatment if condition permits IV TKO STABLE VENTRICULAR TACHYCARDIA AMIODARONE 150 mg IV over 10 minutes (intermittent IV push or IV infusion of 15 mg/min) repeat If rhythm persists and patient remains stable, 150 mg IV over 10 minutes AMIODARONE UNSTABLE VENTRICULAR TACHYCARDIA Poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION: If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) 100 joules (low energy setting 75 W/S) 200 joules (low energy setting 120 W/S) 300 joules (low energy setting 150 W/S) 360 joules (low energy setting 200 W/S) If VT recurs, use lowest energy level previously successful Key Treatment ations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Give AMIODARONE via Infusion or slow IV push only Caution with administration of AMIODARONE. May cause hypotension, especially if given rapidly. AMIODARONE should not be used in unstable patients. Patients with pre-existing hypotension should be considered unstable and should not receive AMIODARONE. If sedation done for cardioversion, monitor respiratory status closely and support ventilations as needed Contra Costa County Prehospital Care Manual January 2010 Page 65

10 A8 ADULT SUPRAVENTRICULAR TACHYCARDIA Heart rate greater than 150 beats per minute regular rhythm usually with narrow QRS complex OXYGEN INITIAL THERAPY High flow. Be prepared to support ventilation as needed. CARDIAC MONITOR 12-LEAD ECG pre- and post-treatment if condition permits IV TKO STABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) May have mild chest discomfort VALSALVA ADENOSINE 6 mg rapid IV - followed by 20 ml normal saline flush If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once. UNSTABLE SVT May need immediate synchronized cardioversion Signs of poor perfusion, moderate to severe chest pain, dyspnea, blood pressure less than 90 or CHF If rhythm not regular, SVT unlikely If wide QRS complex, consider ventricular tachycardia ADENOSINE SEDATION SYNCHRONIZED CARDIOVERSION 6 mg rapid IV - followed by 20 ml normal saline flush. If not converted, 12 mg rapid IV 1-2 minutes after initial dose, followed by 20 ml normal saline flush. May repeat dose once. Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) 50 joules (low energy setting 50 W/S) 100 joules (low energy setting 75 W/S) 200 joules (low energy setting 120 W/S) 300 joules (low energy setting 150 W/S) 360 joules (low energy setting 200 W/S) Key Treatment ations Document rhythm during treatment with continuous strip recording Rhythm analysis should be based on recorded strip, not monitor screen Be prepared for previously stable patient to become unstable Proceed to cardioversion if patient becomes unstable Do not administer Adenosine if poison - or drug-induced tachycardia If sedation done for cardioversion, monitor respiratory status closely and support ventilation as needed Page 66 Contra Costa County Prehospital Care Manual January 2010

11 A9 OTHER CARDIAC DYSRHYTHMIAS ADULT SINUS TACHYCARDIA Heart rate , regular ATRIAL FIBRILLATION Heart rate highly variable, irregular ATRIAL FLUTTER Variable rate depending on block. Atrial rate , saw-tooth pattern INITIAL THERAPY OXYGEN Low flow. High flow if unstable. CARDIAC MONITOR 12-lead ECG pre- and post-treatment if patient symptomatic and condition permits 12-LEAD ECG IV TKO UNSTABLE ATRIAL FIBRILLATION OR ATRIAL FLUTTER Ventricular rate greater than 150, and: BP less than 80, or unconsciousness / obtundation, or severe chest pain or dyspnea OXYGEN High flow. Be prepared to support ventilation. SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION. If awake and aware, sedate with MIDAZOLAM - initial dose 1 mg IV, titrate in 1-2 mg increments (max. dose 5 mg) Atrial Flutter Only - Initial Level: 50 joules (low energy setting 50 joules) Atrial Flutter and Atrial Fibrillation: 100 joules (low energy setting 75 joules) 200 joules (low energy setting 120 joules) 300 joules (low energy setting 150 joules) 360 joules (low energy setting 200 joules) Key Treatment ations Sinus tachycardia commonly present because of pain, fever, hypovolemia Atrial fibrillation may be well-tolerated with moderately rapid rates ( ) and often requires no specific treatment other than observation (oxygen, monitoring and transport) If sedation done for cardioversion, monitor respiratory status closely and support ventilation as needed Computerized rhythm analysis on 12-lead ECG is frequently incorrect and requires review of the ECG to verify rhythm Computerized analysis for Acute MI (STEMI) may be incorrect with very fast rhythms. If ***Acute MI*** or ***Acute MI Suspected*** message encountered, the patient s heart rate is important information to relate to the STEMI center at time of activation. Contra Costa County Prehospital Care Manual January 2010 Page 67

12 A10 ADULT SHOCK HYPOVOLEMIC OR SEPTIC SHOCK - Signs and symptoms of shock with dry lungs, flat neck veins May have poor skin turgor, history of GI bleeding, vomiting or diarrhea May be warm and flushed, febrile May have history of high fever (sepsis) SHOCK (NOT CARDIOGENIC) OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO FLUID BOLUS ml NS Recheck vitals every 250 ml to a maximum of 1 liter BLOOD GLUCOSE Check and treat if indicated DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table) Related guidelines: Altered level of consciousness (G2), Respiratory Depression or apnea (G12) CARDIOGENIC SHOCK Signs and symptoms of shock, history of CHF, chest pain, rales, shortness of breath, pedal edema OXYGEN High flow. Be prepared to support ventilations as needed. Keep patient warm CARDIAC MONITOR Treat dysrhythmias per specific treatment guideline EARLY TRANSPORT CODE 3 IV or IO TKO BLOOD GLUCOSE Check and treat if indicated DOPAMINE Begin infusion at 5 mcg/kg/min if hypotension persists (see table) 12 LEAD ECG Perform if time and condition permits Related guideline: Altered Level of Consciousness (G2) Page 68 Contra Costa County Prehospital Care Manual January 2010

13 G1 GENERAL ALLERGY / ANAPHYLAXIS Serious reactions involve upper or lower respiratory tract - dyspnea, stridor, wheezing, anxiety, tachycardia, tightness in chest Some reactions involve only skin (hives, itching) Marked, sudden swelling of head, face neck and airway represents a serious systemic reaction (angioedema) OXYGEN High flow. Be prepared to support ventilations. EPI-PEN May assist with administration of patient s auto-injector CARDIAC MONITOR Treat dysrhythmias per specific treatment guidelines If upper or lower respiratory tract symptoms or hypotension: EPINEPHRINE 1:1000 IM ALBUTEROL Adult mg IM (use 0.3 mg in elderly, small patients or mild symptoms) Pediatric 0.01 mg/kg IM maximum dose 0.3 mg Adult and pediatric - 5 mg/6 ml saline via nebulizer may repeat as needed IV TKO If itching or hives, consider: Adult - 50 mg slow IV or IM 25 mg if patient has taken po diphenhydramine DIPHENHYDRAMINE Pediatric 1 mg/kg IV or IM (maximum dose 50 mg) 0.5 mg/kg dose if patient has taken po diphenhydramine MONITOR PATIENT Carefully monitor vital signs, respiratory status, and response to treatments If serious progression of symptoms after treatment with IM epinephrine: Includes profound hypotension, absence of palpable pulses, unconsciousness, cyanosis, severe respiratory distress or respiratory arrest. In pediatric patients, hypotension is late sign of shock. IO If IV access not immediately available FLUID BOLUS Adult - wide open NS. Recheck vitals after every 250 ml Pediatric - 20 ml/kg NS bolus, may repeat X 2 EPINEPHRINE 1:10,000 IV If patient not responsive to IM epinephrine treatment: Adult - titrate in 0.1 mg doses slow IV or IO to a maximum dose of 0.5 mg. Use extreme caution with patients with cardiac history, angina, hypertension. Pediatric - titrate in up to 0.1 mg doses slow IV or IO to a maximum of 0.01 mg/kg Key Treatment ations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual January 2010 Page 69

14 G2 GENERAL ALTERED LEVEL OF CONSCIOUSNESS Glasgow Coma Scale less than 15 uncertain etiology. AEIOU/TIPPS OXYGEN SPINAL IMMOBILIZATION ORAL GLUCOSE CARDIAC MONITOR High flow. Be prepared to support ventilations as needed. need for spinal precautions if known diabetic, conscious, able to sit upright, able to self-administer Adult - 30 g po Pediatric g po BLOOD GLUCOSE Check level IV TKO If glucose 60 or less: DEXTROSE Adult DEXTROSE 50% 25 g IV Pediatric DEXTROSE 10% 0.5 g/kg IV (5 ml/kg) If unable to establish IV: Adult 1 mg IM GLUCAGON Pediatric - 24 kg or more 1 mg IM Pediatric - Less than 24 kg 0.5 mg IM BLOOD GLUCOSE Recheck if symptoms not resolved DEXTROSE Repeat initial IV dose if glucose remains 60 or less Related guideline: Respiratory Depression or Apnea (G12) Key Treatment ations Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 12 breaths per minute) Patients with hypoglycemia as a result of oral diabetic medications are at higher risk of recurrent hypoglycemia and transport is highly recommended in these patients With prolonged hypoglycemia and in many elderly patients, increase in level of consciousness after dextrose given may not be as rapid as in others. Recheck glucose before considering repeat treatment. In patients with starvation, poor oral intake, or alcohol intoxication/alcoholism, glucagon may not be effective because of poor glycogen stores in liver Glucagon may take minutes or longer to increase glucose level (peak effects in minutes). Recheck glucose before considering additional treatment. transport earlier in patients with poor vascular access who are not responding to glucagon or have reasons listed above for possible impaired response to glucagon Most patients with hypoglycemia have diabetes. Other causes of hypoglycemia include renal failure, starvation, alcohol intoxication, sepsis, rare metabolic disorders, aspirin overdoses and sulfa drugs. Hypoglycemia may also occur rarely following gastric surgery for weight loss. Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 70 Contra Costa County Prehospital Care Manual January 2010

15 G3 GENERAL BEHAVIORAL EMERGENCY A behavioral emergency is defined as combative or irrational behavior not caused by medical illnesses such as hypoxia, shock, hypoglycemia, head trauma, drug withdrawal, intoxicated states or other conditions Combative or irrational behavior may be caused by psychiatric or other behavioral disorder History of event and past history are important in patient evaluation Past history of psychiatric condition does not eliminate need to assess for other illnesses SCENE SAFETY ASSESS PATIENT VITAL SIGNS OXYGEN CARDIAC MONITOR BLOOD GLUCOSE CHEMICAL RESTRAINT Many patients merit a weapons search by law enforcement Physical restraints may be needed if patient exhibits behavior that presents a danger to him/herself or others Assess for evidence of hypoxia, hypoglycemia, trauma other medical causes for behavioral symptoms Obtain vital signs as possible Provide as possible if there is question of hypoxia or other medical condition Place as possible / safe Obtain as possible / safe BASE ORDER REQUIRED Despite verbal de-escalation and physical restraint, if adult patient (15 years or older) remains extremely combative and struggling against restraints, consider: MIDAZOLAM 5 mg IM. Lower doses should be considered in elderly or small patients (under 50 kg) MIDAZOLAM 1-5 IV mg in 1 mg increments if IV established and patent Monitor closely for respiratory compromise. Assess and document mental status, MONITOR PATIENT vital signs, and extremity exams (if restrained) at least every 15 minutes. Related guidelines: Altered Level of Consciousness (G2), Trauma (G16) Key Treatment ations Calming measures may be effective and may preclude need for restraint in some circumstances Utilize a single person to establish rapport. Separate patient from crowd and seek quiet environment if possible, but maintain contact with other personnel and ability to exit rapidly. Avoid violating patient s personal space, making direct eye contact or sudden movements. Frequent reassurance and calm demeanor of personnel are important. Enlist assistance of law enforcement if restraint needed. Never transport patient in prone position. Assure adequate resources available to manage patient s needs. Restraint may require up to five persons to safely control patient. Patients with past history of violent behavior are more likely to exhibit recurrent violent behavior In pediatric patients, consider child s developmental level when providing care Sedation with Midazolam intended for adult patients only (age 15 and over) Not all patients will respond to Midazolam. Repeat dosage is not recommended. Contra Costa County Prehospital Care Manual January 2010 Page 71

16 G4 GENERAL BURNS Damage to the skin caused by contact with caustic material, electricity, or fire Second or third degree burns involving 20% of the body surface area, or those associated with respiratory involvement are considered major burns Move patient to safe area Stop the burning process OXYGEN Protect the burned area Assess for associated injuries IV or IO MORPHINE SULFATE IV Remove contact with agent, unless adhered to skin Brush off chemical powders Flush with water to stop burning process or to decontaminate High flow. Be prepared to support ventilation as needed. Do not break blisters, cover with clean dressings or sheets. Remove restrictive clothing/jewelry if possible. TKO For pain relief in the absence of hypotension (systolic BP less than 90), significant other trauma, altered level of consciousness: Adult 2-20 mg IV or IO, titrated in 2-4 mg increments Pediatric mg/kg IV See Pediatric Drug Chart MORPHINE SULFATE IM If IV or IO access not available: Adult 5-20 mg IM Pediatric 0.1 mg/kg IM See Pediatric drug chart Key Treatment ations Airway burns may lead to rapid compromise of airway (soot around nares, mouth, visible burns or edematous mucosa in mouth are clues) Transport to closest receiving facility for advanced airway management if time permits Do not apply wet dressings, liquids or gels on burns. Cooling may lead to hypothermia. Refer to Rule of Nines to determine burn surface area (in Policy and Hospital Reference section) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 72 Contra Costa County Prehospital Care Manual January 2010

17 G5 GENERAL CHILDBIRTH ROUTINE OR COMPLICATED IMMINENT DELIVERY - Regular contractions, bloody show, low back pain, feels like bearing down, crowning Prepare for Delivery IV Deliver Infant Clamp/Cut Cord Warming Measures Reassure mother, instruct during delivery TKO if time allows As head is delivered, apply gentle pressure to prevent rapid delivery of the infant Gently suction baby's mouth, then nose, keeping the head dependent If cord is wrapped around neck and can't be slipped over the infant's head, double-clamp and cut between clamps Immediately double-clamp cord 6-8 inches from baby and cut between clamps (if not done before delivery) Dry baby and keep warm, placing baby on mother's abdomen or breast Placenta Delivery Post-Delivery Observation If placenta delivers, save it and bring to the hospital with mother and child. DO NOT PULL ON UMBILICAL CORD TO DELIVER PLACENTA. Observe mother and infant frequently for complications. To decrease post-partum hemorrhage, perform firm fundal massage, put baby to mother's breast. Transport Prepare mother and infant for transport. Neonatal care or resuscitation as indicated. COMPLICATED DELIVERY BREECH DELIVERY Presentation of buttocks or feet Allow delivery to proceed passively until the baby's waist appears Rotate baby to face down position (DO NOT PULL) Delivery If the head does not readily deliver in 4-6 minutes, insert a gloved hand into the vagina to create an air passage for the infant Transport Early transport if available notify receiving hospital as soon as possible PROLAPSED CORD - Cord presents first and is compressed, compromising infant circulation Insert gloved hand into vagina and gently push presenting part off of the cord Manage Cord Do not attempt to reposition the cord Cover cord with saline soaked gauze Position Patient Place mother in trendelenburg position with hips elevated Transport Early transport if available notify receiving hospital as soon as possible Contra Costa County Prehospital Care Manual January 2010 Page 73

18 G6 GENERAL DYSTONIC REACTIONS History of ingestion of phenothiazine or related compounds, primarily anti-psychotic and antiemetic medications (for nausea/vomiting). Symptoms include restlessness, muscle spasms of the neck, jaw, and back, oculogyric crisis. OXYGEN High flow. Be prepared to support ventilations as needed. IV DIPHENHYDRAMINE TKO Adult mg IV or 50 mg IM if unable to establish IV access Pediatric 1 mg/kg IV or 1 mg/kg IM if unable to establish IV access Key Treatment ations Common drugs implicated in dystonic reactions include many anti-emetics and anti-psychotic medications Prochlorperazine (Compazine) Haloperidol (Haldol) Metoclopromide (Reglan) Phenergan (Promethazine) Fluphenazine (Prolixin) Chlorpromazine (Thorazine) Many other antipsychotic and anti-depressant drugs Rarely benzodiazepine drugs have been implicated as a cause of dystonic reaction Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 74 Contra Costa County Prehospital Care Manual January 2010

19 G7 GENERAL ENVENOMATIONS Snake Bites, Insect Stings SNAKE BITES If the snake is positively identified as non-poisonous, treat with basic wound care INSECT STINGS Symptoms of stings usually occur at the site of injury and have no specific treatment Allergic reactions can be severe, and may cause anaphylactic shock Keep patient calm Address constricting items WOUND MANAGEMENT OXYGEN Remove rings, bracelets or other constricting items from affected extremity Snake bite: Splint extremity and keep at level of heart Insect Stings: Flick stinger off do not squeeze stinger. Apply cold pack. High flow If signs of shock or allergic reaction Be prepared to support ventilations Monitor vital signs CARDIAC MONITOR if patient potentially unstable IV TKO Related Guidelines: Shock (A10, P8), Allergy / Anaphylaxis (G1) Contra Costa County Prehospital Care Manual January 2010 Page 75

20 G8 GENERAL HEAT ILLNESS / HYPERTHERMIA HEAT EXHAUSTION Presentation: Flu-like symptoms, cramps, normal mental status HEAT STROKE Presentation: Altered level of consciousness, absence of sweating, tachycardia, and hypotension Low flow for heat exhaustion OXYGEN High flow if altered level of consciousness / suspected heat stroke Move patient to cool environment Promote cooling by fanning COOLING MEASURES Remove clothing and splash / sponge with water Place cold packs on neck, in axillary and inguinal areas IV FLUID BOLUS BLOOD GLUCOSE DOPAMINE TKO. Perform if heat stroke or marked symptoms with heat exhaustion. If hypotensive or suspected heat stroke: Adult 500 ml NS bolus May repeat X 1 Pediatric 20 ml/kg NS bolus. May repeat X 1 Check level if altered level of consciousness, treat as indicated For adult patients only if hypotension persists despite fluid boluses Begin at 5 mcg/kg/min (see table) Related guidelines: Altered Level of Consciousness (G2), Seizure (G14) Key Treatment ations Seizures may occur with heat stroke treat as per treatment guideline for seizure Increasing symptoms merit more aggressive cooling measures. With mild symptoms of heat exhaustion, movement to cooler environment and fanning may suffice. Conditions that may lead to or worsen hyperthermia include: o Psychiatric Disorders o Heart Disease o Diabetes o Alcohol o Medications o Fever o Fatigue o Obesity o Pre-existent dehydration o Extremes of age (Elderly and pediatric) Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 76 Contra Costa County Prehospital Care Manual January 2010

21 G9 GENERAL HYPOTHERMIA MODERATE HYPOTHERMIA Conscious and shivering but lethargic, skin pale and cold SEVERE HYPOTHERMIA Stuporous or comatose, dilated pupils, hypotensive to pulseless, slowed to absent respirations Severe hypothermia patients may appear dead. When in doubt, begin resuscitation OXYGEN SPINAL PRECAUTIONS WARMING MEASURES Low flow. High flow if decreased level of consciousness (warm humidified oxygen if available). Be prepared to support ventilations. For patients with possible trauma or submersion Gently move to sheltered area (warm environment) Minimize physical exertion or movement of the patient Cut away wet clothing and cover patient with warm, dry sheets or blankets CARDIAC MONITOR EARLY TRANSPORT Do not delay transport if patient unconscious IV TKO BLOOD GLUCOSE Check and treat if indicated NALOXONE If respiratory rate less than 12 and narcotic overdose suspected ADVANCED AIRWAY Only if unable to ventilate using BVM Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment ations Avoidance of excess stimuli important in severe hypothermia as the heart is sensitive and interventions may induce arrhythmias. Needed interventions should be done as gently as possible. o Check for pulselessness for seconds to avoid unnecessary chest compressions o Defer ACLS medications until patient warmed o If Ventricular Fibrillation or Pulseless Ventricular Tachycardia present, shock X 1 and defer further shocks Patients with prolonged hypoglycemia often become hypothermic blood glucose check essential Patients with narcotic overdose may develop hypothermia Contra Costa County Prehospital Care Manual January 2010 Page 77

22 G10 GENERAL PAIN MANAGEMENT (NON-TRAUMATIC) All patients expressing verbal or behavioral indicators of pain shall have an appropriate assessment and management of pain Morphine should be given in sufficient amount to manage pain but not necessarily to eliminate it Low flow OXYGEN IV TKO ASSESS PAIN PAIN RELIEF MEASURES MORPHINE SULFATE IV MORPHINE SULFATE IM Closed head injury Altered level of consciousness Headache Respiratory failure or worsening respiratory status Childbirth or suspected active labor Assess and document the intensity of the pain using the visual analog scale Reassess and document the intensity of the pain after any intervention that could affect pain intensity Psychologic measures and BLS measures, including cold packs, repositioning, splinting, elevation, and/or traction splints, are important considerations for patients with pain See contraindications and cautions below: For pain relief: Adult 2-20 mg IV, titrated in 2-5 mg increments to pain relief Pediatric mg/kg IV See Pediatric Drug Chart If no IV access: Adult mg IM Pediatric 0.1 mg/kg IM See Pediatric Drug Chart Contraindications and Cautions for Morphine Sulfate Contraindications for Morphine: Hypotension o Adults - Systolic BP less than 90 o Pediatric - Hypotension or impaired perfusion (e.g. capillary refill > 2 seconds) Infants 1mo-1yr systolic BP < 60 mmhg Toddler 1-4 yrs systolic BP < 75 mmhg School age 5-13 yrs systolic BP < 85 mmhg Adolescent >13 yrs systolic BP < 90 mmhg Cautions for Morphine: Use with caution in patients with suspected drug or alcohol ingestion or with suspected hypovolemia Key Treatment ations Have Naloxone available to reverse respiratory depression should it occur Preferred route of administration for Morphine Sulfate is IV Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 78 Contra Costa County Prehospital Care Manual January 2010

23 G11 GENERAL POISONING - OVERDOSE If possible, determine substance, amount ingested, time of ingestion. Bring in container or label. Be careful not to contaminate yourself and others DECONTAMINATION OXYGEN Remove contaminated clothing, brush off powders, wash off liquids. Irrigate eyes if affected. Low flow. Be prepared to support ventilations. CARDIAC MONITOR IV TKO if unstable patient or suspected serious ingestion Related guidelines: Respiratory Depression or Apnea (G12), Altered Level of Consciousness (G2), Seizures (G14), Shock (A10, P8) TRICYCLIC ANTIDEPRESSANT OVERDOSE Frequently associated with respiratory depression, usually tachycardia. Widened QRS complexes and associated ventricular arrhythmias are generally signs of a life-threatening ingestion. For adults only: For life-threatening hemodynamically significant SODIUM BICARBONATE dysrhythmias, 1 meq/kg slow IV or IO ORGANOPHOSPHATE POISONING Hypersalivation, sweating, bronchospasm, abdominal cramping, diarrhea, muscle weakness, small/pinpoint pupils, muscle twitching, and/or seizures may occur ATROPINE CALCIUM CHLORIDE For adults only: 1-2 mg IV Repeat every 3-5 minutes as necessary until relief of symptoms Large doses of Atropine may be required HYDROFLUORIC ACID EXPOSURE For adults only: For tetany or cardiac arrest, 500mg IV (5 ml of 10% solution) MORPHINE SULFATE IV MORPHINE SULFATE IM For adults only: In the absence of hypotension, significant other trauma or altered level of consciousness: 2-20 mg IV titrated in 2-5 mg increments to pain relief For adults only: If no IV access, 5-10 mg IM Key Treatment ations Few overdoses have specific antidotes. Supportive care is the mainstay of treatment. Contact Base Hospital if any questions concerning treatment of overdose in pediatric patients Contact Base Hospital for other suspected overdoses that may have specific treatment (e.g. Calcium Channel Blocker overdose) Poison Control Center can offer information but cannot provide medical direction to EMS Contra Costa County Prehospital Care Manual January 2010 Page 79

24 G12 GENERAL RESPIRATORY DEPRESSION OR APNEA Absence of spontaneous ventilations or respiratory rate less than 12 without cardiac arrest BVM VENTILATION Assist ventilation or provide ventilation if no spontaneous respirations OXYGEN High flow CARDIAC MONITOR Adult not in shock: 2 mg IN (intranasal) if narcotic overdose suspected NALOXONE INTRANASAL or IM Adult not in shock but unsuitable for IN (copious secretions): 1-2 mg IM Pediatric 0.1 mg/kg IM maximum dose 2 mg IV TKO if intravenous treatment indicated If patient in shock, if IN or IM routes ineffective (within 3 minutes), or if IV access already available for another reason: NALOXONE IV Adult 1-2 mg IV Pediatric 0.1 mg/kg IV maximum dose 2 mg Repeat NALOXONE IV or IM if no response and narcotic overdose suspected maximum dose 10 mg Titration of Diluted NALOXONE IV ADVANCED AIRWAY for patients with chronic narcotic use for terminal disease or chronic pain: Dilute 1:10 with normal saline and administer in 0.1 mg (1 ml) increments titrate to increased respiratory rate when indicated - only if naloxone ineffective and BVM ventilation not adequate Related guidelines: Altered Level of Consciousness (G2), Respiratory Distress (G13) Key Treatment ations SAFETY WARNING! Naloxone will cause acute withdrawal symptoms in patients who are habituated users of narcotics (whether prescribed or from abuse) Use of diluted Naloxone IV and titration with small increments may help decrease adverse effects of naloxone in patients who have chronic narcotic usage for terminal disease or pain relief Naloxone treatment should only be given to patients with respiratory depression (rate less than 12) Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%) Older patients are at higher risk for cardiovascular complications Be prepared for patient agitation or combativeness after naloxone reversal of narcotic overdose Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 80 Contra Costa County Prehospital Care Manual January 2010

25 G13 GENERAL RESPIRATORY DISTRESS Wheezing may be noted in asthma, COPD exacerbation, or pulmonary edema Rales may be present in pneumonia, pulmonary edema, and many other conditions INITIAL THERAPY OXYGEN Low flow increase as indicated. Be prepared to support ventilation. CARDIAC MONITOR CPAP If respiratory rate greater than 25, accessory muscle use, pulse ox less than 94% IV TKO. Do not delay transport for vascular access if in extremis. ASTHMA ALBUTEROL Adult and Pediatric 5 mg in 6 ml NS via nebulizer. Repeat as needed. EPINEPHRINE 1:1000 SC (subcutaneously) EPINEPHRINE 1:1000 IM ALBUTEROL For use in asthma only: Use only if respiratory status deteriorating despite repeat treatment with Albuterol and transport time more than 10 minutes. Do not use in patients with history of coronary artery disease or hypertension. Adult mg SC Pediatric mg/kg SC - max dose 0.3 mg Never give Epinephrine 1:1000 intravenously! If respiratory arrest from asthma or bronchospasm: Adult mg IM Pediatric mg/kg IM - max dose 0.3 mg COPD EXACERBATION 5 mg in 6 ml NS via nebulizer. Repeat as needed. SUSPECTED PULMONARY EDEMA (ADULTS ONLY) 0.4 mg sublingual if systolic BP between 90 and mg sublingual if systolic BP 150 or greater Repeat every 5 minutes until symptoms improve NITROGLYCERIN Maximum dose 4.8 mg ( mg doses) Discontinue if hypotension develops Caution: Do not administer if patient has taken erectile dysfunction medications Viagra or Levitra within prior 24 hours or Cialis within 36 hours 2-5 mg IV in 1-2 mg increments for relief of anxiety. Do not administer if BP less MORPHINE SULFATE than 90, if patient has altered mental status or decreased respiratory effort. Related guidelines Chest pain / Suspected ACS (A2), Shock (A10) Key Treatment ations CPAP is not a ventilation device. Patients with inadequate respiratory rate or inadequate depth of respiration will need assistance with BVM. Patients with potential respiratory failure should be transported emergently. Patients requiring advanced airway management in these situations are best handled in the hospital setting and CPAP may be a valuable bridge in care to potentially delay need for emergent intubation. IV access should not delay transport. For suspected pulmonary edema, re-evaluate blood pressure between each dose of nitroglycerin. If blood pressure initially over 150, then between 150 and 90 after treatment, lower dosage to 0.4 mg. If cardiac ischemia suspected in addition to pulmonary edema, treat as per chest pain protocol (Aspirin, 12-lead ECG if possible). cardiac etiology for diabetic patients with respiratory distress Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual January 2010 Page 81

26 G14 SEIZURE / STATUS EPILEPTICUS GENERAL Tonic, clonic movements followed by a period of unconsciousness (post-ictal period) A continuous or recurrent seizure is defined as seizure activity greater than 10 minutes or recurrent seizures without patient regaining consciousness OXYGEN High flow. Be prepared to support ventilations. Protect patient Do not forcibly restrain but protect from injuring self CARDIAC MONITOR IV TKO BLOOD GLUCOSE Check and treat if indicated For continuous or recurrent seizures: Adult initial dose 1 mg IV - titrate in 1-2 mg increments max. dose 5 mg MIDAZOLAM IV Pediatric titrate in up to 1 mg IV increments up to 0.1 mg/kg If IV access unavailable: Adult 0.2 mg/kg IM - maximum dose 10 mg MIDAZOLAM IM Pediatric 0.2 mg/kg IM - maximum dose 10 mg MONITOR PATIENT Carefully observe vital signs, respiratory status support ventilations as needed Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) SAFETY WARNING: Use caution when treating with Midazolam in pediatric patients previously treated by family or caretaker with rectal diazepam (Valium, Diastat) as a higher incidence of respiratory depression may occur. Wait five (5) minutes after last rectal dose to determine effect and need for treatment. using reduced dosage of Midazolam. Key Treatment ations Most seizures are self-limiting and do not require prehospital medication Seizures may appear frightening to observers. Provide reassurance to parents/family. spinal immobilization if history of fall or trauma Febrile seizures in children are generally self-limiting For febrile patients, remove or loosen clothing, remove blankets to address cooling measures Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 82 Contra Costa County Prehospital Care Manual January 2010

27 G15 GENERAL STROKE Sudden onset of weakness, paralysis, confusion, speech disturbances, visual field deficit, may be associated with headache Determination of time of onset of symptoms is the most crucial historical information needed If patient awoke with symptoms, time patient last seen normal is the time that should be noted OXYGEN CARDIAC MONITOR STROKE SCALE TRANSPORT BLOOD GLUCOSE IV FLUID BOLUS CONTACT RECEIVING HOSPITAL High flow. Be prepared to support ventilations as needed. Note findings of stroke scale and time of onset of symptoms Minimize scene time Check and treat if indicated TKO. Perform enroute ml if hypotensive or poor perfusion reassess Report time of symptom onset (time last seen normal), ETA, physical exam and findings of Cincinnati Stroke Scale using SBAR format Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12), Seizure (G14) CINCINNATI STROKE SCALE If any one of the three tests are abnormal and is a new finding, the Stroke Scale is abnormal and may indicate an acute stroke Finding Patient Activity Interpretation Facial Droop Ask patient to smile and show teeth or grimace Normal: Symmetrical smile or face Abnormal: Asymmetry (one side droops or does not move) Arm Weakness Speech Abnormality Ask patient to close both eyes and extend both arms out straight for 10 seconds Have the patient say the words, The sky is blue in Cincinnati Normal: Both arms move symmetrically or do not move Abnormal: One arm drifts down or arms move asymmetrically Testing with patient holding palms upward is most sensitive way to check. Patients with arm weakness will tend to pronate (turn from palms up to sideways or palms down). Normal: The correct words are used and no slurring of words is noted Abnormal: If the patient slurs words, uses the wrong words, or is unable to speak (aphasia) Contra Costa County Prehospital Care Manual January 2010 Page 83

28 G16 GENERAL SPINAL IMMOBILIZATION OXYGEN EARLY TRANSPORT WOUND / GENERAL CARE NEEDLE THORACOSTOMY IV FLUID BOLUS BLOOD GLUCOSE CARDIAC MONITOR MORPHINE SULFATE IV MORPHINE SULFATE IM INDICATIONS AND PRECAUTIONS FOR MORPHINE USE As indicated TRAUMA High flow. Be prepared to support ventilations. Limit scene time to less than 10 minutes when possible. Load and go if high risk. Place splints, cold packs, dressings and pressure on bleeding sites as needed. Keep patient warm minimize exposure after assessment Evaluate for and treat tension pneumothorax if indicated TKO. If patient critical, DO NOT DELAY ON-SCENE FOR IV OR IO ACCESS. Start two (2) large bore IV s en route when possible. If stable, single IV acceptable. If markedly hypotensive (absent peripheral pulses or BP less than 90), Adult ml NS, recheck vitals. Titrate to presence of peripheral pulses Pediatric 20 ml/kg NS. If continued poor perfusion, may repeat X 2 Test if GCS less than 15. See Altered Level of Consciousness (G2). See indications and precautions below: Adult 2-20 mg IV in 2-5 mg increments. Titrate to pain relief and systolic BP greater than 100. See precautions below. Pediatric mg/kg IV See Pediatric Drug chart When IV access not available (non-critical patients only): Adult 5-10 mg IM Pediatric 0.1 mg/kg IM See Pediatric Drug chart Morphine may be used for relief of extremity pain in the absence of head or torso trauma, hypotension (age-specific), poor perfusion or ALOC. Use with caution in patients with drug or alcohol intoxication. Related guidelines: Altered Level of Consciousness (G2), Respiratory Depression or Apnea (G12) Key Treatment ations ALS procedures in the field (IV and advanced airway) do not improve outcome in critical patients. o IV starts should be done en route on these patients o Advanced airway should only be done if patient is unable to be ventilated via BLS maneuvers Repeated IV attempts in non-critical pediatric patients should be avoided Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. CRUSH INJURY SYNDROME (ADULTS ONLY) Caused by muscle crush injury and cell death. Most patients have an extensive area of involvement such as a large muscle mass in a lower extremity and/or pelvis. May develop after one hour in severe crush, but usually requires at least 4 hours of compression Hypovolemia and hyperkalemia may occur, particularly in extended entrapments Hyperkalemia should be suspected if ECG monitor reveals peaked T waves, absent P waves or widened QRS complexes FLUID BOLUS 20 ml/kg NS prior to release of compression IF ECG CHANGES SUGGEST HYPERKALEMIA: ALBUTEROL - 5 mg in 6 ml NS continuously via nebulizer CALCIUM CHLORIDE - 1 gm slow IV over 60 seconds. Note: Flush tubing after administration of calcium chloride to avoid precipitation with sodium bicarbonate. SODIUM BICARBONATE - 1 meq/kg IV. Additionally, consider 1 meq/kg added to IV 1L NS - use second IV line as other medications may not be compatible Page 84 Contra Costa County Prehospital Care Manual January 2010

29 P1 PEDIATRIC Scene Safety Body Substance Isolation Systematic Assessment Determine Primary Impression Base Contact Transport Document PEDIATRIC PATIENT CARE Pediatric patient is defined as age 14 or less. Neonate is 0-1 month These basic treatment concepts should be considered in all pediatric patients Use universal blood and body fluid precautions at all times Management and support of ABC s are a priority Identify pre-arrest states Assure open and adequate airway Place in position of comfort unless condition mandates other position spinal immobilization if history or possibility of traumatic injury exists Assess environment to consider possibility of intentional injury or maltreatment Apply appropriate field treatment guidelines Explain procedures to family and patient as appropriate Provide appropriate family support on scene Contact base hospital if any questions arise concerning treatment or if additional medication beyond dosages listed in treatment guidelines is considered Use SBAR to communicate with base Minimize scene time in pre-arrest patient, critical trauma, shock or respiratory failure Transport patient medications or current list of patient medications to the hospital Give report to receiving facility using SBAR Document patient assessment and care per policy Key Treatment ations Apparent Life-Threatening Event (ALTE) An Apparent Life-Threatening Event (ALTE) Is an event that is frightening to the observer (may think the infant has died) and involves some combination of apnea, color change, marked change in muscle tone, choking, or gagging. It usually occurs in infants less than 12 months of age, though any child with symptoms described under 2 years of age may be considered an ALTE. Most patients have a normal physical exam when assessed by responding personnel. Approximately half of the cases have no known cause, but the remainder of cases have a significant underlying cause such as infection, seizures, tumors, respiratory or airway problems, child abuse, or SIDS. Because of the high incidence of problems and the normal assessment usually seen, there is potential for significant problems if the child's symptoms are not seriously addressed. OBTAIN DETAILED HISTORY ASSESSMENT TREATMENT TRANSPORT Obtain history of event, including duration and severity, whether patient awake or asleep at time of episode, and what resuscitative measures were done by the parent or caretaker. Obtain past medical history, including history of chronic diseases, seizure activity, current or recent infections, gastroesophageal reflux, recent trauma, medication history. Obtain history with regard to mixing of formula if applicable. Perform comprehensive exam, including general appearance, skin color, interaction with environment, or evidence of trauma Treat identifiable cause if appropriate If treatment/transport is refused by parent or guardian, contact base hospital to consult prior to leaving patient. Document refusal of care. Contra Costa County Prehospital Care Manual January 2010 Page 85

30 P2 PEDIATRIC AIRWAY VENTILATIONS CARDIAC ARREST INITIAL CARE AND CPR Open airway and utilize BLS airway for initial management Ventilations: Give 2 breaths initially Administer each breath over 1 second and observe for chest rise Check pulse - If no pulse or if heart rate less than 60 with poor perfusion, begin CPR CPR For 2 minutes or 5 cycles before rhythm analysis if unwitnessed arrest Until monitor/defibrillator available for rhythm analysis if witnessed arrest COMPRESSIONS CARDIAC MONITOR IV / IO ACCESS MEDICATIONS AND DEFIBRILLATION BLOOD GLUCOSE PREVENT HYPOTHERMIA TRANSPORT Compressions: Depth one-third to one-half depth of chest allow full recoil of chest Rate - 100/minute Compression/ventilation ratio - 30:2 for one rescuer, 15:2 for two rescuers Rotate compressors every 2 minutes To minimize CPR interruptions: Perform CPR during charging of defibrillator Resume CPR immediately after shock (do not stop for pulse or rhythm check) Determine cardiac rhythm and follow specific treatment guideline If IV access not apparent or unsuccessful, use IO access Use length-based tape to determine weight if not known o If child is obese and length-based tape used to determine weight, use next highest color to determine appropriate equipment and drug dosing See Pediatric Drug Chart for medication dose and defibrillation energy levels Treat if indicated. Glucose may be rapidly depleted in pediatric arrest. Move to warm environment and avoid unnecessary exposure Pediatric arrest victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids rapid transport to definitive care Page 86 Contra Costa County Prehospital Care Manual January 2010

31 P3 PEDIATRIC WARM PATIENT CLEAR AIRWAY DRY AND STIMULATE EVALUATE RESPIRATIONS, HEART RATE AND COLOR REASSESS / BEGIN CPR IF INDICATED NEONATAL CARE AND RESUSCITATION Provide warmth move to warm environment immediately If needed, position airway or suction. Rapidly suction secretions from mouth or nares. Dry child thoroughly, stimulate, reposition if needed, place hat on infant If breathing, heart rate above 100 and pink, observational care only If breathing, heart rate above 100 and central cyanosis OXYGEN 100% by mask reassess in 30 seconds o If cyanosis resolves (skin pink) observational care only o If persistent central cyanosis after oxygen, initiate bag mask ventilation at rate of 40-60/minute If apneic, gasping, or heart rate below 100 initiate bag mask ventilation at a rate of 40-60/minute with OXYGEN 100% reassess in 30 seconds o If heart rate increases to above 100 and patient ventilating adequately, discontinue bag mask ventilation and continue close observation o If heart rate persists below 100 continue bag mask ventilation If heart rate less than 60 despite ventilation with oxygen for 30 seconds, begin CPR (3:1 ratio 90 compressions and 30 ventilations/minute). Reassess in 30 seconds. If heart rate remains less than 60 despite adequate ventilation and chest compressions: IV/IO TKO ml NS bag (use care to avoid inadvertent fluid administration). Do not delay transport for IV or IO access. EPINEPHRINE 1:10,000, 0.01 mg/kg IV or IO. Repeat every 3-5 minutes if heart rate remains below 60. FLUID BOLUS 10 ml/kg NS IV or IO. May repeat once if needed. NALOXONE 0.1 mg/kg IV or IO if depressed respiratory status despite efforts. Avoid use if long term use of opioids during pregnancy known or suspected. Key Treatment ations For uncomplicated deliveries, treatment priorities are to warm, dry, and stimulate the infant Anticipate complex resuscitation if not term gestation, amniotic fluid not clear, if newborn is not breathing or crying or if newborn does not have good muscle tone Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual January 2010 Page 87

32 P4 PEDIATRIC INITIAL CARE DEFIBRILLATION CPR BVM VENTILATION IV or IO DEFIBRILLATION EPINEPHRINE CPR DEFIBRILLATION AMIODARONE CPR TRANSPORT VENTRICULAR FIBRILLATION PULSELESS VENTRICULAR TACHYCARDIA See Cardiac Arrest - Initial Care and CPR (P3) 2 joules/kg AED can be used if patient over 1 year and pediatric electrodes available (age 1-8) or if adult electrodes can be applied without touching each other Use infant paddles and manual defibrillator up to 1 year of age or 10 kg For 2 minutes or 5 cycles between rhythm check and shock Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate TKO. Should not delay defibrillation or interrupt CPR 4 joules/kg 1:10, mg/kg IV or IO every 3-5 minutes - See Pediatric Drug Chart For 2 minutes or 5 cycles between rhythm check and shock 4 joules/kg 5 mg/kg IV or IO (see Pediatric Drug Chart for dosage) For 2 minutes or 5 cycles between rhythm check and shock If Return of Spontaneous Circulation see guidelines for Shock (P8) if treatment indicated Key Treatment ations Uninterrupted CPR and timely defibrillations are the keys to successful resuscitation. Their performance takes precedence over advanced airway management and administration of medications. To minimize CPR interruptions, perform CPR during charging, and immediately resume CPR after shock administered (no pulse or rhythm check) Avoid hyperventilation with BLS airway management, which may cause gastric distention and limit chest expansion. Provide breaths over one second, with movement of chest wall as guide for volume needed. If advanced airway placed (40 kg and over), perform CPR continuously without pauses for ventilation Prepare drugs before rhythm check and administer during CPR Give drugs as soon as possible after rhythm check confirms VF/pulseless VT (before or after shock) Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for medication dose and defibrillation energy levels. Page 88 Contra Costa County Prehospital Care Manual January 2010

33 P5 PEDIATRIC INITIAL CARE BVM VENTILATION IV or IO PULSELESS ELECTRICAL ACTIVITY / ASYSTOLE See Cardiac Arrest Initial Care and CPR (P3) Defer advanced airway (for patients 40 kg and over) unless BLS airway inadequate TKO EPINEPHRINE 1:10, mg/kg IV or IO every 3-5 minutes treatable causes treat if applicable: 20 ml/kg NS may repeat X 2 for hypovolemia FLUID BOLUS VENTILATION Ensure adequate ventilation (8-10 breaths per minute) for hypoxia WARMING For hypothermia MEASURES NEEDLE For tension pneumothorax THORACOSTOMY To determine treatment for other identified potentially treatable causes - Hydrogen BASE CONTACT Ion (Acidosis), Hyperkalemia, Toxins Safety Warning: Unlike adult resuscitation, atropine is not used in treatment of asystole or PEA in the pediatric patient If Return of Spontaneous Circulation see guidelines for Shock (P8) if treatment indicated Key Treatment ations Uninterrupted CPR is key to successful resuscitation. This takes precedence over advanced airway management and administration of medications. If advanced airway placed in patients 40 kg and over, perform CPR continuously without pauses for ventilation Avoid hyperventilation. If intubated, give 8 to 10 ventilations per minute, administered over one second. Prepare drugs before rhythm check and administer during CPR Follow each drug with 5-10 ml NS flush (minimum). Increase accordingly for patient size (20 ml in adolescents). Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual January 2010 Page 89

34 P6 PEDIATRIC SYMPTOMATIC BRADYCARDIA 90% of pediatric bradycardias are related to respiratory depression and respond to support of ventilation Only unstable, severe bradycardia causing cardiorespiratory compromise will require further treatment Signs of severe cardiorespiratory compromise are poor perfusion, delayed capillary refill, hypotension, respiratory difficulty, altered level of consciousness OXYGEN High flow. Be prepared to support ventilation. IV or IO TKO. Use IO only if patient unstable and requires medication. Use ml NS bag. If heart rate remains less than 60 with poor perfusion despite oxygenation and ventilation, CPR perform CPR. EPINEPHRINE 1:10, mg/kg IV or IO. Repeat every 3-5 minutes. ATROPINE SAFETY WARNING: Atropine should be considered only after adequate oxygenation/ventilation has been assured 0.02 mg/kg IV, IO (0.1 mg minimum dose) Child (1-8 years): Maximum single dose 0.5 mg. Maximum total dose 1 mg Adolescent (9-14 years): Maximum single dose 1 mg. Maximum total dose 2 mg. If continued heart rate less than 60, repeat 0.02 mg/kg IV or IO Key Treatment ations Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 90 Contra Costa County Prehospital Care Manual January 2010

35 P7 PEDIATRIC TACHYCARDIA Sinus tachycardia is by far the most common pediatric rhythm disturbance UNSTABLE SINUS TACHYCARDIA (narrow QRS less than 0.08) P waves present/normal, variable R-R interval with constant P-R interval Unstable sinus tachycardia is usually associated with shock and may be pre-arrest UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (SVT) (narrow QRS less than 0.08) P waves absent/abnormal, heart rate not variable History generally vague, non-specific and/or history of abrupt heart rate changes Infants rate usually greater than 220 bpm, Children (ages 1 8) rate usually greater than 180 bpm UNSTABLE POSSIBLE VENTRICULAR TACHYCARDIA - Wide QRS (greater than 0.08 sec) In some cases, wide QRS can represent supraventricular rhythm INITIAL THERAPY ALL TACHYCARDIA RHYTHMS Low flow. If increased work of breathing high flow. Be prepared to support OXYGEN CHECK PULSE AND PERFUSION ventilation. Determine stability: Stable - Normal perfusion: Palpable pulses, normal LOC, normal capillary refill, and normal BP for age Unstable - Poor perfusion: ALOC, abnormal pulses, delayed cap. refill, difficult/unable to palpate BP. If unstable, transport early and treat as below. CARDIAC MONITOR Run strip to evaluate QRS Duration IV or IO TKO. Use ml bag NS FLUID BOLUS 20 ml/kg NS if hypovolemia suspected. May repeat X 1. UNSTABLE SUPRAVENTRICULAR TACHYCARDIA (narrow QRS less than 0.08) VAGAL MANEUVERS if will not result in treatment delays. ICE PACK to face of infant/child. BASE CONTACT For all treatments listed below: 0.1 mg/kg rapid IV push followed by ml NS flush (maximum dose 6 mg) ADENOSINE If not converted, 0.2 mg/kg rapid IV push followed by ml NS flush (maximum dose 12 mg) SYNCHRONIZED CARDIOVERSION SEDATION If unable to obtain IV access, prepare for Synchronized Cardioversion. Do NOT delay cardioversion to obtain IV or IO access or sedation. MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) SYNCHRONIZED joule/kg. If not effective, repeat at 2 joules/kg. CARDIOVERSION UNSTABLE POSSIBLE VENTRICULAR TACHYCARDIA ( Wide QRS greater than 0.08 sec) BASE CONTACT For all treatments listed below: SYNCHRONIZED CARDIOVERION SEDATION SYNCHRONIZED CARDIOVERSION Prepare for CARDIOVERSION while attempting IV/IO access, but do not unduly delay care for IV access or medications If IV/IO access has been obtained, consider MIDAZOLAM 0.1 mg/kg IV or IO, titrated in 1 mg maximum increments (maximum dose 5 mg) joule/kg. If not effective, repeat at 2 joules/kg. Early transport appropriate in unstable patients Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Contra Costa County Prehospital Care Manual January 2010 Page 91

36 P8 PEDIATRIC SHOCK Altered level of consciousness; cool, clammy, mottled skin; capillary refill greater than 2 seconds; tachycardia; blood pressure less than 70 systolic Listless infant or child with poor skin turgor, dry mucous membranes, history of fever may indicate sepsis, meningitis OXYGEN Keep patient warm CARDIAC MONITOR EARLY TRANSPORT CODE 3 IV or IO High flow. Be prepared to support ventilations as needed. FLUID BOLUS 20 ml/kg NS may repeat X 2 BLOOD GLUCOSE Check and treat if indicated PREVENT Move to warm environment. Avoid unnecessary exposure. HYPOTHERMIA Related guidelines: Altered level of consciousness (G2), Tachycardia (P7) Key Treatment ations Successful pediatric resuscitation relies on early identification of the pre-arrest state Normal blood pressure, delayed capillary refill, diminished peripheral pulses and tachycardia indicates compensated shock in children Hypotension and delayed capillary refill > 4 seconds indicates impending circulatory failure Systolic blood pressure in children may not drop until the patient is 25-30% volume depleted. This may occur through dehydration, blood loss or an increase in vascular capacity (e.g. anaphylaxis). Decompensated shock (Hypotension with > 5 seconds capillary refill) may present as PEA in children Sinus tachycardia is the most common cardiac rhythm encountered Supraventricular tachycardia should be suspected if heart rate greater than 180 in children (ages 1-8) or greater than 220 in infants Hypoglycemia may be found in pediatric shock, especially in infants Pediatric shock victims are at risk for hypothermia due to their increased body surface area, exposure and rapid administration of IV/IO fluids Use length-based tape for pediatric weight determination. See Pediatric Drug Chart for dose. Page 92 Contra Costa County Prehospital Care Manual January 2010

37 Penetrating Injury (Trauma to head, neck or torso) Blunt Injury (Regardless of mechanism) Blunt Injury (When mechanism of injury is concerning) INDICATIONS FOR SPINAL IMMOBILIZATION Presence of neurologic complaint or deficit paralysis, weakness, numbness, tingling, priapism or neurogenic shock, loss of consciousness Anatomic deformity of spine Altered level of consciousness (GCS < 15) Presence of spinal pain or tenderness Anatomic deformity of spine Presence of neurologic complaint or deficit paralysis, weakness, numbness, tingling, priapism or neurogenic shock Presence of alcohol or drugs or acute stress reaction / anxiety Distracting injury (e.g. long bone fracture, large laceration, crush or degloving injury, large burns) Inability to communicate (e.g. speech or hearing impaired, language gap, small children, developmental or psychiatric conditions) Concerning mechanisms of injury include but are not limited to: Violent impact to head, neck, torso, or pelvis (e.g. assault, entrapment in structural collapse) Sudden acceleration, deceleration or lateral bending forces to neck or torso (e.g., moderate- to highspeed MVC, pedestrian struck, explosion) Falls (especially in elderly patients) Ejection from motorized or other transportation device (e.g. scooter, skateboard, bicycle, motor vehicle, motorcycle, recreational vehicle, or horse) Victims of shallow-water diving incident *** USE CLINICAL JUDGMENT IF IN DOUBT, IMMOBILIZE *** Saline Lock Upper Extremity IV Antecubital IV Intraosseous Access (IO) External Jugular IV VASCULAR ACCESS Indicated for vascular access in upper extremity when medication alone is being administered or a potential need for medication is anticipated Indicated when fluids and / or medications are needed, and patient not in shock or arrest Indicated in arrest, shock or when adenosine (rapid IV bolus) is required o In arrest, use intraosseous access if rapid peripheral access cannot be obtained within seconds Appropriate if other peripheral sites not available and medication or fluids indicated Indicated in cardiac arrest, profound shock, or unstable dysrhythmia when peripheral IV access cannot be accomplished or a suitable vein cannot be rapidly found Should be done only when medication or fluid bolus is being administered, not for prophylactic vascular access Not indicated when other routes for medications available (IM, IN) Not indicated in alert or stable patients IO infusion is PAINFUL! In non-arrest patients, use lidocaine for pain control PRIOR to giving fluid or medication Indicated only when unstable patient requires vascular access for emergent intravenous medication or fluids, no peripheral site is available, and patient not appropriate for IO access (e.g., when patient is alert) Use intraosseous access in arrest situations (IO does not disrupt CPR, higher success rate) Use alternative routes for medications when possible rather than EJ o Patients requiring treatment of hypoglycemia should receive IM glucagon monitoring for minutes is appropriate before EJ considered o Use intranasal or IM route for naloxone in respiratory depression Contra Costa County Prehospital Care Manual January 2010 Page 93

38 12-LEAD ACQUISITION AND LEAD PLACEMENT Limb Lead Placement: Place limb leads on distal extremities if possible Confirm correct lead placement for each limb May be moved to proximal if needed (if motion artifact) Sternal angle Chest Lead Placement: To begin placement of chest leads, locate sternal angle (2 nd ribs are adjacent) then count down to 4 th interspace (below 4 th rib) V4R V1 4th intercostal space at the right sternal border V2 4th intercostal space at the left sternal border V4 5th intercostal space at left midclavicular line Note: Place V4 lead first to aid in correct placement of V3 V3 Directly between V2 and V4 V5 Level of V4 at left anterior axillary line V6 Level of V4 at left mid-axillary line V4R (to detect Right Ventricular Infarct) mirrors V4 on right side of chest move V4 lead across Do V4R if Inferior MI noted (elevation in II, III, avf) Label ECG for V4R Note: Careful skin preparation prior to lead placement (rub with gauze or abrasive, clean skin oils with alcohol) is critical to obtaining a high-quality ECG LOCALIZING SITE OF INFARCT Localization of an infarct pattern adds to the accuracy of ECG interpretation A STEMI will have 1 mm or more ST-segment elevation in two or more contiguous leads (which means findings noted in the same anatomical location of the infarct) o Contiguous leads for inferior infarction include II, III, and avf o Contiguous leads for anterior infarction include V1-V4 (V1-V2 elevation also called septal infarction) o Contiguous leads for lateral myocardial infarction include Leads I, avl, V5, and V6 o Lateral MI findings may be in addition to anterior or inferior MI patterns (anterolateral or inferolateral) In patients with an inferior infarct pattern (Leads II, III, avf), a separate ECG with V4R should be obtained A 1 mm ST-segment elevation in V4R when inferior infarction noted indicates right ventricular infarct I LATERAL avr V1 SEPTAL or ANTERIOR V4 ANTERIOR (V4R RVMI) II - INFERIOR avl LATERAL V2 SEPTAL or ANTERIOR V5 LATERAL III INFERIOR avf - INFERIOR V3 ANTERIOR V6 LATERAL Page 94 Contra Costa County Prehospital Care Manual January 2010

39 STEMI Recognition STEMI Report Destination Policy STEMI RECOGNITION AND DESTINATION Patients who have ECGs of acceptable quality with the following messages are candidates for transport to STEMI Receiving Centers: o ***Acute MI*** (Zoll) o ***Acute MI Suspected*** (LIFEPAK 12) o ***Meets ST-Elevation MI Criteria*** (LIFEPAK15) The 12-lead ECG should be inspected prior to initiation of a STEMI Alert a steady baseline in all 12-leads and a tracing free of artifact is critical for accurate interpretation Causes of artifact include patient motion or tremor, poor lead contact, or electrical interference Good skin preparation is essential for optimal lead contact and clear 12-lead tracings If artifact is noted the ECG should be repeated Paced rhythms may cause false readings the pacemaker spike is not always detected by the computer algorithm. Inform facility if patient has a pacemaker during report. If a STEMI is noted on 12-lead ECG, the receiving STEMI facility should be notified as soon as possible following completion of the ECG Patients with an identified STEMI shall be transported to a STEMI Receiving Center (SRC) Patients shall be transported to the closest SRC unless they request another facility A SRC that is not the closest facility is an acceptable destination if estimated additional transport time does not exceed 15 minutes Patients with cardiac arrest who have a STEMI identified by 12-lead ECG before or after arrest shall be transported to the closest SRC Patients with unmanageable airway en route shall be transported to the closest available emergency department STEMI REPORT A patient with a computer interpretation of ***Acute MI*** (Zoll) or ***Acute MI Suspected*** (LP-12) or ***Meets ST Elevation MI Criteria*** (LP-15) is a candidate for transport to a STEMI Receiving Center Verify that 12-lead tracing has good tracings and baseline in all 12-leads and does not have significant baseline artifact or other deficit before initiating a STEMI Alert SITUATION Identify the call as a STEMI Alert Estimated time of arrival (ETA) in minutes Patient age and gender Report ECG computer interpretation has a STEMI message (as listed above) Report if subsequent ECG findings are variable or if ECG quality not optimal (e.g., if no ***Acute MI*** findings noted in tracings without significant artifact) BACKGROUND ASSESSMENT Presenting chief complaint and symptoms Pertinent past cardiac history History of pacemaker (important paced rhythms may give false ECG interpretations) General assessment Pertinent vitals (especially heart rate and BP) and physical exam Cardiac rhythm Pain level RX RECAP Prehospital treatments given Patient response to prehospital treatments Contra Costa County Prehospital Care Manual January 2010 Page 95

40 External Cardiac Pacing KEY PARAMEDIC PROCEDURES Skill Indication Contraindication Comment Continuous Positive Airway Pressure (CPAP) ResQPOD Waveform Capnography (ETCO 2 ) King Airway Endotracheal Intubation Symptomatic bradycardia Pt. has 2 of more findings: RR >25 Pulse ox <94% Use of accessory muscles and patient is awake, able to maintain airway & follow commands Cardiac Arrest All intubated patients (King or Endotracheal Tube) Cardiac arrest Inability to ventilate non-arrest patient (with BLS airway maneuvers) in a setting in which endotracheal intubation is not successful or unable to be done Patient with decreased sensorium (GCS less than or equal to 8) and apneic (adults) Patient with decreased sensorium (GCS less than or equal to 8) and ventilation unable to be maintained with BLS airway Cardiac arrest Hypothermia Pediatric Patients Unconscious or unable to follow commands Respiratory arrest / apnea Pneumothorax Vomiting Major head, facial or chest trauma Cardiac arrest from blunt chest trauma Any condition other than cardiac arrest None Presence of gag reflex Caustic ingestion Known esophageal disease (e.g. cancer, varices, stricture) Laryngectomy with stoma (place ET tube in stoma) Height less than 4 feet Pediatric patients under 40 kg Suspected hypoglycemia or narcotic overdose Maxillo-facial trauma with unrecognizable facial landmarks Seizures Patients with an active gag reflex Careful titration of midazolam or morphine if required for relief of discomfort Increased pulse oximetry is not necessarily indicative of patient improvement follow respiratory rate and level of distress Optional equipment Use King Airway early to facilitate use Essential for ongoing verification of ET tube placement. Use as guide to ventilation rate in perfusing patients. Ideal advanced airway device in cardiac arrest less CPR interruption Patients with perfusing pulses (e.g. trauma or respiratory insufficiency) should be managed with BLS airways unless unable to successfully ventilate Patients with perfusing pulses (e.g. trauma or respiratory insufficiency) should be managed with BLS airways unless unable to successfully ventilate No more than 2 interruptions of ventilation lasting up to 30 seconds during laryngoscopy or intubation attempts Page 96 Contra Costa County Prehospital Care Manual January 2010

41 PEDIATRIC ASSESSMENT PEDIATRIC ASSESSMENT TRIANGLE - GENERAL VISUAL ASSESSMENT Assessment Abnormal Appearance Assess TICLS: Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry Any Abnormal Work of Increased or decreased effort or abnormal Assess effort Breathing sounds Circulation Assess for skin color Abnormal skin color or external bleeding PREHOSPITAL PRIMARY ASSESSMENT Assessment Signs of Life-Threatening Condition Airway Assess patency Complete or severe airway obstruction Breathing Circulation Disability Assess respiratory rate and effort, air movement, airway and breath sounds, pulse oximetry Assess heart rate, pulses, capillary refill, skin color and temperature, blood pressure Assess AVPU response, pupil size and reaction to light, blood glucose Apnea, slow respiratory rate, very fast respiratory rate or significant work of breathing Tachycardia, bradycardia, absence of detectable pulses, poor blood flow (increased capillary refill, pallor, mottling, or cyanosis), hypotension Decreased response or abnormal motor response (posturing) to pain, unresponsiveness Hypothermia, rash (petichiae/purpura) consistent with Exposure Assess skin for rash or trauma septic shock, significant bleeding, abdominal distention BEGIN INTERVENTIONS IMMEDIATELY AND TRANSPORT PROMPTLY IF LIFE-THREATENING CONDITIONS ARE IDENTIFIED IN GENERAL VISUAL ASSESSMENT OR PRIMARY ASSESSMENT VITAL SIGNS / GLASGOW COMA SCALE IN CHILDREN Age Normal RR Normal HR Hypotension by systolic blood pressure Term Neonate Infant (<1 yr) Toddler (1-3 yr) Preschooler (4-5 yr) School Age (6-12yr) Adolescent (13-18 yr) Neonate: Less than 60 mmhg or weak pulses Infant: Less than 70 mmhg or weak pulses 1-10 yrs: Less than 70 mmhg + (age in yrs x 2) Over 10: Less than 90 mmhg Pediatric GCS Infant Score Child Score Spontaneous movements 6 Obeys commands 6 Withdraws to touch 5 Localizes 5 Motor Response Withdraws to pain 4 Withdraws 4 Flexion 3 Flexion 3 Verbal Response Eye Response Extension 2 Extension 2 No response 1 No response 1 Coos and babbles 5 Oriented 5 Irritable cry 4 Confused 4 Cries to pain 3 Inappropriate 3 Moans to pain 2 Incomprehensible 2 No response 1 No response 1 Opens spontaneously 4 Opens spontaneously 4 Opens to speech 3 Opens to speech 3 Opens to pain 2 Opens to pain 2 No response 1 No response 1 Contra Costa County Prehospital Care Manual January 2010 Page 97

42 BREATHING COMPRESSIONS ABC MANEUVERS FOR ADULTS, CHILDREN AND INFANTS INTERVENTION ADULT CHILD INFANT 1 year - Under 1 year adolescent AIRWAY Head tilt chin lift. If trauma suspected, use jaw thrust. INITIAL BREATHS 2 effective breaths (make chest rise) - 1 second per breath RESCUE BREATHING - NO COMPRESSIONS breaths/ minute 1 breath every 5-6 seconds breaths / minute 1 breath every 3-5 seconds WITH CPR AND ADVANCED AIRWAY FOREIGN BODY OBSTRUCTION 8-10 breaths/minute 1 breath every 6-8 seconds Abdominal thrusts Up to 5 back slaps and 5 chest thrusts Perform laryngoscopy and use Magill forceps if BLS efforts unsuccessful PULSE CHECK (10 seconds or less) Carotid Brachial or femoral LANDMARKS Lower half of the sternum between the nipples Just below nipple line METHOD Heel of one hand, other hand on top Heel of one hand, or same as adult 2 or 3 fingers, or 2 thumbs encircling (with two rescuers) DEPTH 1.5 to 2 inches One-third to one-half depth of chest RATE 100 per minute COMPRESSION / VENTILATION RATIO 30:2 30:2 (one rescuer) 2 minutes = 5 cycles 15:2 (two rescuers) 2 minutes = 8-10 cycles Page 98 Contra Costa County Prehospital Care Manual January 2010

43 John Muir Medical Center Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA Contra Costa County Base Hospital Hospital Base Phone ED Phone XCC EMS 2 Taped: (925) Receiving Facility Notification: (925) ED: Alert Code Contra Costa County Hospitals (Receiving Facilities) Hospital Services ED Phone XCC EMS 2 Alert Code Contra Costa Regional Medical Center 2500 Alhambra Avenue Martinez CA Basic ED OB/Neonatal (925) Doctor s Medical Center San Pablo 2000 Vale Road San Pablo CA John Muir Medical Center Concord Campus 2540 East Street Concord CA John Muir Medical Center Walnut Creek Campus 1601 Ygnacio Valley Road Walnut Creek CA Basic ED STEMI Center Basic ED STEMI Center Basic ED OB/Neonatal Trauma Center STEMI Center (510) (925) Receiving Facility Notification: (925) ED: (925) Kaiser Medical Center Antioch 5001 Deer Valley Road Antioch CA Basic ED OB/Neonatal (925) (switchboard) Kaiser Medical Center Richmond 901 Nevin Avenue Richmond CA Basic ED (510) Kaiser Medical Center Walnut Creek 1425 South Main Street Walnut Creek CA San Ramon Regional Medical Center 6001 Norris Canyon Road San Ramon CA Sutter/Delta Medical Center 3901 Lone Tree Way Antioch CA Basic ED OB/Neonatal STEMI Center Basic ED OB/Neonatal STEMI Center Basic ED OB/Neonatal STEMI Center (925) (925) (925) Contra Costa County Prehospital Care Manual January 2010 Page 99

44 DESTINATION DETERMINATION BASIC PROCEDURE Field personnel shall assess a patient to determine if the patient is unstable or stable Patient stability must be considered along with a number of additional factors in making destination and transport code decisions FACTORS TO CONSIDER Patient or family s choice of receiving hospital and ETA to that facility Recommendations from a physician familiar with the patient s current condition Patient s regular source of hospitalization or health care Ability of field personnel to provide field stabilization or emergency intervention ETA to the closest basic emergency department Traffic conditions Hospitals with special resources Hospital diversion status UNSTABLE PATIENTS STABLE PATIENTS Usually transported to the closest appropriate acute care hospital emergency department or specialized care centers if indicated If the patient or family requests, or if other factors exist which indicate that another facility be considered, field personnel are to contact the base hospital and present their findings, including ETAs to both facilities. Base personnel will assess the benefits of each destination and may direct field personnel to a facility other than the closest. Stable patients are transported to appropriate acute care hospitals within reasonable transport times based on patient s/family preference If a patient does not express a preference, the hospital where the patient normally receives health care or the closest ED is to be considered Patients on 5150 Holds Obstetric Patients DESTINATION 5150 and OBSTETRIC PATIENTS A patient placed on a 5150 hold in the field shall be assessed for the presence of a medical emergency. Based upon the history and physical examination of the patient, field personnel shall determine whether the patient is stable or unstable. Stable patients on 5150 holds shall be transported to Contra Costa Regional Medical Center Unstable patients on 5150 holds shall be transported to the closest acute care hospital: A patient with a current history of overdose of medications is to be considered unstable A patient with history of ingestion of alcohol / illicit street drugs is considered unstable if: o Significant alteration in mental status (e.g., decreased LOC or extremely agitated); or o Significantly abnormal vital signs; or o Any other history or physical findings that suggest instability (e.g. chest pain, shortness of breath, hypotension, diaphoresis A patient is considered Obstetric if pregnancy is estimated to be of 20 weeks duration or more. Obstetric patients should be transported to hospitals with in-patient OB services in the following circumstances: Patients in labor Patients whose chief complaint appears to be related to the pregnancy, or who potentially have complications related to the pregnancy Injured patients who do not meet trauma criteria or guidelines Obstetric patients with impending delivery or unstable conditions where imminent treatment appears necessary to preserve the mother s life should be transported to the nearest basic emergency department Stable obstetric patients should be transported to the emergency department of choice if their complaints are clearly unrelated to pregnancy Page 100 Contra Costa County Prehospital Care Manual January 2010

45 TRAUMA TRIAGE CRITERIA Unmanageable airway or arrest not meeting field Closest receiving facility determination of death The following meet high-risk criteria and merit direct transport to the trauma center: BP < 90 in adults Physiologic Criteria GCS 13 or below if not pre-existing Penetrating injury to head, neck, torso, groin, pelvis or buttocks Fracture of femur Fracture of long bone(s) resulting from penetrating trauma Anatomic Criteria Traumatic Paralysis Amputation above wrist or ankle Major burns associated with trauma Mechanism Criteria Combined Criteria (combined mechanism and physical findings) Motor vehicle crash with: o Extrication > 20 minutes Note: In the absence of o Fatalities in the same vehicle significant symptoms or o Ejection physical findings with Unrestrained motor vehicle crash with: these mechanisms, o Head on mechanism > 40 mph call base hospital for o Extrication required destination determination Fall 15 feet or greater Motorcycle crash with: o Abdominal or chest tenderness o Observed loss of consciousness Unrestrained motor vehicle crash with abdominal tenderness TRAUMA BASE CALL-IN CRITERIA (IF NOT HIGH-RISK CRITERIA) Base Hospital Destination Decision Required Prior to Transport Precaution with Elderly Patients Additional ations: Evidence of high-energy dissipation or rapid deceleration which may include: o vehicle rollover with unrestrained occupant o intrusion of passenger space by 1 foot or greater o impact of 40 mph or greater (restrained) o persons requiring disentanglement from a vehicle Adult hit by vehicle traveling faster than 15 mph Child (under 15) or elderly patient (65 years and over) struck by a vehicle Persons ejected from a moving object (motorcycle, horse, etc.) Significant blunt force to the head, neck, thorax (chest/back), abdomen or pelvis Penetrating injury to extremities (above knee or elbow) without apparent fracture Patients 65 years of age and older may sustain significant injuries with less forceful mechanisms, and may merit call-in for less significant mechanisms (e.g. ground level fall with new alteration of mental status) Base contact should be made if a patient meets call-in criteria and it is believed trauma center services may be needed, even in the event that the trauma has occurred several hours prior to EMS response If no significant symptoms or physical findings noted despite above mechanism(s), call-in not required and patient may be transported to hospital of choice or to closest facility Contra Costa County Prehospital Care Manual January 2010 Page 101

46 Time Criteria Clinical Criteria Use and Cancellation HELICOPTER TRANSPORT CRITERIA USE HELICOPTER ONLY WHEN BOTH TIME AND CLINICAL CRITERIA MET Helicopter transport generally should be used only when it provides a time advantage. Helicopter field care and transport time (which includes on-scene time, flight time, and transport from helipad to the emergency department) is optimally minutes in most cases Also consider: Time to ground transport to a rendezvous site, or a time delay in helicopter arrival Exception: Patients with potential need for advanced airway intervention (GCS 8 or less, trauma to neck or airway, rapidly decreasing mental status) may be appropriate even when time criteria not met Trauma patients who meet high-risk criteria according to EMS trauma triage policy, except for: o Stable patients with isolated extremity trauma o Patients with mechanism but no significant physical exam findings Trauma patients who do not meet high-risk criteria but by evaluation of mechanism and physical exam findings, appear to have potential significant injuries that merit rapid transport Patients with specialized needs available only at a remote facility such as burn victims/critical pediatric Critically ill or injured patients whose conditions may be aggravated or endangered by ground transport (e.g. limited access via ground ambulance or unsafe roadway) The decision to use or cancel a helicopter rests with the Incident Commander (IC). If criteria not met, helicopter should be cancelled. ations for IC: Patient need Estimated ground transport time versus air response and transport Proximity of a helispot or need for a helicopter/ambulance rendezvous site ETA of the helicopter Restraint Types Restraint Issues Law Enforcement Role Transport Issues RESTRAINTS Leather or soft restraints may be used during transport Handcuffs may only be used during transport if law enforcement accompanies the patient in the ambulance. Patients may not be handcuffed to the gurney. Chemical restraint requires a base hospital order Patients shall be placed in Fowler s or Semi-Fowler s position Patients shall not be restrained in hogtied or prone position Method of restraint should allow for monitoring of vital signs and respiratory effort and should not restrict the patient or rescuer s ability to protect the airway should vomiting occur Restrained extremities should be monitored for circulation, motor and sensory function every 15 minutes Law enforcement agencies are responsible for capture and/or restraint of assaultive or potentially assaultive patients Law enforcement agencies retain responsibility for safe transport of patients under arrest or on 5150 holds Patients under arrest or 5150 hold should undergo a weapons search by law enforcement personnel Patients under arrest must be accompanied by law enforcement personnel If an unrestrained patient becomes assaultive during transport, ambulance personnel shall request law enforcement assistance, and make reasonable efforts to calm and reassure the patient If the crew believes their personal safety is at risk, they should not inhibit a patient's attempt to leave the ambulance. Every effort should be made to release the patient into a safe environment. Ambulance personnel are to remain on scene until law enforcement arrives to take control of the situation. Page 102 Contra Costa County Prehospital Care Manual January 2010

47 RULE OF NINES BURN SURFACE AREA BURN PATIENT DESTINATION General Destination Principles Burned patients with unmanageable airways should be transported to the closest basic ED Patients with minor burns and moderate burns can be cared for at any acute care hospital Adult and pediatric patients with burns and significant trauma should be transported to the closest appropriate trauma center Patient Selection for Initial Transport to Burn Center The following patients may be appropriate for initial transport to a Burn Center: Partial thickness (2nd degree) greater than 20% TBSA Full thickness (3rd degree) greater than 10% Significant burns to face, hands, feet, genitalia, perineum, or circumferential burns of the torso or extremities Chemical or high voltage electrical burns Smoke inhalation with external burns Procedure for Burn Center Destination Contact Burn Center prior to transport to confirm bed availability Consult base hospital if any questions regarding destination decision BURN CENTERS Hospital Services Phone Santa Clara Valley Medical Center 751 S. Bascom Avenue San Jose CA Adult and Pediatric Burn Center UC Davis Medical Center Regional Burn Center 2315 Stockton Blvd. Sacramento CA Adult and Pediatric Burn Center St. Francis Burn Center 900 Hyde Street San Francisco CA Adult and Pediatric Burn Center (No Helipad available) Contra Costa County Prehospital Care Manual January 2010 Page 103