SSM EMS Medical Direction 2016

version 2.0 DO

MD List of Changes for 2016

All Protocol and Procedure numbers removed.

All end boxes changed from, “Notify Destination or Contact Medical Control” to “Notify destination and consider contacting Medical Control”.

Universal Patient Care Protocol (Pearls section) updated.

Deceased persons protocol‐ updated criteria for calling deceased.

Added Purple DNR to Pearls on Deceased Person.

Excited Delirium Syndrome‐ Ketamine dosage updated, changed in drug formulary.

Prehospital therapeutic hypothermia removed from all protocols.

Added Ketamine to Adult COPD/Asthma, added to drug formulary.

Physical Restraints Procedure made a basic skill.

Criteria for termination of efforts changed in Asystole/PEA protocols. List of Changes for 2016 for Changes of List

VF/V‐tach Protocols‐ vasopressin removed.

Adult diabetic protocol‐ Dextrose 50% removed from all protocols, replaced with Dextrose 10%.

Updated Policy on patient resuscitation.

Added Transport Destination Protocol for the Stroke Protocol.

Updated Policy for DNR, term agent inserted.

Added i‐gel to the BIAD Procedure.

Spinal motion restriction changes.

Refusal Policy revised.

Added Ketamine to pain protocol (must call first) changed in Drug Formulary.

Cyanokit dosage changed to 5g IV/IO for adult, 70 mg/kg pediatric, in the Protocol and Drug Formulary.

Adult diabetic, Pearls “Patient Refusal”

Pt added to Stroke Protocol, 3rd page

IV/IO access Protocol changed to Venous Access Protocol, added “No IO for STEMI/Stroke”

Pain control BP >90 revised

“up to” added before 4 mg of Glucagon for Beta Blocker Overdose.

Symptomatic Tachycardia, CP, AMS, s/s shock/poor perfusion, usually occurs at rates > 220‐Age of pt. added to Pearls.

Intranasal Procedure added.

SSM EMS Protocols 2016

Acknowledgement Page

I have received a copy of the SSM EMS Medical Direction 2016.

All skills authorized herein are typically taught during EMT/Paramedic training. In addition to the in-service class, I will read this document thoroughly and will notify my supervisor of any instruction I do not understand.

I understand the instructions in this document are written orders from the Medical Director to me, and I will comply with these orders.

EMT/Paramedic's Signature:______

Date:______

Employee's name (print)______

MO EMT/Paramedic license number: ______

Expiration Date:______

Please return a signed copy of this form to the SSM EMS Liason. General Protocols

Section Table of Contents

Universal Patient Care Well Person Check Refusal

Deceased Persons General Protocols Section Central Line Emergencies Trach Emergencies Ventilator Emergencies Epistaxis Dental Emergencies Fever/ Control Venous Access Behavioral Excited Delirium Police Custody Team Focused CPR

SSM EMS Protocols 2016 Universal Patient Care

Continuously monitor the scene for signs of NO Is the scene safe? YES instability/danger. Mass assembly consider WMD Call for help / additional CREW SAFETY IS PRIORTY ONE! resources UNSAFE If the scene becomes unsafe, Stage until scene safe retreat immediately.

SAFE

Resources are sufficient for NO all to be treated immediately?

Call for help / additional YES Required VS: resources pressure B Palpated pulse rate Triage Protocol Bring all necessary equipment to patient Respiratory rate begin early Demonstrate professionalism and courtesy Pulse oximetry Utilize appropriate PPE If Indicated: Consider Airborne or Droplet Isolation Blood B if indicated General Protocols Section 12 Lead ECG Adult Assessment Procedure Temperature Pain scale Pediatric Assessment Procedure End tidal EtCO2 Use Broselow-Luten tape CO Monitoring

Mechanism of injury YES NO present? Trauma Medical Patient Patient

Spinal Motion Restriction B Protocol

Significant mechanism Shows symptoms of YES YES of injury? a STEMI or CVA? NO Prepare patient for rapid transport. NO B Attempt to keep scene time < 10 min. Focused assessment B on specific injury Patient presentation YES fits specific protocol? Continue on-going assessment NO Repeat initial VS Evaluate interventions / procedures Transfer to higher level of care. Patient -off includes summary of care, Notify destination and consider response to care, last set of vital signs, contacting Medical Control patient information, personal property.

Exit to Appropriate Protocol(s)

SSM EMS Protocols 2016 Universal Patient Care

Scene Safety Evaluation: Identify potential hazards to rescuers, patient and public. Identify number of patients and utilize triage protocol if indicated. Observe patient position and surroundings.

General: All patient care must be appropriate to your level of training and documented in the PCR. The PCR / EMR narrative should be considered a story of the circumstances, events and care of the patient and should allow a reader to understand the complaint, the assessment, the treatment, why procedures were performed and why indicated procedures were not performed as well as ongoing assessments and response to treatment and interventions.

Adult Patient: An adult should be suspected of being acutely hypotensive when Systolic Blood Pressure is less than 90 mmHg. Diabetic patients and women may have atypical presentations of cardiac related problems such as MI. General weakness can be the symptom of a very serious underlying process. Beta blockers and other cardiac drugs may prevent a reflexive tachycardia in shock with low to normal pulse rates.

Geriatric Patient: Hip fractures and dislocations have high mortality. Altered mental status is not always dementia. Always General Protocols Section check Blood Sugar and assess signs of stroke, trauma, etc. with any alteration in a patient’s baseline mental status. Minor or moderate injury in the typical adult may be very serious in the elderly.

Pediatric Patient: Pediatric patient is defined by those which fit on the Broselow‐Luten Resuscitation Tape, Age less than 12 and / or weight 49 kg or less. Patients off the Broselow‐Luten tape should have weight based medications until age 16 or greater or weight greater than or equal to 50 kg. Special needs children may require continued use of Pediatric based protocols regardless of age and weight. Initial assessment should utilize the Pediatric Assessment Triangle which encompasses Appearance, Work of Breathing and Circulation to skin. The order of assessment may require alteration dependent on the developmental state of the pediatric patient. Generally the child or infant should not be separated from the caregiver unless absolutely necessary during assessment and treatment.

Special note on oxygen administration and utilization: Oxygen is found everywhere in prehospital patient care and probably over utilized. Oxygen is a pharmaceutical with indications, contraindications as well as untoward side effects. Recent research demonstrates a clear link with increased mortality when given in overdose (hyperoxia / hyperventiation) in cardiac arrest. Utilize when indicated and not because it is available. A reasonable target oxygen saturation for most patients is 90‐99 % regardless of delivery device.

Pearls  Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with GCS, and location of injury or complaint.  Any patient contact which does not result in an EMS transport must have a completed patient care record with explicit disposition information and patient instructions.  A pediatric patient is defined by fitting on the Broselow-Luten tape or Age < 12 or weight ≤ 49 kg.  Pediatric Airway Protocols are defined by patients < 12 years of age.  Timing of transport should be based on patient's clinical condition and the transport policy.  Blood Pressure is defined as a Systolic / Diastolic reading. A palpated Systolic reading may be necessary at times.  SAMPLE: Signs / Symptoms; Allergies; Medications; PMH; Last oral intake; Events leading to illness / injury

SSM EMS Protocols 2016 Well Person Check

Universal Patient Care Protocol

Circumstances suggest Involve law that patient is a threat to YES B enforcement themselves or others? NO

Exit to Person is willing NO Refusal Protocol to be evaluated? YES

Obtain Vital Signs: B GCS, HR, RR, BP, Sp02 YES Blood Glucose Analysis B Procedure General Protocols Section Patient has Hx of diabetes or shows signs of hypoglycemia? Exit to Blood Glucose YES Appropriate Protocol NO < 70 mg/dL?

NO

GCS <15 Pulse >110 or <50, SBP >200 or <85, DBP>120, Strongly recommend further treatment YES RR > 24 or < 6, and transport for evaluation Pulse ox <94%, or blood glucose > 250 mg/dL? Patient is willing to be transported for evaluation? YES NO NO Exit to Refusal Protocol

NO Does the person have Patient is requesting to be YES YES a medical complaint? transported for evaluation? NO

Is a mechanism of injury present Wound Care - General YES B that supports trauma or other injury? Procedure NO

Re-Confirm patient has no medical complaint. If there is no medical complaint than no further action is required. Provide patient with vital sign results and suggest to them contact their doctor to report results.

SSM EMS Protocols 2016 General Protocols Section 2016 ions measured. The PCR once begun, document as much as as document begun, once get worse. See Refusal Protocol. vital signs, if vital signs are not within normal cause further harm, and if they still still do not want further and if they cause harm, of injury they are considered patients and must ay initially present for a “routine check”. Please a “routine check”. ay initiallypresent for be observed and respirat accuratelythoroughly describe the patient and ave no medical complaints. Must be able to document ed patientsshall haveaPCR completed. and tient care record (PCR) completed. SSM EMS Protocols and/or decline further evaluation for further treatment and transport. call 911 if symptoms persist or ALL responders. Well Person Check Person Well This protocol applies to to applies protocol This have an appropriate evaluation and a pa If a person has a medical complaint or a mechanism complaint or medical a person has a If consider are service request who All persons you can. Even patients who refuse vital signs can must and all cases, and narrative is key in these, encounter. Inform the patient that refusing care and transportand care can Inform the patient that refusing range for patient, strongly advise to be transported, urge them to Should a patient refuse evaluation evaluation a patient refuse Should confirm with the patienth twice at leastwith that they confirm x3. alert and oriented Make sure you complete a medical/trauma survey, take Patients who are denying more severe symptoms m Pearls:        General Protocols Section 2016 NO NO NO Exit to NO present condition present Patient has a court Appropriate Protocol(s) appointed guardian? (up to and including death) Inform patient of all the risks associated with the patient’s ion with a doctor ion with a formation? NO YES YES B YES choice? situation? Patient able to Patient has an Patient able to YES appreciationthe of YES Patient understands understands Patient communicate a clear relevant in in a rational manner? a rational in manipulate information NO NO YES to discuss disposit Consider contactingMedical Control YES

NO of age? YES YES Exit to Enter from Patient is > 18 years Patient wants further present condition? present risks associated with with associated risks Appropriate Protocol Patient informed of the the hospital of their choice ? Refusal Refusal Patient is now willing to be treatment and / or transport to transportedevaluation? for SSM EMS Protocols Protocol based on SpProtocol ecific Complaint

NO NO patient boxes guardian parent or parent Substitute for in following a non-crew member. elements of this protocol. this elements of Advise patient to call 9-1-1 if patient to Advise they develop anythey develop symptoms. Complete PCR and document document and Complete PCR Have patient sign refusal. The YES signature should be witnessed by signature should be NO YES of patient guardian? parent of legal legal of parent emancipation? Able tocontact Patient has court paperwork proving and/or transported? wants patient treated treated patient wants Coordinate disposition disposition Coordinate Parent or legal guardian B Contact parent or legal guardian legal or parent Contact NO YES B General Protocols Section 2016 High risk their illness or ion. Patient should injury are considered the EMS provider agrees

rs, significant mechanism of irations measured. The includinga mental status once begun, document as much as as document begun, once he facts of the situathe facts of ctual understanding of cility. Encourage patient to allow an Encouragecility. patient to allow mplaint or a mechanism of mechanism mplaint or a in EMS. Only motor vehicle accidents have a higher accidents have vehicle Only motor in EMS. ated x3. The PCR narrative is key in these and all t must include vital signs and documentation of the ay initially present for a “routine check”. Please “routine check”. a ay initiallypresent for the decision, whether or not This should remain stableInability to This should remain over time. l or drug intoxication, mino e event is very important Medical Direction before releasing the patient. Demonstrate a rational process to come a to decision. Should options and risks and benefits. he choice consistently demonstrates incapacity. Refusal parent/legal guardian according to RSMO.431-061. SSM EMS Protocols ughly describe the patient encounter. injuries/illnesspregnancy,bite related to the skin, that breaks of kindany ce that they have no medical complaints. and/or decline further evaluation onally, patients with a potentialfor trauma should have a mechanism ent to accept transport to medical fa transportent to accept to Ability to communicatet understandingan of ALL responders her medical attention, the you can. Even patients who refuse vital signs can be observed and resp documentto alert and orient able responder must be cases, and must accurately and thoro This protocol applies to to applies protocol This Patients who are denying more severe symptoms m confirm with the patienttwi at leastwith confirm All persons who request service and have a medical co haveserviceAll persons who request and patients and shall have a PCR completed. For patientcategory,be brief bu in thisthe PCR may Additi lack of a medical complaint. trauma exam completed. evaluation a patient refuse Should Any female under the age of 18 that is pregnant, shall18 that is pregnant,under produce of age theAny female an emancipation order signed by a judge before decisionmaking any medical without consulting injury, high suspicion of abuse or neglect,high suspicionor of abuse injury, or submersion / near drowning. Pearls:      be able to describe thereasoning they are using tocome to Consider discussing high risk refusalsrisk with SSM Consider discussing high be able to recognizesignificance the outcomepotential of the from or her decision. his in a rational manner: of information Manipulation with decision. refusals include, but are not limitedchest to, pain, alcoho Patient Refusal: Patient refusals are great source a of liability incidence of litigation. Encourage pati incidence of litigation. assessment, including vital signs. Documentation of th Patient should be able to display a fa Relevant be able should information is understood: Patient Guide to Assessing Capacity:Guide to Assessing clear choice: communicate a to be able Patient should assessmentcapacitythe patient’s describing to refuse care. inabilitychoiceacommunicate to expressor an t situation that requires furt Appreciation of the situation: Deceased Persons

History: Key Information: Differential:  Person encountered by EMS who  Name of primary care  Attended Death (a patient with meets criteria for obvious death physician a primary care physician who  Patient with DNR in place who is  Known medical conditions apparently died of natural pulseless and apneic  List of medications causes (aka “natural death”))  Patient with other approved  Last time known to be alive  Unattended Death (a patient advanced directive requiring no CPR without a primary care be administered who is pulseless physician who apparently dies and apneic of natural causes (aka “natural  Patient for whom resuscitative efforts death”)) are ceased on scene  Suspicious Death (law enforcement)

Enter from ongoing Enter from ongoing Universal Patient Care Protocol Asystole/PEA Protocol OR Resuscitation Protocol OR

Injury incompatible with life Valid DNR and/or NO paperwork NO obvious signs of: General Protocols Section present? Decomposition, rigor Traumatic mortis, dependent lividity? arrest with NO YES asystole? YES Exit to YES Appropriate Resuscitation Protocol

Confirm in at least two (2) leads. Print a long DO NOT START or P lead II strip for the Medical Examiner TERMINATE Time of death shall be time printed on strip RESUSICATION EFFORTS

Call for law enforcement, B if not already on scene

Obvious crime scene or YES suspicious circumstances? Minimize personnel into the scene NO B Preserve evidence Attempt to NOT disturb the scene

Leave all medical devices in place B Move patient only if necessary Document any manipulation of scene or body Coordinate with law enforcement and P assist if needed with contacting Medical Examiner’s Office

Consider contacting Medical Control to discuss disposition with a doctor

SSM EMS Protocols 2016 General Protocols Section 2016 re physician, known medical conditions, nt produces, a Do Not Resuscitate Not Resuscitate a Do nt produces, nor the Out of Hospital DNR. The form should be nt or remote, must be referred to the medical nt ANYof scene and or body. manipulationnt appropriate County Medical Examiner. Examiner. appropriate County Medical SSM EMS Protocols SSM EMS Protocols e scenes until proven otherwise. rney or legal guardian, at any poi rmation in PCR; Name of primaryrmation ca Deceased Persons Deceased All death scenes are considered crim examiner. Contact (or have law enforcement contact) Scene preservation is most important, docume rece deaths, whether traumatic All out-of-hospital If a family member, power of atto (DNR) form signed by a physician and the patient,by a ho form signed (DNR) on the form. preferable done purple info surefollowing to gather the Be list of medications, last time known to be alive. Pearls:       General Protocols Section 2016 Fever Hemorrhage Reactionsfrom home nutrientor medication distress Respiratory Shock Differential      position catheter Exit to s- Adult / Pediatrics Adult s- Continue infusion Stop infusion if ongoing if infusion Stop Stop infusion if ongoing if infusion Stop veinagardcatheter over Do not exceed20 mL / kg Appropriate Protocol(s) Apply tegaderm or veinagard over evident. ConsiderVenigard orTegaderm covering with a Clampcatheter proximaldisruption to May use hemostat wrapped in gauze Apply direct pressure around catheter Apply direct pressure around catheter Clamp catheter and apply tegaderm or Place patient on left side in head down Stop infusion if ongoing, clamp catheter P P P P B B B SSM EMS Protocols ing / manipulating an indwelling catheter. manipulating ing / op. Ask family or caregiver if it is appropriate to stop or change infusion. they have specific knowledge and skills. External catheterdislodgement dislodgement catheter Complete catheter Damaged site catheter at Bleeding Internal bleeding clot Blood Air embolus Erythema, warmth or drainage about catheter site indicating infection YES Emergencies Involving Involving Emergencies YES YES YES YES YES Signs and Symptoms Signs and         BP cuff on the same side where a PICC line is located. Indwelling Central Line Central Indwelling NO NO NO NO NO NO site? Chest Pain? Ongoing infusion? partially dislodged? Airway, Breathing or Airway, Breathing Suspect Air Embolus Circulation Problem? Damage to catheter? Tachypnea, Dyspnea, Dyspnea, Tachypnea, contacting Medical Control Medical contacting Catheter completely or Hemorrhage at catheter catheter at Hemorrhage Tunneled Catheter (Broviac / Hickman) inserted (peripherally PICC central catheter Implanted catheter Hickman) / (Mediport Notify destination and consider Notify Do not place a tourniquet or Do not attempt to force catheter open if occlusion stSome infusionsto detrimental may be Cardiac arrest: Access central catheter and utilize if functioning properly. Hyperalimentation infusions (IV nutrition): If stopped for any reason monitor for hypoglycemia. Always talk to family / caregivers as Use strict sterile technique when access Central Venous Catheter Type Catheter Venous Central line of Occlusion dislodge partial or Complete disruption partial or Complete Universal Patient Care Protocol      Pearls   History       General Protocols Section 2016 NO Equipment failure. Or stoma Exit to YES Caregiver to insert Protocol(s) Continued Appropriate Tracheostomy Tube Tracheostomy Respiratory Distress Allow Place Appropriately sized Respiratory Distress? Place Trachesotomy Tube / Tube Trachesotomy Place Appropriately sized ETT into endotracheal tube into stoma Allergic reaction Asthma Aspiration Septicemia body Foreign Infection Congenitaldisease heart Medication or toxin Trauma Pneumothorax and P P B Differential          YES Procedure Procedure Remove Inner Cannula NO Remove Speaking Valve SSM EMS Protocols bstructed tracheostomy tube / ETT, Assist Ventilations via Remove Decannulation plug O Tracheostomy Tube / ETT Remove Obturator Airway: Suctioning Advanced Airway: Suctioning Advanced contacting Medical Control Medical contacting Tracheostomy Tracheostomy Tube available? Respiratory Distress Respiratory Nasal flaring Chest wallretractions or (with without abnormal breath sounds) Attemptscough to Copious secretions notedcoming out of the tube Faint breath sounds on both sides of chest despite significant respiratory effort AMS Cyanosis Notify destination and consider Notify P P P B Signs and Symptoms Signs and        NO NO NO YES NO With a Tracheostomy Tube- Adult / Pediatrics Adult Tube- Tracheostomy a With NO isplaced tracheostomy tube / ETT, Procedure YES YES YES YES D

Continued Removed? Removed? Inner Cannula Tracheostomy Tracheostomy Tube in place? (Double lumen) Speaking Valve Decannulation plug plug Decannulation Obturator Removed? Respiratory Distress? Monitor and Reassess and Monitor DOPE: Use patients equipment if available and functioning properly. Estimate suction catheter size by doubling the inner tracheostomy tube diameter and rounding down. Suction depth: Ask family / caregiver. No more than 3 to 6 cm typically. Instill 2 – 3 mL of NS before suctioning. Do not suction more than 10 seconds each attempt and pre-oxygenate before and between attempts. DO NOT force suction catheter. If unable to pass, then tracheostomy tube should be changed. Always deflate tracheal tube cuff before removal. Continual pulse oximetry and EtCO2 monitoring if available. Always talk to family / caregivers as they have specific knowledge and skills. Birth defect (tracheal atresia, tracheomalacia, craniofacial abnormalities) Surgical complications (accidental damage to phrenic nerve) or brain (post-traumatic Trauma spinalinjury) cord Medical condition (bronchial or pulmonary dysplasia, muscular dystrophy) Airway: Suctioning Advanced Universal Patient Care Protocol P         Pearls History     P General Protocols Section 2016 Exit to Equipment failure. YES Appropriate Protocol(s) or Disruption of oxygensource Dislodged or obstructed tracheostomy tube Detached or disrupted ventilator circuit Cardiac arrest Increased oxygen requirement/ demand Ventilator failure Pneumothorax and Differential       NO other problems? Problem with Circulation and maintain current settings Transport on patient’s ventilator contacting Medical Control Medical contacting Notify destination and consider Notify P with a Protocol Correct cause Tracheostomy Tube Respiratory Distress Emergencies Emergencies SSM EMS Protocols bstructed tracheostomy tube / ETT, P monitoringbe must utilized duringassessment transport. and O 2 Transport requiring maintenance of a mechanical ventilator Power or equipment failure at residence NO Signs and Symptoms Signs and   YES YES YES YES YES Low Power: Internal battery depleted. or circuit. airway obstructed / Plugged Pressure: High Involving Ventilators- Adult / Pediatrics Adult Ventilators- Involving and NO NO NO NO NO YES or at baseline isplaced tracheostomy tube / ETT, 35 – 45 mmHg? ventilate with BVM and Oxygen 2 D Tube / ETT?Tube / Tube / ETT?Tube /

Cause corrected? Cause Oxygen saturation 94 % Problem with Airway, ≥

EtCO (Ask Caregiver: What is Dislodged Tracheostomy Remove patient from ventilator and manually Detached Oxygen Source Obstructed Tracheostomy DOPE: Unable to correct ventilator problem: Remove patient from ventilator and manually ventilate using BVM. Take patient’s ventilator to hospital even if not functioning properly. Typical alarms: Low Pressure / Apnea: Loose or disconnected circuit, leak in circuit or around tracheostomy site. Always talk to family / caregivers as they have specific knowledge and skills. Always use patient’s equipment if available and functioning properly. Continuous pulse oximetry and end tidal CO Detached Ventilator Circuit? Birth defect (tracheal atresia, tracheomalacia, craniofacial abnormalities) (damage complications Surgical to phrenic nerve) or brain (post-traumatic Trauma spinalinjury) cord Medical condition (bronchopulmonary dysplasia, muscular dystrophy) Ventilation or Oxygengation? baseline saturation for patient) B Universal Patient Care Protocol    Pearls    History     General Protocols Section 2016

YES Exit to if indicated Appropriate Trauma Protocol Head tilt forward Position of comfort Bleeding controlled? Protocol Venous Access Trauma Infection (viral URI or Sinusitis) Allergic rhinitis Lesions (polyps, ulcers) Hypertension P Compress nostrils with direct pressure Differential      B Protocol NO

NO Consider Direct pressure ay Management Hypotensive SBP < 90 Venous Access Protocol Have patient blow nose, age specific hypotension? Procedure followed by Direct Pressure Epistaxis contacting Medical Control Medical contacting SSM EMS Protocols Bleeding from nasal passage nasal from Bleeding Pain Nausea Vomiting OxymetazolineNostril Sprays to 2 Airw Notify destination and consider Notify B Airway Suctioning: Basic Procedure Airway Suctioning: grel (Plavix), aspirin/dipyridamole (Aggrenox), and ticlopidine (Ticlid) can adin), heparin, enoxaparin (Lovenox), dabigatran (Pradaxa), rivaroxaban

Signs and Symptoms Signs and     Airway Suctioning:Basic P B B YES e amount of blood lossamount withepistaxis.e YES YES he counter headache relief powders. Exit to NO NO Appropriate Head Tilt Forward Position of Comfort Significant or Active bleeding Hypotension Protocol Leave Gauze in place if present multi-system trauma? multi-system Age history medical Past Medications (HTN, anticoagulants, aspirin, NSAIDs) Previous episodes of epistaxis Trauma bleeding of Duration Quantity of bleeding Avoid Oxymetazolineknown in patients haveor a of greater than 110 diastolicwho blood pressure coronary artery disease. Age specific hypotension: 0 – 28 days < 60 mmHg, 1 month – 1 year < 70 mmHg, 1 year – 10 years < 70 + ( 2 x 90 mmHg. 11 yearsage)mmHg, greater < and It is very difficult to quantify th Bleeding may also be occurring posteriorly. Evaluate for posterior blood loss by examining the posterior pharnyx. Anticoagulants include warfarin (Coum Recommended Exam: Mental Status, HEENT, Heart, Lungs, Neuro (Xarelto), and many over t and many over(Xarelto), Anti-platelet agents like aspirin, clopido Anti-platelet agents like aspirin, contribute to bleeding. into posteriorpharynx? Universal Patient Care Protocol B History             Pearls   General Protocols Section

2016 Exit to Exit to Protocol Protocol Appropriate Trauma Appropriate Trauma Appropriate Cardiac Appropriate Cardiac Decay Infection Fracture Avulsion Abscess cellulitis Facial Impacted tooth (wisdom) TMJ syndrome infarction Myocardial Differential          See below if indicated

Appropriate Pain Protocol Pressure Preparation exert pressure contamination contacting Medical Control Medical contacting

May rinse gross Cardiac Monitor Notify destination and consider Notify / Commercial Treat Dental Avulsion: Avulsion: Dental Treat with patient closing teeth to Control Bleeding with Direct Direct with Bleeding Control 12 Lead ECG Procedure Do not rub or scrub tooth scrub or not rub Do Control Bleeding with Direct Pressure Direct with Bleeding Control Place tooth in / Normal Small gauze placed into socket SSM EMS Protocols Bleeding Pain Fever Swelling fractured or missing Tooth P B B B B Signs and Symptoms Signs and      Dental Problems Dental YES YES YES YES YES

NO NO NO NO NO Exit to Bleeding? Transport? Dental Avulsion? Dental System Trauma? System Dental or Jaw Pain Significant or Multi- Appropriate Protocol hot). Significant soft tissue swelling to the face or oral cavity can represent a cellulitis or abscess. Scene and transport times should be minimized in complete tooth avulsions. Reimplantation is possible within 4 hours if the tooth is properly cared for. Occasionally cardiac chest pain can radiate to the jaw. All pain associated with teeth should be associated with a tooth which is tender to tapping or touch (or sensitivity to cold or Recommended Exam: Mental Status, HEENT, Neck, Chest, Lungs, Neuro Age history medical Past Medications Onset of pain / injury Trauma with "knocked out" tooth Location of tooth Whole vs. partial tooth injury Suspicious for Cardiac? for Suspicious Universal Patient Care Protocol     Pearls  History        Fever / Infection Control

History Signs and Symptoms Differential  Age  Warm  / Sepsis  Duration of fever  Flushed  Cancer / Tumors / Lymphomas  Severity of fever  Sweaty  Medication or drug reaction  Past medical history  Chills/Rigors  Connective tissue disease  Medications Associated Symptoms  Arthritis  Immunocompromised (transplant, (Helpful to localize source)  Vasculitis HIV, diabetes, cancer)  myalgias, cough, chest pain,  Hyperthyroidism  Environmental exposure headache, dysuria, abdominal pain,  Heat Stroke  Last acetaminophen or ibuprofen mental status changes, rash  Meningitis

Universal Patient Care Protocol

Contact, Droplet, and Airborne Precautions B Temperature Measurement Procedure

P Venous Access Protocol

Temperature NO Pediatric patient? General Protocols Section NO YES > 101.5° F (38.6° C)? YES

Pediatric Acetaminophen P 15 mg/kg PO Exit to Appropriate Protocol

Exit to Appropriate Protocol

Pearls  Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro  Febrile seizures are more likely in children with a history of febrile seizures and with a rapid elevation in temperature.  Patients with a history of liver failure should not receive acetaminophen.  UTILIZE STANDARD UNIVERSAL PRECAUTIONS FOR ALL PATIENTS WITH SUSPECTED INFECTION.  All-hazards precautions include standard PPE plus airborne precautions plus contact precautions. This level of precaution is utilized during the initial phases of an outbreak when the etiology of the infection is unknown or when the causative agent is found to be highly contagious (e.g. SARS).  Droplet precautions include standard PPE plus a standard surgical mask for providers who accompany patients in the back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be utilized when influenza, meningitis, , streptococcal pharyngitis, and other illnesses spread via large particle droplets are suspected. A patient with a potentially infectious rash should be treated with droplet precautions.  Airborne precautions include standard PPE plus utilization of a gown, change of gloves after every patient contact, and strict hand washing precautions. This level of precaution is utilized when multi-drug resistant organisms (e.g. MRSA), scabies, or zoster (), or other illnesses spread by contact are suspected.  Rehydration with fluids increases the patient’s ability to sweat and improves temperature control.  All patients should have drug allergies documented prior to administering any medications.  Consider whether elevated temperature is due to “fever” (and suspected infection), or a possible environmental heat emergency. NSAIDs should not be used in the setting of environmental heat emergencies.  Do not give aspirin to a child, or NSAIDs to a pregnant woman.

SSM EMS Protocols 2016 General Protocols Section

2016 or

or NO NO Enter from Monitor Infusion Monitor Saline Lock life threatening life Major trauma, Venous Access: medical condition? YES Protocol based on Protocol specific complaint

burns > 15% TBSA? Extremity Procedure Extremity STEMI, acute stroke P B

P YES YES NO Access condition? successful? Progressed to a to Progressed life threatening life X2 ATTEMPTS YES UNSUCCESSFUL contacting Medical Control Medical contacting Notify destination and consider Notify YES YES properly? CVC flows Patient has a central venous venous central CVC Procedure catheter (CVC)? Venous Access: NO P SSM EMS Protocols NO NO (No previous Venous Access: Venous Access: Patient has a central venous venous central (ped or adult device) device) or adult (ped catheter (CVC)?

attempts at access) Intraosseous Procedure most suitable site available External Jugular Procedure Venous Access Venous P OR YES STROKE X2 large bore X2 large Venous Access: Venous Access: Extremity Procedure Extremity NO IO FOR STEMI OR Intraosseous Procedure P CVC Procedure Venous Access: P General Protocols Section 2016 discouragedwith in patients cardiaca pre-existing arrest, external central venous dialysis fistula, avoid IV attempts, blood draws, ity (LE) sites; LE IVs are appropriate adult or pediatric device (e.g. IO drill). 8 years of age. to EMS arrival may be used for EMS IV fluids and ≥ the upper extremityupper thethe affected side. on keep vein open) unless administeringfluidbolus. SSM EMS Protocols Venous Access Venous of two (2) IV attempts on stable patients.two (2) IV attempts of maximum Any working venousAny workingaccessed already catheter prior medications. Intraosseous access should be obtained only with the injections, and blood pressure measurements in catheter may be accessed for use. vasculardiseasediabetes. or post-mastectomyIn patientsa working and patients with Any prehospitalor medications approved fluids forIV use may given also be intraosseous throughIV. an External jugular access is only indicated for patients All IV rates should be at KVO (minimal rate to Use micro drip sets for all patients 6 years old or less.oryearspatients old 6 micro drip sets for all Use Upper extremity IV sites are preferable to lower extrem A Patients that are hemodynamicallyor in extremisunstable,         Pearls   General Protocols Section 2016 may repeat

2.5 mg IV / IM 5 mg IV / IM or or Exit to Protocol after 15 min Exit to sess restraints sess (max total dose 5 mg) Excited Delirium -depressive) if < 80 mg/dL age appropriate Ventilation rate to or Diabetic Protocol one time 35 – 45 mmHg instability/danger. 2 YES 90% Continuously monitor the scene for signs of of signs for scene the Cardiac Monitor ≥ EtCO of Chemical Restraint Procedure

2 Physical RestraintProcedure Monitor and reas and Monitor AlteredMental Status differential Intoxication Alcohol Toxin/ Substance abuse Medication effect / overdose syndromes Withdrawal Depression Bipolar (manic Schizophrenia Anxiety disorders Midazolam 0.2 mg/kg IntraNasal Adult Haloperidol 5 mg IM SpO Consider Differential          Venous Access Protocol Midazolam 5 mg IntraNasal May repeatdose maintain Consider YES B Pediatric in 3 -5 minutes if needed 65 ≥ Continuously monitor respiratory status status respiratory monitor Continuously 0.1 mg/kg IV / IO (max dose 2.5 mg) maintain Adult Midazolam 10 mg IntraNasal or . once Age

P NO SAFE Scene safe? pain, hyperthermia? Patient suspected of having head trauma? retreat immediately SSM EMS Protocols SSM EMS Protocols the scene becomes unsafe, becomes scene the Behavioral If CREW SAFETY IS PRIORTY ONE! YES Anxiety, agitation, confusion agitation, Anxiety, Affect change, hallucinations Delusional thoughts, bizarre behavior violent Combative Expression of suicidal / homicidal thoughts Blood Glucose Analysis Procedure Blood Glucose hallucination, inability to talk down, super Universal Patient Care Protocol Patient exhibiting paranoia, hyper- aggression, Signs and Symptoms Signs and      B human strength with near complete tolerance to YES NO UNSAFE NO NO Patient is a contacting Medical Control Medical contacting violent, agitated,or possible psychosis? Notify destination and consider Notify Physical RestraintProcedure Monitor and Reassess and Monitor threat to self or others, Exit to Protocol Head Trauma Trauma Head age appropriate resources Consider Situational crisis Situational illness/medications Psychiatric Injury to self or threats to others tag alert Medic Substance abuse / overdose Diabetes B Stage until scene safe History       Call for helpadditional / General Protocols Section 2016 ening in adults observed by ALS personnel on ted by EMS must be accompanied by benzodiazepines may be indicated for Diphenhydramine 50 mg IV / IO / IM pat down and remove all weapons before transporting. story of psychosis or extreme alcohol intoxication, or a raint mustraint be continuously and benzodiazepines together may lead to respiratory lead may together and benzodiazepines e or chronic drug abuse, particularly stimulant drugs such as SSM EMS Protocols SSM EMS Protocols Behavioral us, Skin, Heart, Lungs, Neuro in pediatrics. 1 mg/kg IV / IO / IM cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may also also may trauma or head withdrawal Alcohol agents. or similar amphetamines methamphetamine, cocaine, crack cocaine, contributethe to condition. reactions: Extrapyramidal and associated with use of physical control measures, including physical restraints and Tasers. Most commonly seen in male subjects with a history of serious mental illness and/or acut or Condition causing involuntary muscle movements or spasms typically of the face, neck and upper extremities. May present with contorted neck and trunk with difficult motor movements. Typically an adverse reaction to antipsychotic drugs like Haloperidol and may occur with your administration. When recognized give Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Potentially life-threat Crew / responders safety is the main priority. SEE PHYSICAL/CHEMICAL RESTRAINT PROCEDURE Any patient who is handcuffed or restrained by Law Enforcement and transpor law enforcement in the ambulance. Law Enforcement MUST Consider antipsychotics (Haloperidol) for patients with hi upon theirscene or immediately arrival. Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) Do not irritate the patient with a prolonged exam. Do not overlook the possibility of associated domestic violence or child abuse. If patient is suspected of agitated delirium suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early. Do not position or transport any restrained patient is such a way that could impact the patients respiratory or circulatory status. Excited Delirium Syndrome: Recommended Exam: Mental Stat benzodiazepine for patients with other presumed Whilesubstance abuse. patients with alcohol intoxication, consider alcohol that depression. All patients who receive either physical or chemical rest           Pearls   General Protocols Section 2016 Max 10 mg status status -depressive) Midazolam 2.5 mg IV / IO reassess restraints5 min.q q 5 min to effect, or Chemical Restraint Procedure Continuously monitorrespiratory Midazolam 5 mg IntraNasal / IM Repeat Midazolam 2.5 mg IV / IO NO P P AlteredMental Status differential Intoxication Alcohol Toxin/ Substance abuse Medication effect / overdose syndromes Withdrawal Depression Bipolar (manic Schizophrenia Anxiety disorders contacting Medical Control Medical contacting Differential          Notify destination and consider Notify . SAFE if < 80 mg/dL retreat immediately Diabetic Protocol the scene becomes unsafe, becomes scene the Patient >14 years of age?

Behavioral Protocol If Physical RestraintProcedure Thiamine 100 mg or IM IV CREW SAFETY IS PRIORTY ONE! SSM EMS Protocols P B YES Anxiety, agitation, confusion agitation, Anxiety, Affect change, hallucinations Delusional thoughts, bizarre behavior violent Combative Expression of suicidal / homicidal thoughts YES Signs and Symptoms Signs and      YES UNSAFE Excited Delirium Syndrome Delirium Excited OR OR NO NO Access Protocol Cardiac Monitor Procedure Procedure respiratory status status respiratory 10 mg IntraNasal Chemical Restraint Continuously monitor Alcoholism suspected? Alcoholism Ketamine 5 mg / kgIM Ketamine5 mg Midazolam 5 mg IM /or Ketamine 1.5 mg / kg IV Consider Blood Glucose Analysis reassess restraints q 5 min. resources Venous Situational crisis Situational illness/medications Psychiatric Injury to self or threats to others tag alert Medic Substance abuse / overdose Diabetes Emergence Phenomena present? P P P B Stage until scene safe History       Call for help / additional General Protocols Section 2016 ead to misinterpretation of rious mental illnessrious and/or the patients respiratory or so contribute to the condition. extreme alcohol intoxication, extreme or a L RESTRAINT PROCEDURE in patients with psychiatricin patients with disorders, anxiety, hallucinations, speech and visual relays, which l use of physical control measures,use of physicalincluding ects with a history of se suchcrack as cocaine, cocaine, methamphetamine, e abuse. While benzodiazepines may be indicated for ting sensations, delirium, recovery agitation, and ch a way that couldway impact that ch a forcementaccompaniedbe and transported must by EMS t motor movements. Typicallyt motoran adverse movements. reaction to th your administration.th When recognizedgive cardiac arrest, consider a fluid bolus and sodium bolus a fluid consider cardiac arrest, es for behavior (hypoglycemia, overdose, substance abuse, restraint must be continuously observed by ALS personnel ohol and benzodiazepines togethermay lead to respiratory or 1 mg/kg/ IM IV / IO in pediatrics. . SEE PHYSICAL/CHEMICA SSM EMS Protocols patients with history of psychosispatientsof with history or ohol withdrawal or head trauma may al delirium, psychomotor delirium, agitation, / bizarre behavior, insensitivity to pain, hyperthermia and increased : d be searchedfor weapons/contraband by law enforcement before being put loaded on : A hallmark eventmore common of Ketamine,A : Excited Delirium Protocol Delirium Excited Medical emergency: Combination of disturbances, disorientation, violent with Potentiallystrength. associated life-threatening and restraintscommonlyin male subj seen Most and Tasers. acuteparticularlydrug or chronicstimulant abuse, drugs amphetamines or similar agents. Alc auditory and visual stimuli. Prophylactic coadministration of a benzodiazepine is used to reduce such phenomena. Extrapyramidal reactions Condition causinginvoluntary muscle movementstypicallyor spasmsneckof the face, upper extremities. and May present with contorted neck and trunkwith difficul have beenhavehallucinations, described floa as vivid dreams, dysphoria. Effects patients >16, and female. Altered auditory drugsantipsychotic like Haloperidol occur and maywi in adults / IM IO / DiphenhydramineIV 50 mg hypoxia, head injury, etc.) the patientirritateexam. prolonged with a Do not reassuringonly one providereven,Talk in should tone; speak. positionDo not or transport any restrainedsu patientis benzodiazepine for patients with other presumed substanc with alcohol intoxication,considerpatients that alc routedestination.on scene and en to sure to considerBe all possiblecaus medical/trauma Any patienthandcuffedorrestrained is who by Law En Consider antipsychotics(Haloperidol) for Crew / responders safety is the main priority by law enforcement in the ambulance. Psychiatric patients shoul the ambulance. depression. All patients who receive either physical or chemical Recommended Exam: Mental Heart, Status, Lungs,Skin, Neuro If patient is suspected of excited delirium suffers of excited delirium suspected is If patient bicarbonate early bicarbonate circulatory status. Emergence phenomena            Pearls   Excited Delirium Syndrome: Delirium Excited General Protocols Section 2016 NO

Exit to YES Exit to as indicated YES if indicated Chest pain / Behavioral Protocol Cardiac History Taser probes Removal Procedure embedded in skin? Wound Care-Taser Probe Appropriate Protocol Wound Care Procedure(s) Agitated DeliriumSecondary to Illness Psychiatric Agitated DeliriumSecondary to Substance Abuse Traumatic Injury Injury Head Closed Asthma Exacerbation Cardiac Dysrhythmia Palpitations / Dyspnea? Multiple Trauma Protocol Trauma Multiple TASER Differential       YES B NO NO NO NO NO Medical Illness? NO Violent, agitated, or a or agitated, Violent, threat to self or others? SSM EMS Protocols Use of Pepper Spray or Taser? Spray Pepper of Use Evidence of Traumatic Injury or Injury Traumatic of Evidence External signs of trauma Palpitations Shortness of breath Wheezing Altered Mental Status Intoxication/Substance Abuse contacting Medical Control Medical contacting Notify destination and consider Notify Universal Patient Care Protocol Signs and Symptoms Signs and       YES Police Custody Police Asthma / COPD History? OBSERVE Wheezing? Dyspnea or or Dyspnea 20 MINUTES YES YES NO PEPPER SPRAY PEPPER Irrigate face / eyes Exit to YES Exit to Dyspnea / Dyspnea Wheezing? Protocol(s) Appropriate Remove contaminated clothing Traumatic Injury Drug Abuse Cardiac History Asthma of History History Psychiatric Respiratory Distress Appropriate Protocol(s) B History      Police Custody General Protocols Section

Pearls  Patient does not have to be in police custody or under arrest to utilize this protocol.

 Patients restrained by law enforcement devices must be transported accompanied by a law enforcement officer in the patient compartment who is capable of removing the devices. However when rescuers have utilized restraints in accordance with Restraint Procedure, the law enforcement agent may follow behind the ambulance during transport, if there are no safety concerns and the arrangement is agreeable to both EMS and Law Enforcement personnel on scene.  The responsibility for patient care rests with the highest authorized medical provider on scene per Missouri law.  If an asthmatic patient is exposed to pepper spray and released to law enforcement, all parties should be advised to immediately contact EMS if wheezing/difficulty breathing occurs.  All patients in police custody retain the right to participate in decision making regarding their medical care and may request medical care of EMS.  If extremity / chemical / law enforcement restraints are applied, follow Restraint Procedure.  Consider utilizing the behavioral protocol as indicated for patients in police custody.  All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival.  Excited Delirium Syndrome: Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Potentially life-threatening and associated with use of physical control measures, including physical restraints and Tasers. Most commonly seen in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may also contribute to the condition.  If a patient suspected of excited delirium suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early.  Do not position or transport any restrained patient in such a way that could impact the patient’s respiratory or circulatory status.

SSM EMS Protocols 2016 Team-Focused CPR: A Coordinated Approach to Cardiac Arrest

Utilize this Protocol Injury incompatible with life with AT ANY TIME and/or Cardiac Arrest Protocol Traumatic arrest with asystole Return of or any signs of: Spontaneous Decomposition Rigor mortis Criteria for death or Circulation Dependent lividity Do Not Resuscitate (DNR) (ROSC) YES form present? DO NOT BEGIN Review DNR form RESUSICATION Go to NO Post Resuscitation Exit to Protocol Deceased Person Protocol First Arriving BLS / ALS Responder CPR (chest compressions) Procedure

High-Quality CPR Is the #1 priority Compression rate of >100 / min. Second Arriving BLS / ALS Responder Age appropriate compression Manual or Automated External General Protocols Section depth Defibrillation Procedure Allow complete chest recoil after DO NOT interrupt compressions each compression Call for additional resources

Minimize interruptions in chest Simple airway adjunct compressions Ventilate with BVM Keep pauses to < 5 seconds Avoid excessive ventilation Effective Team Dynamics Switch compressors every 2 min.  Closed-loop communications Third Arriving BLS / ALS Responder  Clear messages Establish a Team Leader  Clear roles and Utilize checklists (next page) Team Leader should be ALS Personnel responsibilities who delegates tasks to responders.  Knowing one’s limitations Responsible for orchestrating patient care  Knowledge sharing Ensures continuous high-quality CPR  Constructive intervention Responsible for briefing / counseling family Manages Scene / Bystanders  Reevaluation and summarizing  Mutual respect

PEDIATRIC ADULT

If patient is < 35 kg? P Exit to Utilize a Broslow tape Adult Cardiac Arrest Protocol(s)

Exit to Pediatric Cardiac Arrest Protocol(s)

SSM EMS Protocols 2016 General Protocols Section 2016 , with , with 2 limited interruptions and , and cardiac rhythm. 2 ted stroke, environmentalted stroke, protocols, may be STEMI and morerapidmay be , EtCO 2 conjunction: airway, all cardiac protocols, 94-99%. STEMI to the receiving hospital. 2 PULSE CHECK and continuous monitoring of placement ifavailable and difficult IV anticipated. emia, Tablets/Toxins/Tricyclics, Tamponade, Tension inuous compressions with tube. Considerinterruptions. BIAD firsttube. limit to “Hs and Ts” for PEA: Hypovolemia, Hypoxia, Hydrogen Hypoxia,Hypovolemia, ions PEA: “Hs and Ts” for ample, resuscitated Vfib (should be >20 with good waveform). 2 by increasing respiratory rate. 2 SSM EMS Protocols e intervals rhythms. for shockable boembolism (Pulmonary Embolism), Trauma Team Focused CPR: Focused Team

enal failure,overdose/ingestion, suspec it is attached BVM. to -- Vasopressor agent(s) indicated for MAP < 60. for SBP or < 90 indicated agent(s) Vasopressor -- , ASSESS EtCO , consider utilizing relevant protocols in of arrest early: For ex ; if STEMI evident, call CODE Make room to work. Make room to CAUSE CAUSE if appropriate. A Coordinated Approach to Cardiac Arrest to Cardiac Approach A Coordinated supply and pulse to TITRATE to SpO Ox 2 waveform is present and value is being monitored. being is value and is present waveform 2 with oxygen cylinder in 2 allergic reaction, diabetic, dialysis/r Success is based on properplanningandexecution and a team-based Procedures approach. requirespace and patient access. Consider possible continuous compressions. interrupt compressionsendotrachealDo not place to transportConsider is indicated. traditional ACLS (acidosis), Hyperkalemia, Hypothermia, Hypo/Hyperglyc When considering pneumothorax, Thrombosis (MI), Throm etc. Efforts should be directed at high quality and cont at high should be directed Efforts early defibrillation when indicated. Consider early IO DO NOT HYPERVENTILATE: Ventilate generally 8 – 10 breaths per minute or as guided by EtCO guided as or minute 10 breaths per 8 – Ventilate generally HYPERVENTILATE: DO NOT Temperature probe is in place and temperature is visible. administered. being IO) with fluids or (IV obtained Access has been in arrest. early treated and considered been have PTX) tension (including causes Underlying is not a Gastric distention factor. atFamily is receiving care and is the patient’s side. to event). up leading events medications, information, (patient information patient Gather ITD is in place, ITD is in place, Obtain 12 lead EKG Obtain 12 Assess for & TREAT bradycardias < 60 bpm. Pressure Blood Obtain Evaluate for post-resuscitation airway placement (e.g. ETT). Strongly consider bougie use if is indicated. change airway CONTINUOUS perform is moved, patient When cardiac rhythm. fails. airway case advanced for BVM in available Mask is SpO sounds, breath pulse, confirm ambulance, in Once Do not try to obtain a “normal” EtCO a “normal” obtain to try not Do FINGER on pulse; maintain for 10 minutes. Keep assessing the patient during this time. this during the patient assessing Keep minutes. for 10 maintain pulse; FINGER on rhythm. monitor of cardiac visualization Continuous Check O ITD has been removed Team Leader identified. is Leader Team attached. leads with all the rhythm is viewing provider a dedicated and is visible Monitor minute. per beats at 100-120 ongoing are compressions confirmed Metronome minut 2 at occurring Defibrillations O Appropriate personnel present in the back of the ambulance for transport. for the ambulance back of in the present personnel Appropriate EtCO     Pearls   Post ROSC Cardiac Arrest Checklist Arrest Post ROSC Cardiac Pre-ROSC Cardiac ArrestChecklist Adult Cardiac

Section Table of Contents

Cardiac Arrest Section Protocols Cardiac Adult V‐Fib/Pulseless V‐Tach Asystole/PEA Post Resuscitation Narrow Complex Tachycardia Wide Complex Tachycardia Bradycardia Chest Pain CHF/Pulmonary Edema LVAD

SSM EMS Protocols 2016 Cardiac Arrest

History Signs and Symptoms Differential  Events leading to arrest  Unresponsive  Medical vs. Trauma  Estimated downtime  Apneic  VF vs. Pulseless VT  Past medical history  Pulseless  Asystole  Medications  PEA  Existence of terminal illness  Primary Cardiac event vs. Respiratory arrest or Drug Overdose

Universal Patient Care Protocol Injury incompatible with life and/or Traumatic arrest with asystole High-Quality CPR or any signs of: Criteria for death or Do Not Resuscitate (DNR) Decomposition YES Rigor mortis form present? Compression rate of >100 / min. Dependent lividity Review DNR form Compression depth of at least 2" NO Allow complete chest recoil after DO NOT BEGIN each compression Section Protocols Cardiac Adult RESUSICATION Minimize interruptions in chest Exit to CPR Procedure compressions Deceased Person B Change Compressors every 2 minutes Keep pauses to < 5 seconds Protocol (Limit interruptions to ≤ 5 seconds) Avoid excessive ventilation Switch compressors every 2 min. Advanced Life NO Support (ALS) YES available?

AT ANY TIME Return of P Cardiac Monitor Spontaneous Circulation (ROSC) Defibrillation:Automated B Procedure if available Go to Post Resuscitation Protocol

Shockable Rhythm? YES Shockable Rhythm? NO NO YES

CPR Procedure Shock Delivery (5 cycles / 2 min.) B Reassess and then repeat CPR Procedure B (5 cycles / 2 min.) Exit to Exit to Airway Protocol(s) Reassess and then repeat Asystole / PEA VF / Pulseless VT Airway Protocol(s) and and Airway Airway Protocol(s) Protocol(s) as indicated as indicated Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Cardiac Arrest Adult Cardiac Protocols Section Protocols Cardiac Adult

Pearls  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Consider early IO placement if available and / or difficult IV access anticipated.  DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compressions to ventilations are 30:2. If advanced airway in place ventilate 8–10 breaths per minute with continuous, uninterrupted compressions.

 Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  Breathing / Airway management after second shock and / or 2 rounds of compressions (2 minutes each round.)

 Resuscitation is based on proper planning and organized execution. Procedures require space and patient access. Make room to work. Utilize Team Focused Approach assigning responders to predetermined tasks and use the Cardiac Arrest Checklist and Code Commander when personnel are available to do so.  Reassess, document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care.  Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport to closest facility. Place mother supine and perform Manual Left Uterine Displacement moving uterus to the patient’s left side. IV/IO access preferably above diaphragm. Defibrillation is safe at all energy levels.  Refer to Dialysis / Renal Failure protocol caveats when faced with dialysis / renal failure patient experiencing cardiac arrest.  Consider Opioid Overdose: Naloxone 2 mg IntraNasal / IV / IO / IM.

SSM EMS Protocols 2016 Ventricular Fibrillation Pulseless Ventricular Tachycardia

History Signs and Symptoms Differential  Estimated down time  Unresponsive, apneic, pulseless  Asystole  Past Medical History  Ventricular fibrillation or ventricular  Artifact / Device Failure  Medications tachycardia on EKG  Cardiac  Events leading to arrest  Endocrine / Medicine  Renal failure / Dialysis  Drugs  DNR form  Pulmonary

Cardiac Arrest Protocol High-Quality CPR

Manual Defibrillation Procedure Compression rate of >100 / min. P Philips 150J, Physio 200J, Zoll 120J Compression depth of at least 2" Allow complete chest recoil after Simultaneously utilize each compression Dialysis / Renal Minimize interruptions in chest B CPR Procedure (5 cycles / 2 min.) Failure Protocol compressions Venous Access Protocol if indicated Keep pauses to < 5 seconds Section Protocols Cardiac Adult Epinephrine (1:10,000) 1 mg IV / IO Avoid excessive ventilation P Repeat every 3 to 5 minutes Switch compressors every 2 min. Manual Defibrillation Procedure Philips 150J, Physio 300J, Zoll 150J Torsades de Pointes? Low Magnesium state? CPR Procedure (5 cycles / 2 min.) (Malnourished / alcoholic) B Suspected Digitalis Airway Protocol(s) Toxicity? Refractory after 2 shocks? YES Change Defib Pads and Pads Location Magnesium Sulfate 2 g IV / IO P AT ANY TIME Amiodarone 300mg IV / IO over 2 minutes Return of May repeat once at 150 mg IV / IO Spontaneous Circulation P acceptable substitute (ROSC) Lidocaine 1.5 mg/kg IV / IO May repeat once in 5 minutes Go to max of 3 mg / kg Post Resuscitation Manual Defibrillation Procedure Protocol Philips 200J, Physio 360J, Zoll 200J

B High Quality, Continuous Compressions

Consider Magnesium Sulfate 2g IV / IO, P Consider Sodium Bicarbonate 50 meq IV / IO

Exit to Post Resuscitation Return of Spontaneous Circulation? YES Protocol NO

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Ventricular Fibrillation Pulseless Ventricular Tachycardia Adult Cardiac Protocols Section Protocols Cardiac Adult

Defibrillation dose ADULT 150J, 150 J, 200 J 200J, 300J, 360J 120J, 150J, 200J manufacturer PHILIPS PHYSIO ZOLL

Pearls  Recommended Exam: Mental Status  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Consider early IO placement if available and difficult IV anticipated.  DO NOT HYPERVENTILATE: Ventilate 8 – 10 breaths per minute or as guided by EtCO2, with continuous, uninterrupted compressions.  Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  Consider Breathing / Airway management after second shock and / or 2 rounds of compressions (2 minutes each round.)  Avoid Procainamide in CHF or prolonged QT.  Effective CPR and prompt defibrillation are the keys to successful resuscitation.  If no IV / IO, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV / IO is the preferred route when available.  Reassess, document endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care.  Do not stop CPR to check for placement of ET tube or to give medications.  If BVM is ventilating the patient successfully, intubation should be deferred until rhythm has changed or 4 or 5 defibrillation sequences have been completed.  Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions.  Sodium bicarbonate no longer recommended as a standard cardiac arrest medication. Consider in the dialysis / renal patient, extended down-time, known hyperkalemia or suspected overdose at 50 mEq IV / IO.

SSM EMS Protocols 2016 Adult Cardiac Protocols Section 2016 Exit to Protocol Go to (ROSC) Protocol Epinephrine drip Epinephrine Dopamine drip Deceased Persons Deceased Return of AT ANY TIME Post Resuscitation Consider Early for PEA Consider possible hypovolemia forsuspected beta blocker or blocker channel calcium overdose. for suspected hyperkalemia, hypocalcemia IO for possible overdose, failure renal hyperkalemia, organized PEA with rate < 60. Spontaneous Circulation Consider 1. Repeated Saline Boluses for 10% IV/IO 2. Dextrose 3. Naloxone 2mg IV/IO 4. Glucagon, up to 4mg IV/IO/IM 5. Calcium Chloridegram IV/IO1 6. Sodium Bicarbonate 50meq IV/ 7. 8. for IV ONLY 1mg Atropine 9. 10. Chest Decompression YES HypovolemiaAAA, other) (Trauma, Cardiac tamponade Hypothermia Drug overdose (Tricyclic, Digitalis, Beta blockers, Calcium channel blockers) Massive myocardial infarction Hypoxia Tension pneumothorax embolus Pulmonary Acidosis Hyperkalemia Differential           )

or 5 seconds ss Protocol ≤ OLE / PEA after; NO NO NO form present? Cardiac Monitor CPR Procedure External Pacing Procedure Review DNR form

Criteria for death Shockable Rhythm? 3 rounds of epinephrine. of 3 rounds Venous Acce Chest Decompression Procedure

Repeat every 3 5 to minutes Do Not Resuscitate (DNR) Search for Reversible Causes minimum of a BIAD, IO / IV, and contacting Medical Control Medical contacting SSM EMS Protocols Cardiac Arrest Protocol Cardiac Patient in ASYST (Limit interruptions to Pulseless Apneic ECG on activity electrical No auscultation on tones heart No Epinephrine (1:10,000) 1 mg IV / IO Notify destination and consider Notify Normal Saline Bolus 1000 ml IV / IO Consider Change Compressors every 2 minutes Treating all relevant reversible causes, a Signs and Symptoms Signs and     Consider

P B YES YES P

Exit to and/or Asystole / Pulseless Electrical Activity Electrical / Pulseless Asystole Protocol Rigor mortis Exit to Tricyclic Digitalis blockers Beta Calcium channelblockers Decomposition or any signsor any of: DO NOT BEGIN DO NOT BEGIN Protocol Protocol RESUSICATION Dialysis / Dependent lividity if indicated Deceased Person Deceased Renal Failure Reversible Causes Reversible Past medical history medical Past Medications Events leading to arrest End stage renal disease Estimated downtime Suspected hypothermia Suspected overdose     WillDNR, MOST, or Living Injury incompatible with life Rhythm Appropriate Traumatic arrest with asystole History         Tension pneumothorax Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) Hypovolemia Hypoxia (acidosis) ion Hydrogen Hypothermia / Hyperkalemia Hypo Hypoglycemia Asystole / Pulseless Electrical Activity Adult Cardiac Protocols Section Protocols Cardiac Adult

Pearls  SURVIVAL FROM PEA OR ASYSTOLE is based on identifying and correcting the CAUSE: consider a broad differential diagnosis, with early and aggressive treatment of possible causes.  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Consider early IO placement if available and / or difficult IV access anticipated.  DO NOT HYPERVENTILATE: Ventilate 8 – 10 breaths per minute with continuous, uninterrupted compressions, or as guided by EtCO2.  Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  Airway management after 2 rounds of compressions (2 minutes each round.)  Success is based on proper planning and execution. Procedures require space and patient access; make room to work.  If no IV / IO, drugs that can be given down ET tube should have dose doubled and then flushed with 5 ml of Normal Saline followed by 5 quick ventilations. IV/IO is the preferred route when available.  Potential association of PEA with hypoxia so placing definitive airway with oxygenation early may provide benefit.  PEA caused by sepsis or severe volume loss may benefit from higher volume of normal saline administration.  Return of spontaneous circulation after Asystole / PEA requires continued search for underlying cause of cardiac arrest.  Treatment of hypoxia and hypotension are important after resuscitation from Asystole / PEA.  Asystole is commonly an end-stage rhythm following prolonged VF or PEA with a poor prognosis.  Sodium bicarbonate no longer recommended as a standard cardiac arrest drug. Consider in the dialysis / renal patient, known hyperkalemia or tricyclic overdose at 50 mEq total IV / IO.  Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options.  Potential protocols used during resuscitation include Overdose / Toxic Ingestion, Diabetic and Dialysis / Renal Failure.

SSM EMS Protocols 2016 Adult Cardiac Protocols Section 2016 Exit to Protocol to address specific

Chest pain and STEMI Continue differentials associated withthe original dysrhythmia Differential  YES 35 – 45 mmHg 2 Protocol

cess Protocol on and oxygenation NO NO NO NO and STEMI / ROSC with ROSC Hypotension of 90-99% Max total doseMax200 total mcg ifindicated 2 Cardiac Monitor Suspicion of MI? of Suspicion Systolic BP < 90? Antiarrhythmic given? Antiarrhythmic watch for hypotensionwatch for Max total dose 10 mg Midazolam 2.5mg IV/IO Cardiac Arrest 12 Lead ECG Procedure Symptomatic Bradycardia? Symptomatic Repeat Primary Assessment Primary Repeat Return of pulse Consider Sedation / Paralysis / Sedation Consider Venous Ac Monitor Vital Signs / Reassess SSM EMS Protocols contacting Medical Control Medical contacting Fentanyl 50-75mcg IV/IO bolus as needed May repeatmcg25 every minutes 20 Notify destination and consider Notify May repeat in 3-5 minutes as needed-  Signs/Symptoms Use only with definitive airway in place Optimize ventilati YES P

Remove impedance threshold device airway Advanced Maintain an SpO DO NOT HYPERVENTILATE Ventilation rate to maintain EtCO YES YES    

 90 ≥ P B B Post Resuscitation Post Exit to Maximum 2 L Protocol Bradycardia; Bradycardia; Pulse Present Pulse Protocol May repeat as needed if lungs clear Respiratory arrest Respiratory Cardiac arrest further meds or drips. Normal Saline500 Bolus mL IV / IO Rhythm Appropriate Titrate any pressor drugs to SBP Dopamine 5-20 mcg / kg/ min IV / IO usually self limiting after ROSC and may not need If Arrhythmiafollow Persists Arrhythmias are common and History   P Adult Cardiac Protocols Section 2016 d resuscitation is ongoing. diac catherterization and nd continuous monitoring of , and cardiac rhythm. 2 onsultation with medical control. ntinuously, and they require closeand they requirentinuously, , EtCO ventilatory assistance. 2 but will usually normalize. goal is 35 While usually normalize. will but 94-99%. STEMI to the receiving hospital. 2 90. Ensure adequate flui ≥ rrest patient including, car ion and recurrence of cardiac arrest in thearrest postion and recurrence of in cardiac , Lungs, Heart, Abdomen, Extremities, Neuro Abdomen, Heart, , Lungs, (should be >20 with good waveform). with good be >20 (should 2 cardiac arrest during post-resuscitation care. respiratory rate. by increasing 2 SSM EMS Protocols patients fluctuatesco and rapidly ion hypotension include hyperventilation, hypovolemia, pneumothorax, and scitation management may require c orm CONTINUOUS PULSE CHECK a orm CONTINUOUS -- Pressor agent(s) indicated for MAP < 60. for SBP < 90 or indicated agent(s) -- Pressor Post Resuscitation Post , ASSESSEtCO ; if STEMI evident, call CODE call ; if STEMI evident,

diately following post-resuscitation will requirediately following post-resuscitation may be elevated immediately post-resuscitation be elevated may 2 supply and pulse supply and pulse SpO Ox to TITRATE to 2 intensive care service Most patients imme – 45 mm Hg, avoid hyperventilation. of post-a Transport managing to facility capable the Recommended Exam:Mental Status,Neck,Skin monitoring. Appropriate post-resu The condition of post-resuscitationThe condition Continue to search for potential cause of to search for Continue Hyperventilation is a significant cause of hypotens resuscitation phase and must be avoided at all costs. EtCO Initial Common causes of post-resuscitat medication reaction to ALS drugs. vasopressorsotheror Titrate Dopamine to maintain SBP Assess for & TREAT bradycardias < 60 bpm. Pressure Blood Obtain Evaluate for post-resuscitation airway placement (e.g. ETT). Strongly consider bougie use if is indicated. change airway is moved, perf patient When cardiac rhythm. fails. airway case advanced for BVM in available Mask is SpO sounds, breath pulse, confirm ambulance, Once in Obtain 12 lead EKG lead 12 Obtain Appropriate personnel present in the back of the ambulance for transport. for the ambulance of back in the present personnel Appropriate FINGER on pulse; maintain for 10 minutes. Keep assessing the patient during this time. this during the patient assessing Keep 10 minutes. for pulse; maintain on FINGER rhythm. monitor of cardiac visualization Continuous Check O ITD has ITD has removed been Do not try to obtain a “normal” EtCO a “normal” obtain to try not Do   Pearls        Post ROSC Cardiac Arrest Checklist Arrest Post Cardiac ROSC Tachycardia Narrow Complex (≤ 0.11 sec) History Signs and Symptoms Differential  Medications  Heart Rate > 150  Heart disease (WPW, Valvular) (Aminophylline, Diet pills, Thyroid  Systolic BP < 90  Sick sinus syndrome supplements, Decongestants,  Dizziness, CP, SOB, AMS,  Myocardial infarction Digoxin) Diaphoresis  Electrolyte imbalance  Diet (caffeine, chocolate)  CHF  Exertion, Pain, Emotional stress  Drugs (nicotine, cocaine)  Potential presenting rhythm  Fever  Past medical history Atrial/Sinus tachycardia  Hypoxia  History of palpitations / heart racing Atrial fibrillation / flutter  Hypovolemia or Anemia  Syncope / near syncope Multifocal atrial tachycardia  Drug effect / Overdose (see HX) Ventricular Tachycardia  Hyperthyroidism  Pulmonary embolus Universal Patient Care Protocol

Unstable, symptomatic NO YES tachyarrhythmia*? Consider Sedation pre-shock Midazolam 5 mg IntraNasal Supplemental oxygen to * SEE PEARLS B maintain SpO2 ≥ 94 % or 2.5 mg IV / IO May repeat IV / IO if needed; 12 Lead ECG Procedure Section Protocols Cardiac Adult Max 5 mg P Venous Access Protocol 12 Lead ECG not necessary to Synchronized Cardioversion Consider diagnose and treat, but preferred Procedure P 500 cc Normal Saline bolus when patient is stable. Philips: 100, 150, 200J Physio:150, 200, 300, 360J Cardiac Monitor Zoll: 70, 75, 120,150, 200J

Irregular Rhythm Regular Rhythm (SVT)? NO (Atrial Fibrillation / Flutter) NO and patient symptomatic? YES YES P Attempt Vagal Maneuvers Exit to Appropriate Protocol(s) Consider Adenosine 6 mg IV / IO Rhythm Changes? YES Rapid push P NO May repeat 12 mg IV / IO dose x1 if needed May aid rhythm identification Adenosine 6 mg IV / IO Rapid push P Exit to May repeat 12 mg IV / IO x1 dose YES Rhythm Changes? Rhythm Appropriate if needed Protocol NO

Rhythm Changes? YES Diltiazem 20 mg IV / IO NO Age ≥ 60 give 10 mg then P repeat 10 mg in 5 minutes NO Diltiazem 20 mg IV / IO if SBP ≥ 100 Sinus Rhythm If age ≥ 60 give 10 mg then P and/or repeat 10 mg in 5 minutes Rate Controlled? if SBP ≥ 100 B 12 Lead ECG Procedure YES

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Adult Tachycardia Narrow Complex (≤ 0.11 sec)

Cardioversion dose 100J, 150 J, 200 J 200J, 300J, 360J 75J, 120J, 150J, 200J Consider starting at 150J for Atrial ADULT Atrial flutter 50J, 100J, 150J flutter/SVT E Series 70J, 120J, 150J, 200J

manufacturer PHILIPS PHYSIO ZOLL Section Protocols Cardiac Adult

Pearls  Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro  Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE.  If at any point patient becomes unstable move to unstable in algorithm.  UNSTABLE / SYMPTOMATIC tachyarrhythmia is defined as: Have signs of shock / poor perfusion, will generally occur at rates of ≥ 150 beats per minute and may also have; hypotension, acutely altered mental status, or acute congestive heart failure.  For Stable / ASYMPTOMATIC patients (or those with only minimal symptoms, such as palpitations) and any tachycardia with rate < ( 220 - patient’s age) beats per minute, and a perfusing (usually >90 systolic) blood pressure, consider CLOSE OBSERVATION and/or fluid bolus rather than immediate treatment with an anti- arrythmic medication. A patient’s “usual” atrial fibrillation, for example, may not require emergent treatment.  If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g. Diltiazem) or Beta Blockers. Use caution with Adenosine and give only with defibrillator available.  Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.  Regular Narrow-Complex Tachycardias: - Vagal maneuvers and adenosine are preferred. Vagal maneuvers may convert up to 25% of SVT. - Adenosine should be pushed rapidly via proximal IV site followed by 20 mL Normal Saline rapid flush.  Irregular Tachycardias: - First line agents for rate control are calcium channel blockers (or beta blockers). - Consider Calcium Chloride 1 gram IV/IO (ensure IV patency; CaCl is caustic) prior to administration of calcium channel blockers (Diltiazem) for patients with tenuous BP (SBP < 100). Calcium may mitigate hypotensive effects of peripheral vasculature smooth muscle relaxation while not preventing wanted cardiac rate control effects. - DO NOT give both calcium channel blockers and beta blockers to a patient sequentially without contacting Medical Control. This may lead to heart block, profound bradycardia, and/or hypotension. - Adenosine may not be effective in atrial fibrillation / flutter, yet is not harmful and may help identify rhythm.  Synchronized Cardioversion: - Recommended to treat UNSTABLE Atrial Fibrillation, Atrial Flutter and Monomorphic-Regular Tachycardia (SVT.)  Monitor for hypotension and utilize continuous waveform capnography to monitor for respiratory depression associated with Midazolam.  Monitor for hypotension after administration of Calcium Channel Blockers or Beta Blockers.  Continuous pulse oximetry is required for all SVT patients. Consider continuous waveform capnography also.  Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.

SSM EMS Protocols 2016 Adult Cardiac Protocols Section YES 2016

Exit to NO Protocol Rate Sinus and/or

Rhythm 100, 150, 200J Controlled? Maxmg 5 Sedationpre-shock Consider Protocol Procedure Adult VF / 2.5 mg IV / IO NO Rhythm Appropriate Pulseless VT Pulseless or 70, 75, 120,150, 200J Philips: Physio: 200, 300, 360J Zoll: May repeat IV / IO if needed; Midazolam 5 mg IntraNasal Consider Heartdisease Valvular)(WPW, syndrome sinus Sick infarction Myocardial imbalance Electrolyte Exertion, Pain, Emotional stress Fever Hypoxia or Anemia Hypovolemia Drug effect / Overdose (see HX) Hyperthyroidism embolus Pulmonary Synchronized Cardioversion Differential            P sec)

YES 12 Lead ECG not Rhythm Changes? Procedure when patient is stable. necessary to diagnose and treat, but preferred 0.12 Over 2 minutes Irregular Rhythm ≥ (Torsade de pointes) Polymorphic Complex Polymorphic Follow UNSTABLE arm Follow UNSTABLE ( If no immediate conversion: immediate no If Magnesium Sulfate 2g IV/IO Synchronized Cardioversion YES PEARLS

exit to P SEE tachycardias

* treating STABLE Tachycardia If non-sinusrhythm, tachyarrhythmia*?

Atrial/Sinus tachycardia Atrial fibrillation/ flutter Multifocal atrial tachycardia Ventricular Tachycardia appropriate protocol Unstable, symptomatic symptomatic Unstable, 12 Lead EKG Procedure Contact Medical Control to discuss pharmacologically Heart Rate > 150 Heart Rate <90 Systolic BP AMS, SOB, Dizziness, CP, Diaphoresis CHF rhythm presenting Potential SSM EMS Protocols contacting Medical Control Medical contacting Notify destination and consider Notify Rhythm B Complex Signs and Symptoms Signs and      NO Adult is symptomatic Irregular Monomorphic Complex aberrancy),patient and or Atrial Fibrillation with (consider Pre-excitation Wide YES 94 % ≥

2 Rhythm YES Cardiac Monitor if needed 12 mg IV / IO or NO maintain SpO Venous Access Protocol Supplemental oxygen to Consider Rapid push that converted the rhythm rhythm the converted that Amiodarone 150mg IV / IO (Aminophylline, Diet pills, Thyroid supplements, Decongestants, Digoxin) (consider VT or every 5 minutes Regular x1 dose Hang maintenance drip of drug drug of drip maintenance Hang Rhythm Changes? Rhythm Changes?

SVT with aberrancy) Over 10 minutes, may Monomophic Complex repeat 0.5-0.75 mg/kg mg/kg 0.5-0.75 repeat Medications Diet (caffeine, chocolate) Drugs (nicotine, cocaine) history medical Past History of palpitations / heart racing Syncope / near syncope Adenosine 6 mg IV / IO Max total dose 3 mg/kg repeat x 1 response no x 1 if repeat May repeat Lidocaine 0.5-1.5 mg/kg

Universal Patient Care Protocol

P 12 Lead ECG Procedure History       P P P B NO Adult Tachycardia Wide Complex (≥0.12 sec)

Cardioversion dose 100J, 150 J, 200 J 200J, 300J, 360J 75J, 120J, 150J, 200J Consider starting at 150J for Atrial ADULT Atrial flutter 50J, 100J, 150J flutter/SVT E Series 70J, 120J, 150J, 200J manufacturer PHILIPS PHYSIO ZOLL

Pearls  Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro  Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE.

 If at any point patient becomes unstable move to unstable arm in algorithm. Section Protocols Cardiac Adult  If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g., Diltiazem) or Beta Blockers.  Symptomatic tachyarrhythmia is defined as: Occurring at rates of ≥ 150 beats per minute, have signs of shock / poor perfusion and may also have; hypotension, acutely altered mental status, chest pain with evidence of ischemia (STEMI, T wave inversions or depressions), or acute congestive heart failure.  Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc.  DO NOT administer a Calcium Channel Blocker (e.g., Diltiazem, Verapamil) for wide complex tachycardia.  Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful.  Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers.  For ASYMPTOMATIC PATIENTS (or those with only minimal symptoms, such as palpitations) and any tachycardia with rate approximately 100-120 and a normal blood pressure, consider CLOSE OBSERVATION and/or fluid bolus rather than immediate treatment with an anti-arrythmic medication. A patient’s “usual” atrial fibrillation with aberrancy, for example, may not require emergent treatment.  Typical sinus tachycardia is in the range of 100 to (220 – patients age) beats per minute.  Regular Wide-Complex Tachycardias: Unstable condition: - Immediate cardioversion or pre-cordial thump if cardioverter-defibrillator not available. Stable condition: - Typically VT or SVT with aberrancy. Adenosine may be given if regular and monomorphic and if defibrillator available. - Arrhythmias with suspicion of WPW should be treated with Amiodarone or Procainamide.  Irregular Tachycardias: - Wide-complex, irregular tachycardia: Do not administer calcium channel or beta blockers or adenosine as this may cause paradoxical increase in ventricular rate. Will usually require cardioversion. Consider medical control.  Polymorphic / Irregular Wide- Complex Tachycardia: - This situation is usually unstable and immediate cardioversion or defibrillation is warranted. - When associated with prolonged QT this may be Torsades de pointes: Give 2g of Magnesium Sulfate slow IV / IO. Without prolonged QT, likely related to ischemia and Magnesium may not be helpful.  Monitor for hypotension and utilize continuous waveform capnography to monitor for respiratory depression associated with Midazolam.  Continuous pulse oximetry is required for all Wide Complex Tachycardia Patients. Consider continuous waveform capnography also.  Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.

SSM EMS Protocols 2016 Adult Cardiac Protocols Section 2016 Protocol(s)

Respiratory Distress

Appropriate Airway Simultaneously utilize or Acute myocardial infarction Hypoxia failurePacemaker Hypothermia bradycardia Sinus Athletes Head injury (elevated ICP) or Stroke Spinalcord lesion syndrome sinus Sick blocksAV or 3°) (1°, 2°, Overdose Maxmg 5 Sedation pre-shock 2.5 mg IV / IO

YES Differential            Also consider Also or May repeat IV / IO if needed; Midazolam 5 mg IntraNasal Consider therapy for severe symptoms contacting Medical Control Medical contacting Notify destination and consider Notify TranscutaneousProcedure Pacing Pacing should be considered first line line first considered be should Pacing P Dopamine 5 – 20 mcg/kg/min IV / IO Exit to to Exit Protocol P YES Calcium Channel Blocker Overdose / Toxic Ingestion Overdose / Suspected Beta-Blockeror Work of Breathing, Dyspnea / Increased / Increased Dyspnea especially with hypoxia? SSM EMS Protocols HR < 60/min with hypotension, acute altered mental status, chest pain, acute CHF, seizures, syncope, or shock secondary to bradycardia Chest pain distress Respiratory or Shock Hypotension Altered mental status Syncope NO Universal Patient Care Protocol YES Signs and Symptoms Signs and       Heart Rate < 60 / minute and symptomatic: NO Hypotension, Acute Chest Pain,CHF, Acute AMS, Seizures, Syncope, or Shocksecondary bradycardia to 94 %

≥

2 rd YES NO or 3 NO nd Consider 2 Bradycardia: Pulse Present Pulse Bradycardia: or unavailable? Cardiac Monitor Maximummg 3 1 – 10 mcg / min IV / IO degree AV block? Maximum 2 Liters Epinephrine Infusion Supplemental oxygen Venous Access Protocol May repeat as needed Responsive to Atropine to Atropine Responsive Atropine 0.5 mg IV / IO to maintain SpO

12 Lead EKG Procedure Repeat every 3 – 5 minutes For refractoryFor bradycardia with shock, Beta-Blockers Calcium channelblockers Clonidine Digoxin Exit to Normal Saline500 Bolus mL IV / IO

Protocol Appropriate Past medical history medical Past Medications     Pacemaker P P P B P History    Bradycardia: Pulse Present Adult Cardiac Protocols Section Protocols Cardiac Adult

Pearls  Recommended Exam: Mental Status, Neck, Heart, Lungs, Neuro  Bradycardia causing symptoms is typically < 50/minute. Rhythm should be interpreted in the context of symptoms and pharmacological treatment given only when symptomatic, otherwise monitor and reassess.  Identifying signs and symptoms of poor perfusion caused by bradycardia are paramount.  Atropine vs. Pacing: Caution in setting of acute MI. The use of Atropine for PVCs in the presence of a MI may worsen heart damage. Providers should NOT DELAY Transcutaneous Pacing for patients with poor perfusion in the setting of acute MI or second or third degree heart block. Atropine is ineffective in cardiac transplantation.  Well conditioned athletes will present with lower HR, DO NOT treat if asymptomatic.  For patients who are not in second or third degree heart block, either dopamine or pacing or both may be considered for bradycardia not responsive to atropine. Prepare to utilize transcutaneous pacing early if no response to atropine; dopamine may be an effective adjunct for hypotensive patients.  Wide complex, bizarre appearance of complex with slow rhythm consider hyperkalemia.  Consider treatable causes for bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, etc.)  Hypoxemia is a common cause of bradycardia. Be sure to oxygenate the patient and support respiratory effort.  Monitor for hypotension and utilize continuous waveform capnography to monitor for respiratory depression associated with Midazolam.

SSM EMS Protocols 2016 Chest Pain: Cardiac and STEMI

History Signs and Symptoms Differential  Age  CP (pain, pressure, aching, vice-like  Trauma vs. Medical  Medications (Viagra / sildenafil, tightness)  Angina vs. Myocardial infarction Levitra / vardenafil, Cialis / tadalafil)  Location (substernal, epigastric, arm,  Pericarditis  Past medical history (MI, Angina, jaw, neck, )  Pulmonary embolism Diabetes, post menopausal)  Radiation of pain  Asthma / COPD  Allergies  Pale, diaphoresis  Pneumothorax  Recent physical exertion  Shortness of breath  Aortic dissection or aneurysm  Palliation / Provocation  Nausea, vomiting, dizziness  GE reflux or Hiatal hernia  Quality (crampy, constant, sharp,  Time of Onset  Esophageal spasm dull, etc.)  Chest wall injury or pain  Region / Radiation / Referred  Pleural pain  Severity (1-10)  Overdose (Cocaine) or  Time (onset /duration / repetition) Methamphetamine

Universal Patient Care Protocol

Dyspnea / Atypical Exit to Chest Pain Signs / Symptoms symptoms, suspect Appropriate Protocol consistent with cardiac etiology? NO NO of cardiac etiology? YES Section Protocols Cardiac Adult YES

12 Lead ECG Procedure B EMS CODE STEMI: Cath Lab Supplemental oxygen P Activation Procedure Avoid Nitroglycerin maintain SpO2 ≥ 94 % in any patient who Aspirin 324 mg PO has used: P (4 baby aspirin, chewed) Transport based on: Viagra (sildenafil) STEMI Cardiac Monitor Levitra (vardenafil) EMS Triage and Destination Plan in the past 24 hours Immediate Notification of Facility OR YES Immediate Transmission of ECG Suspect an acute MI / STEMI? if capable Cialis (tadalafil) in NO Keep Scene Time to ≤ 10-15 Min. the past 36 hours due to potential severe hypotension. P Venous Access Protocol

Lung Exam: Systolic BP ≥ 100? NO CHF / Pulmonary NO Edema? YES YES Use caution in right sided MI

Wait 10 minutes a minutes 10 Wait Nitroglycerin Paste Exit to SBP > 100 = 1 inch Adult CHF / Pulmonary administering analgesic administering SBP > 150 = 1.5 inch Edema Protocol Remove nitro or any medication SBP > 200 = 2 inch B or patches, wipe the skin clean. Nitroglycerin 0.3 / 0.4 mg SL Normal Saline Bolus Repeat every 3- 5 minutes 500 mL IV / IO

P fter nitro before P Repeat as needed Morphine 4 mg (0.1 mg/kg) IV / IO NO Repeat once in 10 minutes if needed Systolic Maximum 2 L Maximum 8 mg BP ≥ 100? OR Fentanyl 50-100 mcg/kg IV / IO YES Repeat 25 mcg q 10 minutes as needed Notify destination and consider Maximum 200 mcg contacting Medical Control

SSM EMS Protocols 2016 Adult Cardiac Protocols Section 2016 NEEDED FOR CODE STEMI t’s home medication. t’s home transported to the appropriate transported to or Levitra (vardenafil) in the past 24 past Levitra (vardenafil) in the or ds may cause hypotensionds may requiring al pain, or al pain, only generalized complaints. Have a low ng, Heart, Abdomen, Back, Extremities, Neuro I, III, aVF) MI, consider right Sided ECG. If ST Sided ECG. consider right MI, aVF) III, I, , but EKG should be sent for consult and ED notified ED notified consult and be sent for should , but EKG for respiratory depression associated with narcotics. TIVATION PROCEDURE FOR CRITERIA TO PROCEDURE TIVATION Lateral wall MI (vessel likely LCx or LAD branch) likely LCx wall MI Lateral (vessel MI, and ST Depression in the Antero-Septal leads. Antero-Septal in the ST Depression MI, and troglycerin from patien troglycerin from troglycerin and narcotics. = Septal/Anterior wall MI (vessel likely LAD) wall MI (vessel = Septal/Anterior ession EVERYWHERE ELSE is concerning for a possible is concerning for a possible EVERYWHERE ELSE ession hout relief, consider potency of the medication. SSM EMS Protocols r further assessment of Posterior MI. assessmentr furtherPosterior MI. of 36 hours due to potential severe hypotension.potential severe 36 hours due to V4, Nitroglycerin and / or opioi Myocardial Infarction) be Myocardial Infarction) should LAB ACTIVATION PROCEDURELAB ACTIVATION AS onfirm diagnosis. In this example In this diagnosis. wall) to confirm (opposite procal leads iage and Destination Plan. tient who has used Viagra (sildenafil) has used tient who r administration of ni STEMI/Culprit Vessel Localization Aid: Localization Vessel STEMI/Culprit Chest Pain: Cardiac and STEMI and Cardiac Pain: Chest hours or Cialis (tadalafil) in the past Cialis (tadalafil) in the hours or Recommended Exam: Mental Status, Skin, Neck, Lu Items in Red Text are key performance indicators Items in Red pa Avoid Nitroglycerin in any Monitor for hypotension afte Utilize continuous waveform capnography to monitor Nitroglycerin and opioids may be repeated per dosing guidelines. Diabetics, geriatric and female patientshaveoften atypic threshold to perform a 12 lead EKG in theseperform patients.12 lead EKG to threshold a Document(EMT-P)interpretationProcedure along with the PCR as a in the12-Leadtime of the the ECG Ni EMT-B may help administer Aspirin and/or SEE 12-LEAD/CODE STEMI CATH If patient has taken his own nitroglycerin wit facility based on STEMI EMS Tr STEMI EMS on facility based CRITERIA (I inferior from shock resulting Cardiogenic / CHF If elevation noted in transposed V3 or fluid boluses. Consider 15 lead ECG fo Patients with STEMI (ST-Elevation (ST-Elevation STEMI with Patients Pearls              ST Elevation in 2 or more leads: V1, V2, V3, V4 V1, V2, V3, in 2 or more leads: ST Elevation ST Elevation in 2 or more leads: II, III, aVF = Inferior wall MI (vessel likely RCA or LCx) likely RCA or (vessel MI Inferior wall aVF = II, III, in 2 or more leads: ST Elevation V6 = I, aVL, V5, in 2 or more leads: ST Elevation * SEE 12-LEAD/CODE STEMI CATH LAB AC VS. SEND EKG FOR CONSULT. CATH LAB AND ACTIVATE STEMI” “CODE CALL in reci ST DEPRESSION **Look for wall INFERIOR this in EKG there is ST Elevation ST depr with ** Isolated ST elevation in aVR, Not STEMI criteria Main lesion. or Left proximal LAD early. Adult Cardiac Protocols Section

2016 only 90 ≥ (SBP < 90) Dopamine Protocol bradycardia If indicated hypotension if indicated Titrate to SBP Chest Pain/STEMI Simultaneously utilize Simultaneously Airway Protocol(s) Tachycardia followed by Airway Protocol(s) CARDIOGENIC SHOCK CARDIOGENIC Remove CPAP, but Hypertension followed by by followed Hypertension 5 – 20 mcg/kg/min IV / IO while hypotensive Myocardial infarction Myocardial Congestiveheart failure Asthma Anaphylaxis Aspiration COPD effusion Pleural Pneumonia embolus Pulmonary Pericardial tamponade Toxic Exposure P P Differential            NO NO 94 % ≥

2 YES or YES Airway Patent if indicated Improving? Elevated BP Elevated Cardiac Monitor Ventilations adequate Ventilations maintain SpO Airway Protocol(s) SBP > 100 = 1 inch> 100 SBP = 2 inch> 200 SBP Elevated Heart Rate Heart Elevated currently taking diuretic a taking currently Nitroglycerin Paste Nitroglycerin Oxygenation adequate? Supplemental oxygen to SBP > 150 = 1.5 inch 12 Lead ECG Procedure Capnography Procedure Repeat every 5 minutes MODERATE / SEVERE Assess Symptom Severity SSM EMS Protocols Airway CPAP Procedure Furosemide 40 mg IV / IO If currentlydiuretica taking Furosemide 80 mg IV / IO not Protocol Venous Acccess Nitroglycerin 0.3 / 0.4 mg SL If contacting Medical Control Medical contacting Respiratory distress, Respiratory bilateral rales Apprehension, orthopnea Jugular vein distention sputum frothy Pink, Peripheral edema, diaphoresis Hypotension, shock Chest pain P B Notify destination and consider Notify P P Signs and Symptoms Signs and        YES NO CHF / Pulmonary Edema / Pulmonary CHF or NO YES Exit to MILD Protocol Improving? Appropriate Signs / Symptoms Pulmonary Edema? Pulmonary Normal Heart Rate consistent with CHF / SBP > 100 1 = inch SBP > 200 2 = inch Nitroglycerin Paste Nitroglycerin SBP > 150 = 1.5 inch> 150 SBP Elevated or Normal BP Normal or Elevated Repeat every 5 minutes Nitroglycerin 0.3 / 0.4 mg SL 0.4 / 0.3 Nitroglycerin Congestiveheart failure history medical Past Medications (digoxin, Lasix, Viagra / sildenafil, Levitra / vardenafil, Cialis / tadalafil) Cardiac history --past myocardial infarction Universal Patient CareProtocol History     P Adult Cardiac Protocols Section 2016 pulmonary edema. Even pulmonary edema. ol compliance and care. female patientsoftenhave dication from patient prescribed or Levitra (vardenafil) in the past 24 past in the Levitra (vardenafil) or enzodiazepines may precipitate respiratory ) should be monitored continuously for continuously be monitored ) should 2 heir breathing effort. in patients who are already tired, alreadypatients with alteredtired, who are alreadyin es of EMS patients with of EMS patients es ng, Heart, Abdomen, Back, Extremities, Neuro. Back, ng, Heart, Abdomen, nd respiratory status with the above interventions. ST If ECG. Sided Right consider MI, aVF) III, I, drug ingestion. All efforts at verbal coachingAll efforts at verbalbeshould drug ingestion. S treatment, it is no longer routinely recommended. s. Diabetics, geriatric and oglycerin and / or opioids may cause hypotension hout relief, consider potency of the medication. SSM EMS Protocols mfort to maximizet to patients already prescribed me 36 hours due to potential severe hypotension.potential severe 36 hours due to Waveform Capnography (EtCO Capnography Waveform to assist with CPAP compliance. B compliance. CPAP with assist to tient who has used Viagra (sildenafil) has used tient who CHF / Pulmonary Edema / Pulmonary CHF Midazolam 1-2mg IV utilized prior to giving benzodiazepines for patients in respiratory distress. mental status, or who have recent historyrecentofor who havemental alcohol or status, depression or may actually worsen compliance with CPAP patients in persistent respiratory distress. Document 12 Lead ECG and CPAP application in the PCR. EMT-B may administer Nitroglycerin supply. Consider Items in Red Text are key performance measures used to evaluateItems in Red protoc Morphine hasNOT been shown to improvethe outcom Recommended Exam: Mental Status, Skin, Neck, Lu though this historically has been a mainstay of EM past (tadalafil) in the Cialis hours or Avoid Nitroglycerin in any pa Avoid Nitroglycerin in any Consider myocardial infarction in all of these patient elevation is noted in transposed V3 or V4, Nitr requiring fluid boluses. usecontinue NitroglycerinIf Nitro-pasteto not do SL. is used, If patient has taken his own nitroglycerin wit Carefully monitor the level of consciousness, BP, a (I inferior from shock resulting Cardiogenic / CHF If atypical pain, or only generalizedatypical pain, complaints. of co be in a position to patient Allow the Pulse oximetry and End-Tidal and End-Tidal Pulse oximetry      Pearls          Emergencies Envolving Ventricular Assist Devices (LAD or LVAD)

History Signs and Symptoms Differential  End-Stage Heart Failure  The flow through many of these  Stroke  Patient has surgically- devices is not pulsatile, therefore  Cardiac Arrest implanted pump that assists THE PATIENT MAY NOT HAVE  Dysrhythmia different from patient’s baseline the action of one or both A PULSE AT BASELINE. For this  Infection ventricles. reason pulse oximetry readings  Bleeding (LVAD patients are anticoagulated)  Patient may or may not be may also be inaccurate  Dehydration on a list for cardiac  Altered Mental Status may be the  Cardiac Tamponade transplantation only indicator of a problem  Device problem such as low battery or  Consider both LVAD-related and disconnected cable non-LVAD-related problems

Universal Patient Care Protocol

Problem with Circulation, Signs or Symptoms Perfusion, SYMPTOMATIC YES of possible device NO Dysrhythmia not at patient’s malfunction or failure? baseline, any other problems? NO Determine Type of Device and Assess any Alarms YES

CALL VAD COORDINATOR and Section Protocols Cardiac Adult DISCUSS PLAN WITH CAREGIVERS Consider: change device batteries, reconnect cables Exit to Appropriate protocol(s); treat as per usual protocol, AND Continuous Flow Device Pulsatile Flow Device 1. Place an IV, consider fluid bolus 2. Put the patient on the cardiac monitor Auscultate chest for whirring Measure pulse and blood 3. Obtain a 12-lead EKG mechanical pump sound. Assess B pressure. If no pulse or 4. Treat symptomatic dysrhythmias. patient for hypoperfusion: Altered blood pressure, providers 5. If indicated, place defib pads as any Mental Status, pallor, diaphoresis P should go to appropriate other patient ACLS protocol. CALL VAD COORDINATOR and DISCUSS PLAN Start CPR if no pump sound, no WITH CAREGIVERS B pulse or blood pressure, and signs of hypoperfusion.

Treat non-LVAD related conditions per usual P protocol. Transport to appropriate destination; if at all possible to the hospital where LVAD was placed Notify destination and consider contacting Medical Control Pearls  ALWAYS talk to family / caregivers as they have specific knowledge and skills. CALL THE VAD COORDINATOR EARLY as per patient / family instructions or as listed on the device. They are available 24 / 7 and should be an integral part of the treatment plan.  QUESTIONS TO ASK: DOES THE PATIENT HAVE A DNR? Can the patient be cardioverted or defibrillated if needed? Can CHEST COMPRESSIONS be performed in case of pump failure?  Deciding when to initiate Chest Compressions is very difficult. Consider chest compressions. However, if the pump has stopped the heart will not be able to maintain perfusion and the patient will likely die. Ideally, plan the decision in advance with a responsive patient and the LVAD coordinator. If a LVAD patient is unresponsive and pulseless with a non-functioning pump and has previously indicated a desire for resuscitative efforts, begin compressions. Contact the LVAD coordinator and medical control.  Common complications in VAD patients include Stroke and TIA (incidence up to 25%), bleeding, dysrhythmia, and infection.  The Cardiac Monitor and 12 lead EKG are not affected by the VAD and will provide important information.  LVAD patients are preload dependent. Consider that a FLUID BOLUS can often reverse hypoperfusion.  Transport patients with ALL device equipment including any instructions, hand pumps, backup batteries, primary and secondary controllers, as well as any knowledgeable family members or caregivers.

SSM EMS Protocols 20142016 Adult Medical

Section Table of Contents

Airway Pharmacologically Assisted Intubation Failed Airway COPD/Asthma

Seizure Section Protocols Medical Adult Allergic Reaction/Anaphylaxis Diabetic Abdominal Pain Stroke Stroke Transport Destination Plan Shock/Hypotension Hypertension Altered Mental Status

Dialysis/Renal Failure Syncope Back Pain Overdose/Toxic Injestion Vomiting/Diarrhea Pain Control

SSM EMS Protocols 2016 Adult Medical Protocols Section YES to 2016 2 O 2

SpO

90% 90% - 99% 2 Exit to and of ≥ NO YES YES if indicated 2 2 Chest and/or Tension maintain Consider Tube Protocol Effective? Effective? Procedure of 35-45 mmHg BVM / CPAP BVM / CPAP 2 SpO Pneumothorax? bag compliance, Respiratory Distress Decompression With a Tracheostomy With a Supplemental oxygen EtCO Goal SpO Goal Appropriate Protocol

Continuously monitor P EtCO Airway: CPAP Procedure B BVM and supplemental NO NO P B YES YES YES

Consider NO

NO if indicated YES Exit to NO if indicated Oxygenation YES Airway Patent? Support needed? Monitor / Reassess Supplemental Oxygen Appropriate Protocol Breathing / Oxygenation as appropriate Gag reflex present? reflex Gag Consider sedation Altered Mental Status Protocol SSM EMS Protocols Basic Maneuvers First -open airway chin lift / jaw thrust airway or oral -nasal -Bag-valve mask (BVM) Midazolam 5 mg/IN Assess Respiratory Rate, Effort, Is Airway / Breathing Adequate? Spine Protocol Motion Restriction Airway BIAD Procedure Airway BIAD Airway successfully placed? NO B Midazolam 2.5 – 5mg IV/IO/IM contacting Medical Control Medical contacting Adult Airway Adult Oral / Nasal Intubation Procedure Notify destination and consider Notify P P B NO YES NO YES management. OR AND Exit to Exit to containvery useful direct laryngoscopy direct Protocol Protocol Surgical Procedure Visualizewith airway information for airway Airway Foreign Body Airway Foreign Complete Obstruction? utilized together as they Obstruction Procedure Airway Cricothyrotomy Airway Cricothyrotomy Protocols 1 and 2 should be attempts by most more unsuccessful Unable to Ventilate Ventilate to Unable continued attempts intubation attempts Pharmacologically Pharmacologically experienced EMT-P. Adult Failed Airway Assisted Intubation Intubation Assisted Two (2) unsuccessful during or after one (2) or (2) or one or after during Anatomy inconsistent with P P B and Oxygenate adequately Adult Airway

Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital endotracheal intubations are to be considered high risk. If ventilation / oxygenation is adequate, transport may be the best option. The most important airway device and the most difficult to use correctly and effectively is the Bag Valve Mask (not the laryngoscope).

Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques.

Difficult Airway Assessment

Difficult BVM Ventilation‐MOANS: Difficult Mask seal due to facial hair, anatomy, blood or secretions / trauma; Obese or late pregnancy; Age > 55; No teeth ; Stiff or increased airway pressures (Asthma, COPD, Obese, Pregnant).

Difficult Laryngoscopy‐LEMON: Look externally for anatomical distortions (small , short neck, large tongue); Evaluate 3‐3‐2 Rule (Mouth open should accommodate 3 patient fingers, mandible to neck junction should accommodate 3 patient fingers, chin‐neck junction to thyroid prominence should accommodate 2 patient fingers); Mallampati (difficult to assess in the field); Obstruction / Obese or late pregnancy; Neck mobility.

Difficult BIAD‐RODS: Restricted mouth opening; Obstruction / Obese or late pregnancy; Distorted or disrupted airway; Stiff or increased airway pressures (Asthma, COPD, Obese, Pregnant); Section Protocols Medical Adult

Difficult Cricothyrotomy / Surgical Airway‐SHORT: Surgery or distortion of airway; Hematoma over lying neck; Obese or late pregnant; Radiation treatment skin changes; Tumor overlying neck.

Trauma: Utilize in‐line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar front should be open or removed to facilitate translation of the mandible / mouth opening.

Nasotracheal intubation: Orotracheal intubation is the preferred choice. Procedure requires patient have spontaneous breathing. Contraindicated in anatomically disrupted or distorted airways, increased intracranial pressure, severe facial trauma, basal skull fracture, head injury. Not a rapid procedure and exposes patient to risk of desaturation.

Pearls  This protocol is only for use in patients longer than the Broselow-Luten Tape.

 Continuous waveform capnography (EtCO2) is mandatory for the constant monitoring of all patients with any airway device. Document results.  If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway) with continuous pulse oximetry values of ≥ 90% or values expected based on pathophysiologic condition with otherwise reassuring vital signs (e.g. pulse oximetry of 85% with otherwise normal vitals in a post-drowning patient), it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. Consider CPAP as indicated by protocol and patient condition.  For the purposes of this protocol a secure airway is achieved when the patient is receiving appropriate oxygenation and ventilation.  An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage.

 An appropriate ventilatory rate is one that maintains an EtCO2 of 35-45 mmHg. Avoid hyperventilation.  Paramedics should use a BIAD if oral-tracheal intubation is unsuccessful.  Maintain C-spine immobilization for patients with suspected spinal injury.

 Do not assume hyperventilation is psychogenic– use oxygen for goal SpO2 of 90-99%, not a paper bag.  Cricoid pressure no longer routinely recommended. BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) may assist with difficult intubations.  Gastric tube placement should be considered in all intubated patients if available or time allows.  It is important to secure the endotracheal tube well and consider c-collar (in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers. SSM EMS Protocols 2016 Pharmacologically Assisted Intubation

Patient is > 10 years of age? Exit to Pediatric NO YES Pharmacologically Assisted Intubation Complete pre-intubation checklist CHECKLIST Protocol P Ensure that all equipment is working Venous Access Protocol and available.  Suction B Baseline neurologic exam  BIAD and/or materials for surgical airway  All equipment for Oral Tracheal Spine Motion Restriction Protocol Intubation B if indicated  Pulse oximetry  End tidal capnography

Patient suspected of having: YES CVA, head injury, or intracranial hemmorage?

Lidocaine 1.5 mg/kg IV / IO NO P Ideally given 1 min. prior to intubation Etomidate 0.3 mg/kg IV / IO Adult Medical Protocols Section Protocols Medical Adult If ineffective or unavailable, substitute the following P combination Midazolam 0.1 mg/kg IV / IO followed by Fentanyl 1 mcg/kg IV / IO

B Capnography Procedure

Pre-oxygenate the patient B with 100% oxygen and assist ventilations with BVM

Are respirations < 8 and gag reflex absent? NO YES

Oral Tracheal Intubation Procedure BURP maneuver, if indicated P Consider BIAD Procedure Unable to ventilate if unsuccessful first attempt and oxygenate after the first Auscultate over stomach B unsuccessful intubation attempt then lung fields AND ET tube passed Anatomy inconsistent with NO vocal chords under YES continued attempts direct visualization? Capnography Procedure OR B Two (2) unsuccessful attempts Properly secure airway by most experienced EMT-P. Avoid hyperventilation Midazolam 2.5 – 5mg IV / IO Ventilate to maintain: P if indicated, bucking or biting SpO of 90-99% B 2 tube Exit to AND/OR Adult Failed Airway EtCO2 of 35-45 mmHg Protocol Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Pharmacologically Assisted Intubation

Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital endotracheal intubations are to be considered high risk. If ventilation / oxygenation is adequate, transport may be the best option. The most important airway device and the most difficult to use correctly and effectively is the Bag Valve Mask (not the laryngoscope).

Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques.

Difficult Airway Assessment

Difficult BVM Ventilation‐MOANS: Difficult Mask seal due to facial hair, anatomy, blood or secretions / trauma; Obese or late pregnancy; Age > 55; No teeth (roll gauze and place between gums and cheeks to improve seal); Stiff or increased airway pressures (Asthma, COPD, Obese, Pregnant).

Difficult Laryngoscopy‐LEMON: Look externally for anatomical distortions (small mandible, short neck, large tongue); Evaluate 3‐3‐2 Rule (Mouth open should accommodate 3 patient fingers, mandible to neck junction should accommodate 3 patient fingers, chin‐neck junction to thyroid prominence should accommodate 2 patient fingers); Mallampati (difficult to assess in the field); Obstruction / Obese or late pregnancy; Neck mobility.

Difficult BIAD‐RODS: Restricted mouth opening; Obstruction / Obese or late pregnancy; Distorted or disrupted airway; Stiff or Section Protocols Medical Adult increased airway pressures (Asthma, COPD, Obese, Pregnant);

Difficult Cricothyrotomy / Surgical Airway‐SHORT: Surgery or distortion of airway; Hematoma over lying neck; Obese or late pregnant; Radiation treatment skin changes; Tumor overlying neck.

Trauma: Utilize in‐line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar front should be open or removed to facilitate translation of the mandible / mouth opening.

Pearls  This protocol is only for use in patients > 10 years of age because of the use of Etomidate.  Contact medical control before using the Pharmacologically Assisted Intubation Protocol if the patient is stable.

 Continuous waveform capnography (EtCO2) is mandatory for the monitoring of all patients with a BIAD or ET tube. Document results.  If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway) with continuous pulse oximetry values of ≥ 90% or values expected based on pathophysiologic condition with otherwise reassuring vital signs (e.g. pulse oximetry of 85% with otherwise normal vitals in a post-drowning patient), it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. Consider CPAP as indicated by protocol and patient condition.  For the purposes of this protocol a secure airway is achieved when the patient is receiving appropriate oxygenation and ventilation.  An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage.

 An appropriate ventilatory rate is one that maintains an EtCO2 of 35-45. Avoid hyperventilation.  Paramedics should use a BIAD if oral-tracheal intubation is unsuccessful.  Maintain C-spine immobilization for patients with suspected spinal injury.  Cricoid pressure is no longer routinely recommended. BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) may assist with difficult intubations.  Gastric tube placement should be considered in all intubated patients if available or time allows.  It is important to secure the endotracheal tube well and consider c-collar (in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers.

SSM EMS Protocols 2016 Failed Airway: Adult

Protocols 1 and 2 should be Enter from utilized together as they Airway Protocol contain very useful information for airway management. Unable to ventilate and oxygenate adequately during or after one (1) or more unsuccessful intubation attempts. AND Anatomy inconsistent with continued attempts. OR TWO (2) unsuccessful attempts by most experienced EMT-P.

Each attempt should include change in approach or equipment NO MORE THAN TWO (2) ATTEMPTS TOTAL Adult Medical Protocols Section Protocols Medical Adult

Call for additional resources if available

BVM / Adjunctive Airway Maintains SpO2 ≥ 90 % YES or acceptable values based on clinical condition?

NO Continue BVM Supplemental Oxygen

Significant Facial Trauma P Airway: Surgical Procedure YES / Swelling / Distortion? Exit to Appropriate Protocol NO

B Airway: BIAD Procedure

NO BIAD Successful?

YES

Continue Ventilation / Oxygenation maintain SpO of ≥ 90% P 2 Ventilation rate to maintain EtCO2 35 – 45 mmHg

Notify destination and consider contacting Medical Control

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Pearls      Use can probably It cannot on In infections 1. Failure 2. airway 3. rescuer Trauma front ventilation Conditions intubation patients Saturation, Cricothyrotomy The drowning patient) reassuring vital signs (e.g. consistent pulse oximetry of intubations. A difficult information Position Adult Medical Protocols Section 2016

if available Exit to YES IV / IO Consider 0.3 mgIM Improving? if indicated Allergic Reaction/ Airway Protocol(s) Simultaneously utilize Very Diminished/ Very Anaphylaxis Protocol absent lung sounds lung absent Epinephrine 1:1000 Repeat as needed x 3 Normal Saline IV / IO Airway CPAPProcedure Methylprednisolone 125 mg Ipratropium 0.5 mg P NO P Asthma Anaphylaxis Aspiration COPD (Emphysema, Bronchitis) effusion Pleural Pneumonia embolus Pulmonary Pneumothorax Cardiac (MI or CHF) Pericardial tamponade Hyperventilation Inhaled toxin (Carbon monoxide, etc.) NO YES Differential             94 % ≥

2 NO YES Lung Exam Airway Patent Cardiac Monitor Consider Procedure maintain SpO Ventilations adequate, Ventilations Oxygenation adequate? Supplemental oxygen to SSM EMS Protocols Over 10 minutes 12 Lead ECG Procedure Capnography Procedure Shortness of breath Pursed breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi Use of accessory muscles Fever, cough Tachycardia Allergic Reaction/Anaphylaxis? Orotracheal Intubation Venous Access Protocol         Signs and Symptoms Signs and Ketamine 1-2 mg/kg IV / IO Magnesium Sulfate 2 g IV / IO contacting Medical Control Medical contacting P B Induction agent prior to intubation Methylprednisolone 125mg IV/IO Notify destination and consider Notify YES P NO Adult COPD / Asthma / COPD Adult

NO Exit to YES or Asthma? WHEEZING Signs / Symptoms consistent with COPD Appropriate Protocol Lung sounds clear? Repeat as needed x 3 Asthma; COPD -- chronic bronchitis, bronchitis, -- chronic COPD Asthma; emphysema, congestive heart failure Home treatment(oxygen, nebulizer) Medications (theophylline, steroids, inhalers) inhalation smoke exposure, Toxic Albuterol Nebulizer 2.5 mg Universal Patient Care Protocol History     P Adult Medical Protocols Section 2016 ipitate respiratory ol compliance and care. ing cardiogenic shock with kes sense: as pressure increases ld receive a 12 lead ECG at some only utilize patient’s medication.

) should be monitored continuously for continuously be monitored ) should Benzodiazepines may prec 2 disease, take Beta-Blockers / Digoxin or in patients who are already tired, alreadypatients with alteredtired, who are alreadyin ficantnot and doesBeta-Agonist respond to initial drug ingestion. All efforts at verbal coaching All efforts at verbalbeshould drug ingestion. t chambers and greatt causing vessels, cardiacoutput to delay administration of epinephrine. of epinephrine. delay administration SSM EMS Protocols 1Editorial Advisor Art Hseich MA, NREMT) 1Editorial AdvisorMA, Art Hseich ted. The patient must also be breathing and able to follow commandsThe patient must in also be breathing and able ted. for patientsin respiratory distress. and will, lower blood pressure. This ma lower blood pressure. and will, ac ischemia. These patients These shou ac ischemia. 140 give one-half the dose of epinephrine ( = 0.15 mg of 1:1000.) mg ofepinephrine 1:1000.) ( = 0.15 the dose of one-half140 give eady prescribed Albuteroleady prescribed and may ≥ Waveform Capnography (EtCO Capnography Waveform IV to assist with CPAP compliance. compliance. CPAP with assist IV to Adult COPD / Asthma / COPD Adult 50 years of age, have a history of cardiac ≥ Midazolam 1-2mg should be used when Respiratory Distress is signi

2 Pulse oximetry and End-Tidal and End-Tidal Pulse oximetry point in their care, but this should NOT this should NOT in their care, but point patient'sheart rates who have Epinephrine may precipitate cardi utilized prior to giving benzodiazepines mental status, or who have recent historyrecentofor who havemental alcohol or status, depression or may actually worsen compliance with CPAP patients in persistent respiratory distress. EtCO Neck, Heart, Lungs, Abdomen, Extremities, Neuro. Recommended Abdomen, Mental Exam:Skin, Neck, Heart, Lungs, Status,HEENT, Text are key performance measures used to evaluateItems in Red protoc CPAP can, The main concern is that inside the lungs, it also increases pressure on the hear drop. If the patient is hypotensivei.e. the patientIf the patient is— to begin with experiencdrop. Patients who are pulmonary edema is — CPAP not indica order for CPAP to work effectively. (EMS EMT-B may assist patient, if alr EMT-B may assist patient,if Consider A silent chest in respiratoryis a pre-respiratorysilent distress arrest sign. A dose.   Pearls       

Adult Medical Protocols Section 2016 NO NO Known or Suspected 20 Weeks? Procedure Pregnancy > and oxygenation and Naloxone 1-2 mg IV / IO / IntraNasal CONSCIOUSNESS constrictive clothing Thiamine 100 mgIV / IO / IM Venous Access Protocol NOT GIVEN TO RESTORE Blood Glucose Analysis Blood Glucose P YES Titrate to effect adequate ventilation Midazolam 5 mg IntraNasal once; YES Do not wait to obtain IV or IO access. Protect providers and patient. Loosen YES

CNS (Head) trauma Tumor Metabolic,Hepatic, Renal or failure Hypoxia Electrolyte abnormalityMg) (Na, Ca, Drugs,Medications, Non-compliance InfectionFever / Alcohol withdrawal Eclampsia Stroke Hyperthermia Hypoglycemia P P B YES Status Epilepticus? Differential             Airway Protocol(s) contacting Medical Control Medical contacting Notify destination and consider Notify P NO NO Over 2 – 3 minutes Signs of Alcoholism? if indicated minutes, May repeat 2g. Possible opiate overdose? Diabetic Protocol Magnesium Sulfate 4 / g IV IO For persistent seizure after 5-10 impaired patients. SSM EMS Protocols P for the patient “found down” Decreasedmental status Sleepiness Incontinence Observed seizureactivity trauma of Evidence Unconscious include intoxicated/chemically alteredLOC present. This to is without witness to the event and Spinal Precautions must be taken YES Seizure- Adult Seizure- NO Signs and Symptoms Signs and       Max 20 mg Max 20 mg Max 10mg

OR NO YES 2.5 mg IV / IO if indicated if indicated if indicated Procedure Awake, Alert, or Protect patient

Cardiac Monitor arrival onscene? Monitor and Reassess and Monitor Actively Seizing upon If patient begins seizing, Normal Mental Status? Mental Normal Diazepam 5-10 mg IV / IO Blood Glucose Analysis Blood Glucose Venous Access Protocol Lorazepam 1-2 mg IM / IV / IO Midazolam 5 mg IntraNasal / IM Loosen any constrictive clothing continued seizure activity, If Midazolamavailable, not initial dose: continued seizure activity to for continued seizure activity, Repeat intial dosing every 3 to 5 minutes Spine Motion Restriction Protocol B Reported / witnessed seizure seizure / witnessed Reported activity Previous seizure history Medicalalert tag information Seizure medications History of trauma History of diabetes History of pregnancy Time of seizure onset Document number of seizures Alcohol use, abuse or abrupt cessation Fever I Repeat intial dosing every 3 to 5 minutes for Repeat initial dosing every 3 to 5 minutes for P B Universal Patient Care Protocol B History            P Seizure- Adult Adult Medical Protocols Section Section Protocols Medical Adult

Pearls  Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro  Items in Red Text are key performance measures used to evaluate protocol compliance and care

 Midazolam 5 mg IntraNasal is effective in termination of seizures. DO NOT delay IntraNasal administration to obtain IV or IO access in an actively seizing patient.  For a seizure that begins in the presence of EMS, if the patient was previously conscious, alert, and oriented, take time to assess and protect the patient and providers and consider the cause. The seizure may stop, especially in patients who have prior history of self-limiting seizures. However, do not hesitate to treat recurrent or prolonged (> 1 minute) seizure activity.  Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery, or one prolonged seizure lasting longer than 5 minutes. This is a true emergency requiring rapid airway control, treatment, and transport.

 Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma.  Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness  Be prepared for airway problems and continued seizures.  Assess possibility of occult trauma and substance abuse.  Be prepared to assist ventilations and/or manage the airway especially if diazepam or midazolam is used.  For any seizure in a pregnant patient, follow the OB Emergencies Protocol.  Diazepam (Valium) is not effective when administered IM. Diazepam can be given IV or Rectally, Midazolam and Lorazepam are well absorbed when administered IM.

SSM EMS Protocols 2016 Adult Medical Protocols Section 2016

Epinephrine Access Protocol infusion Consider SEVERE if indicated if indicated Anaphylaxis ODT / IV / IO 125mg IV/IO 0.3-0.5 mg IM 500 mL IV / IO 0.5- 1 mg IV/IO if no improvement 50 mg IV / IM / IO Repeat asneeded Famotidine 20mg if not already given MaximumLiters 2 Diphenhydramine Airway Protocol(s) Repeat in 5 minutes minutes 5 in Repeat Epinephrine 1:1000 Methylprednisolone Epinephine 1:10,000 Epinephine Normal Saline Bolus Repeat as needed x 3 Consider +/- Ipratropium 0.5 mg For refractory/peri-arrest (0.15 mg IM if age > 50) Albuterol Nebulizer 5 mg Epinephrine Auto-Injector Assist patient with their prescribed their with patient Assist Venous Urticarial (rash only) Urticarial (rash Anaphylaxis (systemiceffect) Shock (vasculareffect) induced) (drug Angioedema obstruction Airway / Aspiration Vasovagal event Asthma or COPD CHF P B P Differential         94 % 94 ≥ NO Access Protocol Consider 0.3 mg IM if indicated MODERATE ODT / IV / IO SpO2 125mg IV/IO or improving? Symptoms stable 50 mg / IV / IM IO Famotidine 20mg moderate symptoms) moderate if not already given Diphenhydramine Airway Protocol(s) moderate symptoms) Epinephrine 1:1000 Methylprednisolone Simultaneously utilize Repeat as needed x 3 +/- Ipratropium 0.5 mg (AVOID in age > 50 for only only for > 50 age in (AVOID Assess Symptom Severity SSM EMS Protocols Albuterol Nebulizer 5 mg (AVOID in age > 50 for only Epinephrine Auto-Injector Itching or hives respiratory or wheezing / Coughing distress Chest or throat constriction swallowing Difficulty Hypotension or shock Edema N/V Assist patient with their prescribed their with patient Assist Venous Supplemental oxygenmaintain to Signs and Symptoms Signs and        P B Universal Patient Care Protocol B YES NO Allergic Reaction / Anaphylaxis / Reaction Allergic contacting Medical Control Medical contacting Access Protocol MILD Notify destination and consider Notify 50 mg YES (if available) IV / IO / IM 2 Symptoms or improving? Diphenhydramine Symptoms stable Monitor and Reassess and Monitor Onset and location and Onset Insect sting or bite Food allergy/ exposure Medication allergy / exposure New clothing, soap, detergent Past history of reactions history medical Past history Medication for Worsening Signs and and Severe Reactions IndicatedModerate for Venous pulse oximetry and end end and oximetry pulse Cardiac Monitoring with tidal EtCO History         P B Adult Medical Protocols Section 2016

inivil / Zestril (lisinopril)-

sure and perfusion. al symptoms and have no rash / skin y (wheezing, dyspnea, hypoxia) or gastrointestinal pressure medications like Pr in) with normal blood pressure and perfusion.normal blood pressure and in) with Auto-injector only and may assist from patient supply. th normal blood pres present, depending on perfusion. Possible Itching, erythema plus hypoxia) gastrointestinal or symptoms (nausea, vomiting, abdominal of IM epinephrine may require IV epinephrine administration by IV push or SSM EMS Protocols t already prescribed from patient supply. the first drug that should be administered in acute anaphylaxis (Moderate / y administration of epinephrine. Status, Skin, Heart, Lungs r with only respiratory and gastrointestin and r with respiratory only Use an autoinjectordeliver to IM epinephrine any time one is available. 50 years of age, have a history of cardiac disease, take Beta-Blockers / Digoxin or patients who 150; give one-half the dose of epinephrine (0.15 mg of 1:1000) for the initial dose and any repeated ≥ Allergic Reaction / Anaphylaxis / Reaction Allergic Flushing, hives, itching, erythema plus respirator Flushing, hives, itching, erythema wi symptoms (nausea, vomiting, abdominal pa Skin symptoms may or may not be respiratory (wheezing, dyspnea, pain) with hypotension and poor perfusion. Moderate symptoms: Mild symptoms: Severe symptoms: EMT-B may assist with if patien Albuterol Anaphylaxis is an acute and potentially lethal multisystem allergic reaction. Epinephrine is the drug of choice and Severe Symptoms.)IM Epinephrineshould be administered in priority before or during attempts at IV or IO access. To improve patient safety, Anaphylaxis unresponsive to doses repeat epinephrine infusion. Contact Medical Control for refractory anaphylaxis. Symptom Severity Classification: Recommended Exam: Mental Any patient with respiratory symptoms or extensive reaction should receive IV or IM diphenhydramine. The shorter the onset from symptoms to contact, the more severe the reaction. involvement. Angioedema is seen in moderate to severe reactions and is swelling involving the face, or airway structures. This can also be seen in patients taking ACE-inhibitor blood Allergic reactions may occu typically-il. end in Patients who are ≥ rates have heart doses. Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG at some point in their care, but this should NOT dela EMT-B may assist patient with Epinephrine IM as      Pearls        Adult Medical Protocols Section 2016 NO NO . YES YES Exit to Protocol of oral meds 250/ dl mg Overload? CHF / Fluid CHF / Fluid ≥ Blood Sugar Hypotension?

no evidence of 500 mL IV / IO Dehydration with Recommend Transport Transport Recommend Normal Saline Bolus Hypotension / Shock Hypotension / Then infuse 150 mL / hr Due to continuous release P Alcohol / drug use drug / Alcohol Toxic ingestion Trauma; head injury Seizure CVA Altered baseline mental status Differential       if indicated Procedure YES AND Cardiac Monitor nous Access Protocol 12 Lead ECG Procedure Blood Glucose Analysis Analysis Blood Glucose

patient may Blood Sugar > Sugar Blood Ve Exit to THEN AND I P B Procedure NO NO Blood Sugar YES 80 – 249 mg / dl sign a refusal. if condition changes RULE OUT STROKE! Appropriate Protocol patient eats meal now Pt taking Oral mental status? Diabetic Meds? Blood Glucose Analysis Blood Glucose Return to baseline SSM EMS Protocols AND B adult present complaint free, contacting Medical Control Medical contacting 80 IF Notify destination and consider Notify Altered mental status Combativeirritable / Diaphoresis Seizures Abdominal pain vomiting / Nausea Weakness Dehydration breathing rapid / Deep Diabetic Adult Diabetic Signs and Symptoms Signs and          YES YES 94 % ≥

2 cess Protocol NO YES needed NO suspected Improving? Improving? >80 mg/dL < 80 mg/ dl PO tolerant? Blood Sugar Consider Oral Glucose Solution maintain SpO No venous access? venous No Supplemental oxygen to Exit to (100 cc) IV / IO bolus titrate blood glucose to Repeat in 15 minutes if if 15 minutes in Repeat Glucagon 1 – 2 mg IM Protocol Continue infusion of D10, Dextrose10%- 10 grams Thiamine 100 mg IV / IO / IM If malnutrition or alcoholism is Venous Ac B Past medical history medical Past Medications Recent blood glucose check Last meal B Universal Patient Care Protocol P Altered Mental Status P History     NO Adult Medical Protocols Section 2016 IO access may present accessa greater riskIO swallow or protect their airway. l signs. It may be safe to wait for some time for aces the patient at risk ofhypoglycemiarisk recurrentaces the patient at even rongly encouraged to allow transportation to a medical manufacturers recommendation for recommendation manufacturers all glucometers. se care should be instructed to contact their physician mealcomplex withcarbohydrates and protein. that can be delayed for hours and require close monitoring SSM EMS Protocols in, RespirationsNeuro. in, and effort, cility after treatment hypoglycemia: of hed. Patients who meet criteria to refuse care should be instructedbeshouldto refuse care Patients who meet to criteria hed. On the other hand, consider IO access to give DextroseconsiderOn the other hand,givein patients early IO access to complex carbohydrates and protein. Diabetic Adult Diabetic mia my not respond to glucagon. to patientsable to thatto are not Insulin Agents: immediately and consume a meal with even after normal blood glucose is established. Not all oral agents have prolongedContact actionso Medical to refu Patients who meetadvice. criteria Control for after a normal blood glucose is establis contact theirphysician immediately and consume a Many forms of insulin now exist. Longer acting insulin pl Patients takingdiabeticoral medications should be st ofhypoglycemia recurrentrisk They are at facility. Patients with prolonged hypoglyce GlucagonResponsetake 15-20 minutes. can to Consider the entire clinical picture when treating hypoglycemia, a patient’sincludingclinical overall condition and other vita Oral Agents: Glucagon to work, instead of pursuing the more aggressiveperforming coursefaster acting of give IO access to and healing,woundmay have poor Diabetics Dextrose IV/IO solution. healing. for infection or poor wound criticallywho arehypoglycemic.and ill or peri-arrest glucoseadminister oral Do not Recommended exam: Mental Status, Sk Quality checks should be control maintained per Patients refusing transport to medical fa      Pearls    Adult Medical Protocols Section 2016 90 ≥ NO NO NO Exit to Protocol Etiology? s (infectious) s Improving? or Vomiting? if indicated Nausea and / / and Nausea MaximumL 2 Cardiac Monitor Signs / Symptoms titrate to SBP Repeat as needed Suggesting Cardiac Hypotension / Shock Hypotension / Adult Pain Control Protocol Normal Saline Bolus 500 mL

Venous Access Protocol Pneumonia or Pulmonary embolus Liver (hepatitis, CHF) Peptic ulcer disease / Gastritis Gallbladder infarction Myocardial Pancreatitis stone Kidney Abdominal aneurysm Appendicitis Bladder / Prostate disorder Pelvic(PID, Ectopic pregnancy, cyst) Ovarian enlargement Spleen Diverticulitis obstruction Bowel Gastroenteriti Ovarian and Testicular Torsion YES YES I P Differential                 YES YES

shock Exit to Protocol Appropriate as indicated Cardiac Protocol SSM EMS Protocols Vomiting and Diarrhea Pain (location / migration) / (location Pain Tenderness Nausea Vomiting Diarrhea Dysuria Constipation discharge / bleeding Vaginal Pregnancy Hypotension,perfusion, poor Serious Signs / Symptoms? Signs and Symptoms Signs and          Associated symptoms: (Helpful to localize source) Fever, headache, weakness, malaise, myalgias,cough, headache, mental rash changes, status Universal Patient Care Protocol YES NO YES contacting Medical Control Medical contacting Abdominal Pain- Adult Pain- Abdominal Notify destination and consider Notify NO NO Etiology? or Vomiting? if indicated Nausea and / / and Nausea Signs / Symptoms Suggesting Cardiac

Adult Pain Control Protocol Age history / surgical medical Past Medications Onset Palliation / Provocation Quality (crampy, constant, sharp, dull,etc.) Region / Radiation / Referred Severity (1-10) repetition) / (duration Time Fever Last meal eaten Last bowel movement / emesis Menstrual history (pregnancy)

Venous Access Protocol History              P Adult Medical Protocols Section 2016 n, Back, Extremities, 12 Lead and consideration of 15 Lead for these and shouldbe avoidedwith this symptom.in patients / or women especially with upper abdominal complaints. be treated as pregnancyas be treated otherwise. related until proven de in elderlyde in patients;extra may causesedation. SSM EMS Protocols should be considered with abdominalshould be consideredpain especially pain or back with in Abdominal Pain Abdominal a 12-lead EKG on these patients. s with shock/ poor perfusion. patients. aftersignsRepeat each fluid bolus. vital The use of metoclopramide(Reglan)diarrhea may worsen Antacidsrenaldisease.in patients should be avoidedwith The diagnosis of abdominal aneurysm patients over 50 and / or patient over 50 and / patients Recommended Abdome Mental Exam:HEENT, Neck, Heart, Lung, Status,Skin, Neuro childbearingwomenAbdominal pain in of age should Use caution with administration of Metocloprami Have a low threshold to perform Consider cardiac etiology in patients > 50, diabetics and     Pearls     Adult Medical Protocols Section

2016

Cardiac Monitor Exit to Venous Access Protocol Venous Access 12 Lead ECG Procedure

See Altered Mental Status TIA (Transient ischemic attack) Seizure Todd’s Paralysis Hypoglycemia Stroke Tumor Trauma / Renal Failure Dialysis Appropriate Protocol P B Differential       Thrombotic or Embolic (~85%) Hemorrhagic (~15%)    NO NO

120 ≥ 10 Minutes DBP ≤ if possible NO and/or YES

STROKE blood draws? 220 Cardiac Monitor ≥ Last time seen seen time Last accept prehospital Exit to Does receiving facility Transport based on: Venous Access Protocol Venous Access normal is < 8 Hours? 12 Lead ECG Procedure 2 large bore, Signs and Symptoms consistent with Stroke?

hypertension treatment options If SBP contacting Medical Control Medical contacting SSM EMS Protocols Diabetic Protocol Contact Medical Control to discuss Altered mental status Weakness / Paralysis Blindness or other sensory loss Aphasia / Dysarthria Syncope Vertigo / Dizziness Vomiting Headache Seizures Respiratory pattern change hypotension / Hypertension EMS Triage and Destination Plan Immediate Notification Facilityof Keep Scene Time to Time Scene Keep Notify destination and consider Notify after 3 readings at least 5 minutes apart P B Universal Patient CareProtocol Signs and Symptoms Signs and            YES YES P NO YES Suspected Stroke Suspected NO YES Exit to > 30 degrees> 30 Stroke? Procedure >80 mg/dL? >80 Unless hypotensive Unless Glucose reading Elevate patient’shead STROKE SCREEN Consistent with Acute IV site and/or blood draw Appropriate Protocol Do not delay transport for nd Blood Glucose Analysis Blood Glucose Stroke Screen Procedure 2 Stroke Blood Draw Procedure Previous CVA, TIA'sPrevious CVA, Previous cardiac vascular / surgery Associated diseases: diabetes, hypertension, CAD Atrial fibrillation Medications (blood thinners) History of trauma B B P History       Suspected Stroke

For further information regarding current recommendations regarding stroke care, including the rationale to treat or not treat hypertension in the setting of possible stroke, see the current version of:

“Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” Available at: http://stroke.ahajournals.org/content/early/2013/01/31/STR.0b013e318284056a Adult Medical Protocols Section Protocols Medical Adult

Pearls  Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro  Items in Red Text are key performance measures used in the EMS Acute Stroke Care Toolkit.  Acute Stroke care is evolving rapidly. Time of onset / last seen normal parameters may be changed at any time depending on the capabilities and resources of your hospital based on Stroke: EMS Triage and Destination Plan.

 Time of Onset or Last Seen Normal: One of the most important items the pre-hospital provider can obtain, on which all treatment decisions are based. Be very precise in gathering data to establish the time of onset and report as an actual time (i.e. 13:47 NOT “about 45 minutes ago.”) Without this information patient may not be able to receive thrombolytics at facility. For patients with “Woke up and noticed stroke,” Time starts when patient last awake.

 The Reperfusion Checklist should be completed for any suspected stroke patient. With a duration of symptoms of less than twelve (12) HOURS, scene times should be limited to ≤ 10 minutes, early notification of receiving facility should be performed and transport times should be minimized.

 Onset of symptoms is defined as the last witnessed time the patient was symptom free. (i.e. awakening with stroke symptoms would be defined as an onset time when the patient went to sleep or last time known to be symptom free)  The differential listed on the Altered Mental Status Protocol should also be considered.  Be alert for airway problems (swallowing difficulty, vomiting/aspiration).  Hypoglycemia can present as a LOCALIZED neurologic deficit, especially in the elderly.  Document the Prehospital Stroke Screen results in the PCR.

SSM EMS Protocols 2016 Stroke Transport Destination Plan 2016 NO risks NO YES facility destination destination? Stroke Center choice facility interventions and 4.5 - 8 hours?8 4.5 - Have patient sign Should consider refusal specifically

possible associated Patient understands/ Patient

Explain benefits of the refusing recommended Transport to patient’s If transport will not be Level I Stroke Center Duration of symptoms

agrees with recommended delayed by >20 minutes Outside treatment windows, P P Transport to patient’s choice P NO YES NO

Level II

or NO NO YES YES Unstable, transport? Enter from Continually <4.5 hours? destination? Transport to life threating Stroke Center unstable during during transport during reassess patient patient reassess Patient becomes Level I conditions present? Patient understands/ Patient Duration of symptoms agrees with recommended P P Suspected Stroke Suspected Protocol SSM EMS Protocols contacting Medical Control Medical contacting Notify destination and consider Notify YES YES Stroke Patients Stroke

Center options Consider urban areas) urban Transport to air/ground/facility (particularly in non- in (particularly for stabilization St. Luke’s Hospital Barnes-Jewish Hospital Progress West Hospital Missouri Baptist Medical Missouri Baptist Mercy Hospital, St. Louis Hospital, Mercy Barnes-Jewish St. Peters Barnes-Jewish St. Christian Hospital NE-NW Christian Hospital P B SSM DePaul Health Center DePaul SSM St. Louis University Hospital St. Louis University Mercy Hospital, Washington LEVEL I Stroke Centers: nearest appropriate facility SSM St. Clare Health Center SSM LEVEL II Stroke Centers: St. Anthony’s Medical Center St. Anthony’s SSM St. Mary’s Health SSM St. Mary’s Center SSM St. Joseph Health Center SSM SSM St. Joseph Hospital West Adult Medical Protocols Section 2016

pressors 90 ≥ in cardiogenic 90 90 consider Protocol ≥ ≥ if indicated if indicated (ex. Dehydration, GI (ex. STEMI, CHF), (ex. STEMI, Diabetic Protocol Cardiac / Arrhythmia Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic the presence the pulmonary of 2 liter fluid bolus: (ex. PE, Tamponade) Maximum 2 L to effect SBP titrate to SBP (ex. Sepsis, Anaphylaxis), Shock Ectopic pregnancy Dysrhythmias embolus Pulmonary Tension pneumothorax Medication effect / overdose Vasovagal Physiologic (pregnancy) Bolus 500 mL IV / IO after NO Differential         Cardiogenic Hypovolemic edema; utilize Dopamine early: Repeat as needed to SBP ; consider contacting Medical Control Medical contacting Dopamine5 – 20 mcg/kg/min IV / IO Dopamine5 – 20 mcg/kg/min IV / IO Obstructive Notify destination and consider Notify shock Distributive bleed), Use caution with excess fluids For non-cardiogenic shock, Normal Saline or other Crystalloid Solution Consider P if indicated

Type of Type of Shock: Procedure Cardiac Monitor nous Access Protocol 12 Lead ECG Procedure Blood Glucose Analysis Blood Glucose Was trauma involved?

SSM EMS Protocols Restlessness, confusion Weakness, dizziness pulse rapid Weak, Pale, cool, clammy skin Delayed capillaryrefill Hypotension emesis Coffee-ground Tarry stools often suggests History, Exam and Circumstances

Airway Protocol Ve Universal Patient Care Protocol Signs and Symptoms Signs and         I P B after

90 Neurogenic ≥ ONLY 90 ≥ YES (Pneumothorax)

Hypotension / Shock Hypotension Hemostatic Agent (bleeding), Exit to Protocol if indicated Procedure and/or Maximum 2 L Multiple Trauma vasopressors titrate to SBP

Obstructive Obstructive consider early use of Bolus 500 mL IV / IO Wound Care Procedure repeat to effect SBP Hypovolemic Consider Dopamine 5 – 20 mcg/kg/min IV / IO Tourniquet Spine Motion Restriction Protocol 2 liter fluid bolus and patient is peri-arrest. Chest Decompression-Needle Procedure Normal Saline or other Crystalloid Solution (spinal injury), Blood loss - vaginal or vaginal - loss Blood gastrointestinal bleeding, AAA, ectopic Fluid loss - vomiting, diarrhea, fever Infection Cardiac ischemia (MI, CHF) Medications Allergic reaction Pregnancy History of poor oral intake Consider P B History         Hypotension / Shock Adult Medical Protocols Section Protocols Medical Adult

Pearls  Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro  Hypotension can be defined as a systolic blood pressure of less than 90. This is not always reliable and should be interpreted in context and patient’s typical BP if known. Shock may be present with a normal blood pressure initially.  Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation.  Consider all possible causes of shock and treat per appropriate protocol.  Hypovolemic Shock; Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding.  Cardiogenic Shock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventrical / septum / valve / toxins.  Distributive Shock: Sepsis (systemic infection) Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins  Obstructive Shock: Pericardial tamponade. Pulmonary embolus. Tension pneumothorax. Signs may include hypotension with distended neck veins, tachycardia, unilateral decreased breath sounds or muffled heart sounds.  For non-cardiac hypotension, Pressors should only be started after 2 liters of NS have been given.

SSM EMS Protocols 2016 Adult Medical Protocols Section 2016 Exit to Exit to Protocol Protocol Exit to Exit to Protocol(s) Protocol(s) Appropriate Appropriate Cushing’s Response with Bradycardia and Hypertension Chest Pain / STEMI Obstetrical Emergency Hypertensive encephalopathy Hypertensive Primary CNS Injury Myocardial Infarction Aortic Dissection / Aneurysm Eclampsia / Pre-eclampsia Differential      YES YES YES YES cess Protocol NO NO NO NO Cardiac Monitor Pregnancy? Chest Pain? Stroke / AMS? Dyspnea / CHF? Obtain and Document BP 12 Lead ECG Procedure Measurement in Both Venous Ac Most patients, evenwith significant elevation in blood pressure, need contacting Medical Control Medical contacting I Systolic BP 220 or greater Diastolic BP 120 or greater Headache Severe Chest Pain Dyspnea Altered Mental Status Seizure Notify destination and consider Notify P B SSM EMS Protocols   these AND at least one of      Signs and Symptoms Signs and One of these YES Hypertension treated based on those specific protocols. specific those on based treated us, Skin, Neck, Lung, Abdomen,Heart, Back, Extremities, Neuro > 120 > 220 Hypertensive Hypertensive or NO Exit to Systolic BP 3- 5 minutes apart Diastolic BP Appropriate Protocol(s) damage such as MI, CVA or renal failure. This is very difficult to determine in the pre-hospital setting in most cases. BP taken on 3 occasions at least Pain and Anxiety are addressed? Recommended Exam: Mental Stat Elevated blood pressure is based on two to three sets of vital signs, each several minutes apart. Symptomatic hypertension is typically revealed through end organ dysfunction to the cardiac, CNS or renal systems. All symptomatic patients with hypertension should be transported with their head elevated at 30 degrees. habitus. body for utilized cuff pressure blood size appropriate Ensure Documented Hypertension Documented Related diseases: Diabetes; CVA; Renal Failure; Cardiac Problems Medications for Hypertension Compliance with Medications Erectile Dysfunction medications Pregnancy only supportive care. Specific complaints such as chest pain, dyspnea, pulmonary edema or altered mental status should be Universal Patient Care Protocol Hypertension is not uncommon especially in an emergency setting. Hypertension is usually transient and in response to stress stress to response in and transient usually is Hypertension setting. emergency an in especially uncommon not is Hypertension and / or pain. A hypertensive emergency is based on blood pressure along with symptoms which suggest an organ is suffering Aggressive treatment of hypertension can result in harm. Pearls      History       Altered Mental Status

History Signs and Symptoms Differential  Known diabetic, medic alert  Decreased mental status or lethargy  Head trauma tag  Change in baseline mental status  CNS (stroke, tumor, seizure, infection)  Drugs, drug paraphernalia  Bizarre behavior  Cardiac (MI, CHF)  Report of illicit drug use or  Hypoglycemia (cool, diaphoretic  Hypothermia toxic ingestion skin)  Infection (CNS and other)  Past medical history  Hyperglycemia (warm, dry skin; fruity  Thyroid (hyper / hypo)  Medications breath; Kussmaul respirations; signs  Shock (septic, metabolic, traumatic)  History of trauma of dehydration)  Diabetes (hyper / hypoglycemia)  Change in condition  Irritability  Toxicological or Ingestion  Changes in feeding or sleep  Acidosis / Alkalosis habits  Environmental exposure  Pulmonary (Hypoxia)  Electrolyte abnormality  Psychiatric disorder

Universal Patient Care Protocol

Supplemental oxygen to maintain SpO2 ≥ 94 % Utilize Adult Medical Protocols Section Protocols Medical Adult Airway Protocol(s) Spinal Motion Restriction Protocol if indicated where circumstances B Blood Glucose Analysis suggest a mechanism of injury. Procedure 12 Lead EKG Procedure Carboxyhemoglobin Monitoring Procedure P Venous Access Protocol

Exit to Blood Glucose < 80 or ≥ 250? YES Diabetic Protocol NO Exit to Signs of shock / Poor perfusion? YES Hypotension/Shock Protocol Protocol NO Exit to Signs of CVA Or Seizure? YES CVA / Seizure Protocol NO Exit to Signs of OD / Toxicology? YES Overdose / Toxic Exposure Protocol NO Exit to Signs of Hypo / Hyperthermia? YES Hypo / Hyperthermia Protocol NO Exit to Arrhythmia / STEMI? YES Appropriate Cardiac Protocol NO

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Adult Medical Protocols Section 2016 ack, Extremities, Neuro. doubt exists. Recheckglucoseexists.blood after Dextrose doubt or Alcoholics frequently develophypoglycemia and may have for signs of bruising or other injury. other or bruising of signs for SSM EMS Protocols amination instructions. (314-268-4195)amination instructions. Utilize personal protective equipment. e the area and protect others.the area and protect e Altered Mental Status Mental Altered - Your safety is your top priority. is your- Your safety - Secure the scene: Isolat - Alert facility before transportation. receiving - Contact poison control fordecont unrecognized injuries. Consider restraints if necessaryfor patient's and/or personnel's restraint protection per the procedure. Be aware of altered mental status as a presenting sign of an environmental toxin or Haz-Mat exposure. It is safer to assume hypoglycemiathan hyperglycemia if RecommendedMental Exam:Skin, Heart, Status,HEENT, Lungs, Abdomen, B Glucagon. Do not let alcohol confuse the clinical picture. Pay careful attention to the head examthecareful head attention to Pay    Pearls    Adult Medical Protocols Section 2016 Exit to Diabetic Protocol Exit to Protocol Appropriate YES NO Congestiveheart failure Pericarditis Diabetic emergency Sepsis Cardiac tamponade 250? ≥

as this will cause clotting of the shunt 0.12 sec? 0.12 NO NO NO YES Differential      dressing bulky avoid but dressing Apply ≥ Or Serious Dressing must not compress fistula/ shunt 4 hours? significant hemorrhage, apply tourniquet to affected extremity far away from shunt/fistula Procedure Blood Sugar Blood If direct pressuredressing and not effective and Apply firm finger tip pressure to bleeding site <80 Peaked T wave Peaked T Cardiac Monitor QRS Signs / symptoms? Signs Hemodialysis in past B 12 Lead ECG Procedure Blood Glucose Analysis Blood Glucose Venous Access Protocol YES P B YES Exit to SSM EMS Protocols contacting Medical Control Medical contacting Edema Protocol Notify destination and consider Notify CHF / Pulmonary Hypotension Bleeding Fever imbalance Electrolyte vomiting or / and Nausea Altered Mental Status Seizure Arrhythmia for goal SBP >90 YES Signs and Symptoms Signs and         If lungs remain clear Systolic Blood Blood Systolic YES NO 50 mEq IV / IO Pressure < 90? YES Over 2 to 3 minutes3 Over 2 to Sodium Bicarbonate Calcium Gluconate 3g IV/IO) Dialysis / Renal Failure / Renal Dialysis Calcium Chloride 1 g IV/ IO Normal Saline Bolus 250 mL Max 1 Liter,Max 1 (or Repeat as needed NO P P NO NO Exit to YES Arrest? Cardiac Edema? Bleeding? 50 mEq IV/IO Shunt / Fistula CHF / Pulmonary Pulmonary CHF / Sodium Bicarbonate Appropriate protocol Calcium Chloride 1 g IV/IO Peritoneal or Hemodialysis Peritoneal Anemia Catheter access noted Shunt access noted Hyperkalemia Universal Patient Care Protocol History      P Adult Medical Protocols Section 2016 ilize a tourniquet to stop unt / fistula in place. unt / nd Lanoxicaps, regiment may cause digoxin from dialysis fistula, ut from dialysis should not be mixed. Ideally given through given through be mixed. Ideally not should patient receiving medications that include Digoxin, the dead or near-dead patient only with patient only with no other the dead or near-dead tremity which has a sh tremity which , as it may cause digoxin toxicity. SSM EMS Protocols , Neurological, Lungs, and Heart. s medical problemss Hypertension and cardiac typically. are disease away from fistula as possible. that include Digoxin ,Digitalis, Lanoxin a Dialysis / Renal Failure / Renal Dialysis separate lines. Sodium Bicarbonate and Calcium Bicarbonate Chloride / Gluconate Sodium prevalent. History of medications Digitalis, Lanoxin and Lanoxicaps regiment Always consider Hyperkalemia in all dialysis or renal failure patients. Renal dialysispatients havenumerou bleeding. Apply tourniquet as far Apply tourniquet bleeding. toxicity. Administration of Calcium Chloride is contraindicated in RecommendedMental exam: status available. if Utilize IO available access. significant hemorrhagecontrol does not local pressure If Access of shunt or dialysisindicated in catheter isof shunt or Access Do not take Blood Pressure or start IV in ex or start IV in Pressure not take Blood Do      Pearls     Adult Medical Protocols Section 2016 Protocol if indicated Protocol Appropriate if indicated if indicated CO Exposure Protocol Protocol Vasovagal Orthostatic hypotension syncope Cardiac syncope / Defecation Micturition Psychiatric Stroke Hypoglycemia Seizure Shock (see ShockProtocol) Toxicological (Alcohol) Medication effect (hypertension) PE AAA if indicated if indicated Protocol Protocol Diabetic Protocol if indicated if indicated Cardiac / Arrhythmia Cardiac / Multiple Trauma Differential              Altered Mental Status Hypotension / Shock

Spinal Motion Restriction YES YES YES

94 % ≥

2 NO NO NO Access Protocol if indicated Status? Procedure Syncope if indicated Suspected or Hypotension / SSM EMS Protocols Altered Mental

Cardiac Monitor Poor Perfusion? Evident Trauma? Airway Protocol(s) Loss of consciousness with recovery Lightheadedness, dizziness pulse or rapid slow Palpitations, Pulse irregularity Decreased blood pressure Carboxyhemoglobin maintain SpO

Monitoring Procedure Supplemental oxygen to 12 Lead ECG Procedure Blood Glucose Analysis Blood Glucose Venous Signs and Symptoms Signs and      contacting Medical Control Medical contacting Notify destination and consider Notify P B Universal Patient Care Protocol Cardiac history, stroke, seizure stroke, history, Cardiac Occult blood loss (GI, ectopic) Females: LMP, vaginal bleeding Fluid loss: nausea, vomiting, diarrhea history medical Past Medications History       Syncope Adult Medical Protocols Section Protocols Medical Adult

Pearls  Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro  All syncopal / near syncopal patients need a 12 lead EKG and to be continuously monitored. More than 25% of geriatric syncope is cardiac dysrhythmia based.  Assess for signs and symptoms of trauma and/or head injury if associated with fall or if it’s questionable whether the patient fell due to syncope.  Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope.  Syncope patients should be urged to be transported for further evaluation.

SSM EMS Protocols 2016 Back Pain

History Signs and Symptoms Differential  Age  Pain or Tenderness (paraspinous,  Muscle spasm / strain  Past medical history spinous process)  Herniated disc with nerve compression  Past surgical history  Swelling  Sciatica  Medications  Pain with range of motion  Spine fracture  Onset of pain / injury  Extremity weakness  Kidney stone  Previous back injury  Extremity numbness  Pyelonephritis  Traumatic mechanism  Shooting pain into an extremity  Aneurysm  Location of pain  Bowel / bladder dysfunction  Pneumonia  Fever  Spinal Epidural Abscess  Improvement or worsening with  Metastatic Cancer activity  AAA

Universal Patient Care Protocol

Consider Cardiac Etiology B 12 Lead ECG Procedure if indicated Appropriate Cardiac Monitor

Cardiac Protocol Section Protocols Medical Adult if indicated P as indicated Venous Access Protocol

Injury or Traumatic NO YES Mechanism?

Spine Motion Restriction Shock B NO Hemodynamic YES Protocol Instability?

Pain Control Protocol Shock P if indicated Reassess vital signs YES Hemodynamic B Instability? Monitor and Reassess every 3 - 5 minutes NO Normal Saline Bolus 500 mL IV / IO Repeat every 5 minutes to effect P Pain Control Protocol SBP ≥ 90 if indicated Maximum 2 Liters P Monitor and Reassess Airway Protocol(s) if indicated Multiple Trauma Protocol if indicated Hypotension/Shock Protocol if indicated Pain Control Protocol if indicated

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Back Pain Adult Medical Protocols Section Protocols Medical Adult

Pearls  Patients with underlying spinal deformity should be immobilized in their functional position.  Abdominal Aortic Aneurysms are a concern especially in patients over the age of 50 and / or with vascular or hypertensive disease.  Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area.  Patients with midline pain or tenderness over the spinous processes should be spinal motion restriction indicated.  Any bowel or bladder incontinence is a significant finding which requires immediate medical evaluation  In a patient with a history of IV drug abuse, fever, or prior spine surgery a spinal epidural abscess should be considered. SSM EMS Protocols 2016 Adult Medical Protocols Section

st CO 2016 and/or OD Exit to Cyanide / Carbon Monoxide Cyanide Cyanide Exposure Protocol IO / IM if indicated IntraNasal oxygenation CONSCIOUSNESS Airway Protocol(s) Naloxone 1 mg – 2 mg adequate ventilation and Simultaneously utilize NOT GIVEN TO RESTORE Additional doses may be given IV / dose. Naloxone is titrated to effect IntraNasal route is preferred for 1 Hypotension/ Shock Protocol WMD Exit to Protocol P Tricyclic antidepressants (TCAs) Acetaminophen (Tylenol) Aspirin Depressants Stimulants Anticholinergic medications Cardiac Solvents, Alcohols, Cleaning agents Insecticides (organophosphates) Nerve Agent / Organophosphate Differential          YES NO NO OD QRS YES 94 % Tricyclic ≥ 0.12 sec?

< 0.12sec 2 ≥ Repeat 50mEq 50mEq Repeat Antidepressant every 5 minutes 50-150 mEq IV / IO NO NO Until QRS narrows to contacting Medical Control Medical contacting YES Access Protocol Sodium Bicarbonate potential cause Notify destination and consider Notify SSM EMS Protocols Mental status changes Hypotension / hypertension Decreased respiratory rate Tachycardia, dysrhythmias Seizures S.L.U.D.G.E. D.U.M.B.B.E.L.S Cardiac Monitor P Systolic BP < 90? Signs and Symptoms Signs and        Carboxyhemoglobin maintain SpO Altered Mental Status? Monitoring Procedure Adequate Respirations / Supplemental oxygen to Consider 12 Lead ECG Procedure Oxygenation / Ventilation? with serious signs / symptoms Venous Universal Patient Care Protocol OD

Blocker P B B YES Calcium Channel Overdose / Toxic Ingestion / Toxic Overdose IV / IO IV / May repeat if no response no if Over 3 minutes early for severe cases Protocol OD External Pacing Procedure Calcium Chloride 1g IV / IO Dopamine 5 – 20 mcg/kg/min (Or Calcium Gluconate(Or IV/IO) 3g Ingestion or suspected ingestion of a potentially toxic substance Substance ingested, route, quantity ingestion Time of criminal) accidental, (suicidal, Reason Available medications in home medications history, medical Past Beta Blocker Simultaneously utilize Altered Mental Status I P P History       Adult Medical Protocols Section 2016 Abdomen, Extremities, Neuro ontrol early (314-268-4195) vice as certain critically ill overdose patients may quickly

should be considered a HIGH RISK Refusal. RISK HIGH a considered be should SSM EMS Protocols CONTACT MEDICAL CONTROL MEDICAL CONTACT us, Skin, HEENT, Heart, us, Skin, HEENT, Lungs,Heart, contain 2 mg of Atropine and 600 mg of pralidoxime inan autoinjector for self administration or dysrhythmias and mental status changes has any weapons. initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure increased HR, increased temperature, dilated pupils, mental status changes Overdose / Toxic Ingestion / Toxic Overdose decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils non-specific respirations, decreased temperature, decreased BP, decreased HR, decreased increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils increased HR, increased BP, increased temperature, dilated pupils, seizures pupils, dilated temperature, increased BP, increased HR, increased nausea, coughing, vomiting, and mental status changes Contact Missouri Poison C Missouri Contact

: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal Renal later. occur may status mental altered and Tachypnea vomiting. and pain abdominal of consist signs Early : further care and transport, Any suspected Overdose that becomes alert and orientated and wishes to refuse and wishes orientated alert and becomes that Overdose suspected Any Recommended Exam: Mental Stat Insecticides: Overdose or Toxin patients with significant ingestions/exposures should be monitored very closely and aggressively treated as indicated. Do not hesitate to contact medical control for ad overwhelm medication supplies. For example, patients with a tricyclic overdose with a wide QRS and altered mental status with patients improvement; clinical and QRS narrowing until boluses bicarbonate sodium multiple receive should organophosphate toxicity with SLUDGE syndrome may require more atropine than is usually carried on the ambulance. Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or Aspirin dysfunction, liver failure, and or cerebral edema among other things can take place later. Depressants: Stimulants: Anticholinergic: Solvents: Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. Nerve Agent Antidote kits Bring pill bottles, contents, emesis to the emergency department. S.L.U.D.G.E: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis D.U.M.B.B.E.L.S:Urination, Diarrhea, Miosis, Bradycardia,Bronchorrhea,Emesis, Lacrimation,Salivation. Tricyclic: 4 major areas of toxicity: decreased mental status, dysrhythmias, seizures, hypotension, then coma and death. death. to status mental alert from progression a rapid be may There Acetaminophen: Cardiac Medications: patient care. These kits may be available as part of the domestic preparedness for Weapons of Mass Destruction. Pearls                  Adult Medical Protocols Section 2016 90 ≥ NO NO NO NO Exit to Etiology? Protocol Improving? Procedure MaximumL 2 Abdominal Pain? Signs / Symptoms Repeat as needed Titrate to SBP Suggesting Cardiac Nausea / Vomiting? / Nausea Hypotension / Shock Blood Glucose Analysis Blood Glucose Normal Saline Bolus 500 mL Venous Access Protocol B YES P YES YES YES CNS (increased pressure, headache, stroke, CNS lesions, trauma or vestibular) hemorrhage, infarction Myocardial Drugs (NSAID's, antibiotics, narcotics, chemotherapy) disorders Renal or GI Diabetic ketoacidosis Gynecologic disease (ovarian cyst, PID) influenza) (pneumonia, Infections Electrolyte abnormalities Food or toxin induced abuse or Substance Medication Pregnancy Psychological YES Differential             s / Symptomss / IV / IO IV / Protocol if indicated if indicated IM / IV / IO as indicated May subsitute Appropriate or, but not both perfusion, shock? Hypotension, poor Adult Pain Control Ondansetron 4 mg Carboxyhemoglobin Appropriate Protocol Monitoring Procedure Cardiac Protocol(s) Metoclopramidemg 10 Serious SignSerious May repeat x1 in 15 minutes Ondansetron8 mgODT x1 SSM EMS Protocols contacting Medical Control Medical contacting Notify destination and consider Notify P B Universal Patient Care Protocol Abdominal Pain? Character of pain (constant, intermittent, sharp, dull, etc.) Distention Constipation Diarrhea Anorexia Radiation NO YES YES       Associated symptoms: (Helpful to localize source) Fever, headache, blurred vision, weakness, malaise, myalgias, cough, headache, dysuria, mental status changes, rash  Signs and Symptoms Signs and YES YES Vomiting and Diarrhea and Vomiting NO NO NO NO Normal Saline Etiology? Improving? Procedure Bolus 500 mL Abdominal Pain? Then 150 mL / hr Signs / Symptoms Suggesting Cardiac Nausea / Vomiting? / Nausea Consider Blood Glucose Analysis Blood Glucose Normal Saline Bolus 500 mL Age Time of last meal movement/emesis bowel Last Improvement or worsening with food or activity problem of Duration Other sick contacts history medical Past Past surgical history Medications Menstrual history (pregnancy) history Travel / diarrhea emesis Bloody Venous Access Protocol B P P History             Vomiting and Diarrhea Adult Medical Protocols Section Protocols Medical Adult

Pearls  Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro  The use of metoclopramide (Reglan) may worsen diarrhea and should be avoided in patients with this symptom.  Isolated vomiting may be caused by pyloric stenosis (in pediatrics), bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures).

SSM EMS Protocols 2016 Adult Pain Control

History Signs and Symptoms Differential  Age  Severity (pain scale)  Per the specific protocol  Location, Duration  Quality (sharp, dull, etc.)  Musculoskeletal  Severity (1 - 10)  Radiation  Visceral (abdominal)  If child or non-verbal use Wong-  Relation to movement, respiration  Cardiac Baker faces scale  Increased with palpation of area  Pleural / Respiratory  Past medical history  Neurogenic  Pregnancy Status  Renal (colic)  Drug Allergies and Medications

Enter from Protocol based on Specific Complaint

**MUST call for orders** P Ketamine for pain control: 0.02 mg/kg IV / IO / IM / IntraNasal Assess Pain Severity Use combination of MOI, injury or illness severity, circumstances, and pain scale. Adult Medical Protocols Section Protocols Medical Adult Anticipated difficult IV access? NO

P Venous Access Protocol YES

Fentanyl 1 mcg/kg IV / IO / IM initial dose Max initial dose 100 mcg, Consider give SLOW over 2-3 mins. Fentanyl 2 mcg/kg IntraNasal P OR P Max initial dose 100 mcg Morphine 0.1 mg/kg IV / IO / IM initial dose attempt Max initial dose 10mg, Venous Access Protocol give SLOW over 2-3 mins.

Continuously monitor respiratory status with SpO2 P st Supplemental oxygen to 10 minutes after 1 dose May repeat Morphine 2 mg IV / IO / IM maintain SpO2 ≥ 94 % every 5 minutes as needed until improvement. Does the patient Maximum total dose 20 mg P NO show signs of OR YES May repeat Fentanyl 25 mcg IV / IO / IM sedation? every 10 minutes as needed until - open airway chin lift / jaw thrust improvement. B - nasal airway Maximum total dose 200 mcg - bag - valve mask (BVM) Capnography Procedure Consider P Narcan 0.4 mg IV / IO Consider Cardiac Monitor OR P Monitor and Reassess Narcan 0.8 mg IntraNasal Vital signs and pain scale every 5 minutes following narcotic dose

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Pain Control: Adult Adult Medical Protocols Section Protocols Medical Adult

Pearls  Recommended Exam: Respiratory Status, Mental Status, Area of Pain, Neuro.  Pain severity (0-10) is a vital sign to be recorded before and after PO, IV, IO, IM or IN medication delivery and at patient hand off. Monitor Bp to be >90 and respirations closely as sedative and pain control agents may cause hypotension and/or respiratory depression.  Patients may display a wide variation of response to opioid pain medication (Morphine and Fentanyl, aka “narcotics”). Consider the patient’s age, weight, clinical condition, other recent drugs or alcohol, and prior exposure to opiates when determining initial opioid dosing. Weight-based dosing may provide a standard means for dose calculation, but does NOT predict patient response. For example, minimal doses of opioids may cause respiratory depression in the elderly, opiate naïve, and possibly intoxicated patients.  DO NOT administer opioids together with benzodiazepines; this combination results in a deeper level of anesthesia with a significant risk for airway and respiratory compromise.  All patients receiving pain medications shall have continuous pulse oximetry monitoring. All patient showing signs of sedation after pain medication such as lethargy, slowing respirations must be placed on continuous end tidal CO2 capnography if available.

 Vital signs should be obtained before, every 5 minutes after, and before patient hand off with all pain medications.  All patients who receive ANY pain medications must be transported.  Burn patients may require higher than usual opioid doses to effect adequate pain control. IF AN ADULT PATIENT HAS SUFFERED BURNS THAT REQUIRE TRANSPORT TO A BURN CENTER, THE MAXIMUM TOTAL DOSE OF FENTANYL is 300mcg AND THE MAXIMUM TOTAL DOSE OF MORPHINE IS 50mg. Do not hesitate to contact medical control regarding the pain management strategy for patients in severe pain despite medications or with significant burns.

SSM EMS Protocols 2016 Obstetrical Protocols Obstetrical Protocols Section Protocols Obstetrical

Section Table of Contents

Obstetrical Emergencies Childbirth/Labor Newly Born

SSM EMS Protocols 2016 Obstetrical Emergency

History Signs and Symptoms Differential  Past medical history  Vaginal bleeding  Pre-eclampsia / Eclampsia  Hypertension meds  Abdominal pain  Placenta previa  Prenatal care  Seizures  Placenta abruptio  Prior pregnancies / births  Hypertension  Spontaneous abortion  Gravida / Para  Severe headache  Visual changes  Edema of and face

Universal Patient Care Protocol

Exit to Known or suspected NO Appropriate Protocol pregnancy / missed period? YES

Consider Blood Glucose Analysis Diabetic Protocol B Procedure Left lateral recumbant position Obstetrical Protocols Section P Venous Access Protocol

NO Vaginal Bleeding / Abdominal Pain? YES

Hypertension? NO Exit to Childbirth YES Labor? YES Protocol NO NO Seizure Activity? YES YES Seizure Activity?

Magnesium Sulfate 4 g IV / IO NO Over 2 – 3 minutes P For persistent seizure after 5-10 minutes, May repeat 2 g MAGNESIUM is the PRIORITY for Exit to PREGNANT SEIZURE. Abdominal Pain If patient remains seizing with EMS, or Hypotension / NO Midazolam 5 mg IntraNasal / IM Appropriate Poor Perfusion / Shock? or 2.5 mg IV / IO Protocol in addition to Magnesium YES May repeat every 3 to 5 minutes for continued seizure activity Normal Saline Bolus P Max 20 mg of Midazolam 1000 mL IV / IO P Repeat as needed to effect If Midazolam not available: SBP ≥ 90 Diazepam 5 mg IV / IO or Maximum 2 L Lorazepam 2-4mg IM / IV / IO Repeat 2 mg every 3 to 5 minutes for Exit to continued seizure activity, Max 10mg Hypotension / Shock NO Improving? Protocol Cardiac Monitor YES

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Obstetrical Emergency Obstetrical Protocols Section Protocols Obstetrical

Pearls  Recommended Exam: Mental Status, Abdomen, Heart, Lungs, Neuro  Severe headache, vision changes, or RUQ pain may indicate preeclampsia.  In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure.  Maintain patient in a left lateral position to minimize risk of supine hypotensive syndrome, which may occur as the fetus gets large enough to compress the vena cava.  Ask patient to quantify bleeding - number of pads used per hour.  Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation. Greater than 20 weeks generally require several hours of fetal monitoring. DO NOT suggest that the patient needs an ultrasound.  Magnesium may cause hypotension and decreased respiratory drive.  A patient who is pregnant and seizing should be presumed to have eclampsia, a true medical emergency. Magnesium administration should be a priority in these patients. However, IntraNasal benzodiazepines may be given first due to rapidity of IntraNasal administration. For crews with two ALS providers, one provider should administer IntraNasal benzodiazepine while the other provider establishes IV access for Magnesium.  Do not delay IntraNasal administration of Midazolam with difficult IV or IO access.

SSM EMS Protocols 2016 Obstetrical Protocols Section NO 2016 Go to Go Protocol Delivery? Newly Born Abnormal Crowning presentation? Protocol Obstetrical as indicated Emergency Childbirth Procedure >36 WeeksGestation Buttock Hand Abnormal presentation Abnormal Prolapsed cord previa Placenta placenta Abruptio YES B YES Differential     Transport deliveryimminent Do Not Pull Breech Birth Encourage Mother to refrain from pushing Unless Support Presenting Parts B NO additional resources Crowning at relieve Inspect Perineum Spasmodic pain Vaginal discharge or bleeding Crowning or urge to push Meconium recumbent position Multiple gestation Expedite transport Priority symptoms: for multiple gestation High risk pregnancy <36 weeks gestation weeks <36 (No digital vaginal exam) vaginal digital (No contacting Medical Control Medical contacting Placepatient in Leftlateral Hypertension / Hypotension / Hypertension     Signs and Symptoms Signs and Abnormal Vaginal Bleeding / over cord SSM EMS Protocols Consider Notify destination and consider Notify Venous Access Protocol Hips elevated Hips knees to chest Saline dressing vagina to Insert fingers into pressure on cord B Universal Patient Care Protocol P B B Prolapsed Cord Shoulder Dystocia B Childbirth / Labor Childbirth from face part of infant. No Crowning Lateral Position Unable to Deliver Transport in Knee to to Knee in Transport Place 2 fingers along along 2 fingers Place Chest Position or LeftChest Position or supporting presenting Create air passage by by passage air Create Monitor and Reassess and Monitor duration of contractions side nose and push away Document frequency and Due date Time contractions started / how often Rupture of membranes Time / amount of any vaginal bleeding Sensation of fetal activity Past medical and delivery history Medications Gravida / Status Para High Risk pregnancy B History          Childbirth / Labor Obstetrical Protocols Section Protocols Obstetrical

APGAR SCORE SIGN 0 1 2 1 min. 5 min. Heart rate Absent < 100 > 100

Respiratory rate Absent Weak, irregular Good, crying

Muscle tone Flaccid Arms and legs flexed Well flexed

Reflex irritability No response Grimace Cough or sneeze

Skin color Blue, pale Hands and feet blue Completely pink

TOTAL SCORE

Pearls  Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro  Document all times (delivery, contraction frequency, and length).  If maternal seizures occur, refer to the Obstetrical Emergencies Protocol.  After delivery, massaging the uterus (lower abdomen) will promote uterine contraction and help to control post- partum bleeding.  Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.  Record APGAR at 1 minute and 5 minutes after birth.

SSM EMS Protocols 2016 Pediatric/Obstetrical Protocols Section 2016 94 % ≥ score needed Maintain warmth Supplemental Oxygen Monitor and Reassess and Monitor Maintain SpO2 May repeatx 1 YES 10 mL / kg IV / IO Monitor and Reassess and Monitor 0.01 mg/kg IV / IO Secretions drive Respiratory Clear airway if necessary Normal Saline Bolus Epinephrine 1:10,000 Provide warmth / Dry infant Every3 to 5 minutes as Document 1 and 5 min APGAR Airway failure Infection Maternal medication effect Hypovolemia Hypoglycemia Congenitaldisease heart Hypothermia Labored breathing / B Persistent Cyanosis? B P Differential        APGAR score YES NO NO Documentmin1 and 5 YES < 100 NO YES YES YES

CPR Procedure BVM Ventilations SSM EMS Protocols Cardiac Monitor Term Gestation, BVM Ventilations Heart Rate < 60? Heart Rate < 60? Heart Rate Heart Rate < 100? Breathing or Crying, Good Muscle Tone? Muscle Good Newly Born Newly down algorithm to intubation Warm, Dry and Stimulate Clear airway if necessary Capnography Procedure If repeating cycle take corrective Agonal breathing or Apnea? Pulse Oximetry Procedure Respiratory distress Respiratory Peripheral cyanosis or mottling (normal) (abnormal) cyanosis Central responsiveness of level Altered Bradycardia action: Change in position or BVM position in Change action: Venous Access Protocol Technique.If no improvement move Pediatric Airway Protocol(s) P B      Signs and Symptoms Signs and B contacting Medical Control Medical contacting P B B NO Notify destination and consider Notify NO Exit to Suctioning Protocol undergo: substance abuse epinephrine. (<50 mg/dL) (<50 Care of mother Direct Endotracheal recommended ifBVM is needed. ventilations / BVM, Suction only when Pediatric Diabetic Due date and gestational age etc.) (twins gestation Multiple Meconium Delivery difficulties disease Congenital (maternal) Medications Maternal risk factors Airway Suctioning Meconium present: Appropriate Protocol and / or hypoglycemiaand Clear amniotic fluid: compressions and / or or / and compressions newborn is no longer longer no is newborn Most newborns requiring If not responding consider Routine suctioning of the resuscitation will respond to to respond will resuscitation P hypovolemia, pneumothorax History        Non-vigorous newborns may obstruction is present and / or Pediatric/Obstetrical Protocols Section 2016 5 min. 1 min. 2 > 100 Well flexed Good, crying TOTAL SCORE TOTAL Completely pink Completely Cough or sneeze muscle tone generally will need no resuscitation. no will need generally tone muscle APGAR SCORE dial pulse followed palpation of the umbilical pulse. palpationdial pulse followedof 1 < 100 Grimace (Naloxone NO LONGER recommended-supportive(Naloxone NO care only). Weak, irregular Handsblue and feet Arms andlegs flexed SSM EMS Protocols Newly Born Newly Following birth at 1 minute = 60 - 65 %, 2 minutes = 65 – 70%, 65 – 2 minutes= 60 - 65 %, minute = 1 birth at Following 0 Absent Absent Flaccid Blue, pale No response SIGN 3 minutes = 70 – 75 %, 4 minutes = 75 – 80 %, 5 minutes = 80 – 85 % and 10 minutes = 85 – 95%. Skin color Heart rate Muscle tone Consider hypoglycemiain infant. Normal Saline)ml of D50 with 4 ml of (1D50 diluted D10 = Documentand 5 minutein PCR 1 APGARs CPR in newbornsCPR is 100 compressions/minute witha 15-1 compression toventilation ratio. It is extremely important to keep infant warm Maternalsedation or narcotics will sedate infant Transport mother infant when atWITH all possible. good with and breathing cry / strong Term gestation, RecommendedMental Exam:HEENT, Neck, Chest, Heart, Status,Skin, Abdomen, Extremities, Neuro Most important in vital signs the newly born are respirations / respiratory effort and heart rate. Heartbestassessed rate by auscultation of theprecor Expected pulse oximetry readings: Reflex irritability Respiratory rate         Pearls     Pediatric Cardiac

Section Table of Contents Adult Cardiac Protocols Section Protocols Cardiac Adult

Pediatric Cardiac Arrest Pediatric V‐Fib/Pulseless V‐Tach Pediatric Asystole/PEA Pediatric Post Resuscitation Pediatric Tachycardia Pediatric Bradycardia

Pediatric CHF/Pulmonary Edema

SSM EMS Protocols 2016 Pediatric Cardiac Protocols Section 2016

and

YES Exit to Protocol(s) as indicated

Pulseless VT Pulseless Pediatric VF / TIME

Exit to Exit to Pediatric Airway Protocol Go to ANY (ROSC)

Protocol Return of Adult Cardiac Arrest Newly Born Protocol AT Rhythm? Post Resuscitation Shockable Shockable Spontaneous Circulation Foreign body, Secretions, Infection (croup,epiglotitis) and NO Exit to YES Pediatric Respiratory failure (dehydration) Hypovolemia Congenitaldisease heart Trauma Tension pneumothorax, cardiac tamponade, pulmonary embolism Hypothermia Toxin or medication Electrolyte abnormalities (Glucose, Potassium) Acidosis Protocol(s) as indicated Asystole / PEA ) Pediatric Airway YES YES Differential          5 seconds ≤ 100 / min) 31 days old? ≥ ≤ NO NO NO if available 16 years old? ALS Available? ≥ CPR Procedure SSM EMS Protocols Review DNR Form? Push Fast ( Unresponsive Cardiac arrest Protocol(s) Newly Born / Shock Delivery Shock CPR Procedure Pediatric Airway YES (Limit interruptions to   Signs and Symptoms Signs and 5 Cycles / 2 Minutes5 Cycles/ 2 Reassess, then repeat Universal Patient Care Protocol NO Change Compressors every 2 minutes Defibrillation:Procedure Automated Push Hard (1.5" Infant / 2" in Children) Criteria for Death / No Resuscitation B B YES Pediatric Cardiac Arrest Cardiac Pediatric Rhythm? Shockable Shockable contacting Medical Control Medical contacting

Notify destination and consider Notify NO Exit to and/or Protocol(s) Protocol Rigor mortis CPR Procedure Pediatric Airway Decomposition or any signsor any of: 5 Cycles / 2 Minutes DO NOT BEGIN DO NOT BEGIN RESUSICATION Dependent lividity Reassess, then repeat Deceased Persons Deceased Time of arrest Time of Medical history Medications Possibilityof foreign body Hypothermia Injury incompatible with life B Traumatic arrest with asystole History      Pediatric Cardiac Protocols Section 2016 re. Make room ions and ed limited interrupt er of chest, in infants 1.5 of chest, er AD first to limit interruptions. able and / or difficult IV accessdifficult IV or able and / frequently, after every move, and at transfer of ca 2 inuous compressions with pproach assigningresponders to predetermined tasks. rrests. This should be accomplished quickly with BVM or This should be accomplishedBVM quicklyrrests. with 1/3 anterior-posterior diamet ≥ ch. s, a cause must be identified and corrected. SSM EMS Protocols place endotracheal tube. Consider BI onsider early IO placement if avail Ventilate 8 – 10 breaths per minute with continuous, uninterrupt continuous, with minute per 8 – 10 breaths Ventilate

tube placement and EtCO Arrest Cardiac ediatric P interrupt compressions to to interrupt compressions defibrillation when indicated. Compress rk. Utilize Team Focused “Code Commander” A sess and document ET sess and document orderpediatric to be successfularrest in to wo compressions. Do not Team Focused Approach / Pit-Crew Approa BIAD supraglottic device. Patient survival is properonoften dependentAirway ventilation / and oxygenation Interventions. Successplanning is based on properexecution.and Procedures require space and patient access. Airway is a more important intervention in pediatric a anticipated. DO NOT HYPERVENTILATE: Reas early Recommended Exam:Mental Status quality and cont at high should be directed Efforts inches and in children 2 inches. C in children 2 inches. inches and In       Pearls    Pediatric Cardiac Protocols Section 2016

YES Exit to Protocol Torsades May repeat de Pointes? Max dose 2 g every 5 minutes 40 mg/kg IV / IO Given2 min. over Post Resuscitation Magnesium Sulfate readydefibrillate. to Continuous CPR untilContinuous CPR device is charged anddevice is charged P DO NOT DO NOT DELAY SHOCK YES 10 J/kg 10 J/kg Respiratory failure / Airway obstruction hypokalemiaHyper / Hypovolemia Hypothermia Hypoglycemia Acidosis Tension pneumothorax Tamponade Toxin or medication Thrombosis: Coronary / Pulmonary Embolism Congenitaldisease heart Zoll Zoll 4 J/kgZoll 4 2 J/kgZoll 2

, , Differential            , , max dose 2 g 4 J/kg 2 J/kg 10 J/kg 10 J/kg (5 cycles / 2 min.) (5 cycles / 2 min.) (5 cycles / 2 min.) NO Access Protocol Physio Physio Physio Physio

, , , , 40 mg/kg IV / IO 20 mL/kg IV / IO Max dose 100Max mg dose Magnesium Sulfate Normal Saline Bolus Repeat every 3 to 5 min

Max total doseMax3 mg/kg total Max initial dose 300 mg Max dosetotal 15 mg/kg Lidocaine 1 mg/kg IV / IO Venous 4 J/kg 2 J/kg IV / IO Max 1 mg each dose Amiodarone 5 mg/kg IV / IO Pediatric Airway Protocol(s) 10 J/kg 10 J/kg Repeat 0.5 mg/kg every 5 min contacting Medical Control Medical contacting Manual Defibrillation Procedure Manual Defibrillation Procedure Manual Defibrillation Procedure Manual Defibrillation Procedure CPR Procedure CPR Procedure CPR Procedure Return of Spontaneous Circulation? Spontaneous of Return Epinephrine (1:10,000mg/kg) 0.01 Notify destination and consider Notify May repeat as needed maxmL/kg 60 SSM EMS Protocols May repeat every 5 min Repeat dose every 5 min (up to 3 times) Philips Philips Philips Philips Unresponsive P P P P B B B Cardiac Arrest Signs and Symptoms Signs and  Ventricular Fibrillation Ventricular ediatric P Pulseless Ventricular Tachycardia Ventricular Pulseless

TIME

Go to ANY (ROSC)

Protocol Return of AT Arrest Protocol Post Resuscitation Pediatric Cardiac Spontaneous Circulation Airway obstruction Airway Hypothermia Past medical history medical Past Medications Existence of terminal illness Events leading to arrest Estimated downtime      History   Pediatric Ventricular Fibrillation Pulseless Ventricular Tachycardia Pediatric Cardiac Protocols Section

Defibrillation dose PEDIATRIC 2 J/KG, 4 J/KG, 10 J/KG 2 J/KG, 4 J/KG, 10 J/KG 2 J/KG, 4 J/KG, 10 J/KG manufacturer PHILIPS PHYSIO ZOLL

Pearls  Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. Compress ≥ 1/3 anterior-posterior diameter of chest, in infants 1.5 inches and in children 2 inches. Consider early IO placement if available and / or difficult IV access anticipated.  DO NOT HYPERVENTILATE: Ventilate 8 – 10 breaths per minute with continuous, uninterrupted compressions.  Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions.  If no IV / IO access may use Epinephrine 1:1000 0.1 mg/kg (0.1 mL/kg) via ETT (Maximum 10 mg)  Airway is a more important intervention in pediatric arrests. This should be accomplished quickly with BVM or supraglottic device. Patient survival is often dependent on proper ventilation and oxygenation / Airway Interventions  In order to be successful in pediatric arrests, a cause must be identified and corrected.  Respiratory arrest is a common cause of cardiac arrest. Unlike adults early ventilation intervention is critical.  In most cases pediatric airways can be managed by basic interventions and/or BVM.  Reassess and document ET tube placement and EtCO2 frequently, after every move, and at transfer of care.  In order to be successful in pediatric arrests, a cause must be identified and corrected.

SSM EMS Protocols 2016 Pediatric Cardiac Protocols Section 2016 )

TIME

Go to ANY (ROSC)

Protocol Return of AT Reversible Causes Reversible Post Resuscitation Hypovolemia Hypoxia (acidosis) ion Hydrogen Hypothermia / Hyperkalemia Hypo Hypoglycemia Tension pneumothorax Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) Thrombosis; coronary (MI) Maximum 10 mg Spontaneous Circulation

Respiratory failure body Foreign Hyperkalemia Infection (croup, epiglotitis) (dehydration) Hypovolemia Congenitaldisease heart Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis

via ETT ( via ETT )  Differential             5 seconds Max 60 mL/kg ≤ 100 / min) ≥ NO NO t. Unlike adults early airway interventionUnlike adults early airway is critical. t. Procedure Resuscitation (1.5" Infant / 2" in Children) Cardiac Monitor Arrest Protocol CPR Procedure 20 mL/kg IV / IO Pediatric Cardiac Shockable Rhythm? Shockable Review DNR Form? Normal Saline Bolus Chest Decompression-Needle Epinephrine 1:10,000 Criteria for Death / No

Venous Access Protocol Push Fast ( (0.1 mL / kg of 1:10,000) Repeat every 3 – 5 minutes 0.01 mg/kg IV / IO (max 1mg) contacting Medical Control Medical contacting Search for Reversible Causes s, a cause must be identified and corrected. (Limit interruptions to SSM EMS Protocols Notify destination and consider Notify Blood Glucose Analysis Procedure Blood Glucose May repeat as needed Change Compressors every 2 minutes Push Hard Consider Pediatric Airway Protocol(s) YES P B Unresponsive Cardiac Arrest Signs of lividity or rigor P P B   Signs and Symptoms Signs and  YES Epinephrine 1:1000 0.1 mg/kg (0.1 mL/kg) Pediatric Asystole / PEA / Asystole Pediatric

Exit to and/or Protocol Exit to Rigor mortis Decomposition or any signsor any of: DO NOT BEGIN DO NOT BEGIN RESUSICATION Dependent lividity Deceased Persons Deceased Airway obstruction Airway Hypothermia Suspected abuse; shaken baby syndrome, pattern of injuries SIDS Past medical history medical Past Medications Existence of terminal illness Events leading to arrest Estimated downtime Respiratorycommonof arrest causearres cardiac is a In most cases pediatric airways can be managed by basic interventions. may use If access no IV / IO In orderpediatric successful to be In arrest in Consider Early for PEA Injury incompatible with life Appropriate Protocol Traumatic arrest with asystole    Pearls         History   1. Repeated Saline Boluses for possible hypovolemia 2. Dextrose IV/IO 3. Naloxone IV/IO 4. Glucagon IV/IO/IM, OD protocol for suspected beta blocker or overdose. blocker channel calcium 5. Calcium Chloride IV/IO for hyperkalemia, suspected hypocalcemia 6. Sodium Bicarbonate IV/IO for possible overdose, hyperkalemia, failure renal Consider7. Epinephrine drip Consider8. Dopamine drip 9. Chest Decompression Pediatric Cardiac Protocols Section 2016 < 60 mmHg< 60 mmHg< 70 0 – 28 Days Age Based 1 to 10 Years Hypotension 1 Month to 1 Year 11 Years and older < 90 + ( 2 x age) mmHg < 70 + ( 2 x age) mmHg to address specific

Pediatic Pediatic Diabetic Protocol Protocol Protocol Pediatric Bradycardia Tachycardia NO Continue differentials associated withthe original dysrhythmia Differential  YES YES YES 35 – 45 mmHg contacting Medical Control Medical contacting 2 Notify destination and consider Notify in place? on and oxygenation Definitive airway NO 250? NO NO NO of 90-99% if indicated 2 Age based? Hypotension Symptomatic Symptomatic Bradycardia? Tachycardia? <70 or ≥ or <70 Blood Glucose Blood ost Resuscitation ost Cardiac Monitor YES of pulse P 12 Lead ECG Procedure Optimize ventilati Repeat Primary Assessment Primary Repeat Monitor Vital Signs / Reassess SSM EMS Protocols Return Remove impedance threshold device airway Advanced Maintain an SpO DO NOT HYPERVENTILATE Ventilation rate to maintain EtCO      YES  Signs/Symptoms P P B atus, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro Heart, Lungs, Neck, Skin, atus, ediatric ediatric P

and Sedation / Paralysis IV / IO arrest Max total doseMax150 total mcg 20 mL/kg IV / IO Fentanyl 2 mcg/kg IV / IO (max initial dose 75 mcg) From Max total 60 mL/kg Max total 60 Consider Normal Saline Bolus Protocol after ROSC appropriate blood pressure blood appropriate follow Rhythm Dopamine 2-20 mcg/kg/min May repeat x 1 in 3 -5 minutes if needed Titrate any pressor drugs to age May repeat if lungs remain clear Use only with definitive airway in place If arrhythmiapersists Appropriate Arrest Appropriate Protocol and usually self limiting limiting self usually and May repeat 0.5 mcg/kg every 5 min as needed Arrhythmias are common Midazolam 0.1 – 0.2 mg/kg IV / IO (max 5mg) Hyperventilation is a significant cause of hypotension / recurrence of cardiac arrest in post resuscitation phase and must be avoided at all costs. Recommended Exam: Mental St Respiratory Respiratory Cardiac arrest P P  Pearls  History   Pediatric Cardiac Protocols Section YES 2016

Exit to arrhythmia 12 Lead ECG not Cardiac arrest: Over 2 minutes diagnose and treat Appropriate Protocol Over 10 minutes when patient is stable. 40 mg/ kg IV / IO necessary to diagnose and treat, but preferred Magnesium Sulfate Single lead ECG able to or Torsades de pointes NO non-escalating 1 J/kg, 2 J/kg Procedure 2 J/kg P Heartdisease (Congenital) / Hyperthermia Hypo or Anemia Hypovolemia imbalance Electrolyte Anxiety / Pain / Emotional stress Fever / Infection / Sepsis Hypoxia Hypoglycemia Medication / Toxin / Drugs (see HX) embolus Pulmonary Trauma Pneumothorax Tension Physio: Philips:1 J/kg,J/kg 2 (max total dose(max 5 mg) Zoll: Consider sedationpre-shock Differential             Probable Sinus Tachycardia? Sinus Probable Midazolam 0.1 mg/kg / IO IV oncein 3 -5 minutes if needed Synchronized Cardioversion (max dose 2.5 mg) may repeat Midazolam 0.2 mg/kg IntraNasal Adenosine P Amiodarone 5 mg/kg IV / IO Max dose 6 mg Over 20 Minutes Max150 dose mg 0.1 mg / kg IV / IO has history of WPW Consider

If no history of WPW If no response,or patient P P Infant > 220/bpm YES tachycardias Rhythm Converts? treating STABLE 12 Lead ECG Procedure SSM EMS Protocols contacting Medical Control Medical contacting Heart Rate: Child Heart Rate: > 180/bpm Cyanosis or Pale Diaphoresis Tachypnea Vomiting Hypotension Consciousness of Level Altered Congestion Pulmonary Syncope Contact Medical Control to discuss pharmacologically YES Notify destination and consider Notify B Signs and Symptoms Signs and          May repeat Adenosine Adenosine Max6 mg dose Amiodarone Max dose 12 mg Vagal Maneuvers If no response 0.2 mg / kg IV / IO 5 mg/kg IV / IO Over 20 Minutes Max dose 150 mg Probable SVT? 0.1 mg/kg IV / IO rapid push Pediatric Tachycardia Pediatric P P NO Access Protocol NO 0.09 seconds? ≥ nous Cardiac monitor QRS Ve HR Typically > 180 Child HR Typically > 220 Infant

12 Lead EKG Procedure Universal Patient Care Protocol Exit to Go to (Aminophylline, Diet pills, Thyroid supplements, Digoxin) Decongestants, Unstable / Serious Signs and Symptoms? P B Pulseless Tachycardia? Probable Sinus Past medical history medical Past Medications or Toxic Ingestion Drugs (nicotine, cocaine) Congenital Heart Disease Respiratory Distress Syncope or Near Syncope Identify and Treat Underlying Cause Underlying Arrest Protocol AT ANY TIME Appropriate Protocol Pediatric Pulseless History       Pediatric Cardiac Protocols Section 2016 ZOLL 2 J/kg each therapeutic intervention. 0.09 seconds.) P waves0.09 seconds.) absentP or abnormal.R- PHYSIO ≤ 1 J/kg,2 J/kg rmal to > 200 / minute. Most children with VT havechildren with VT Most 200 / minute. rmal to > ves. Infants usually < 220 beats / minute. ChildrenInfantsminute.ves. usually 220 beats / < child blow out “birthday candles” or through an ng, Heart, Abdomen, Back, Neuro Extremities, obtain monitor strips with associated if Diazepam or Midazolam is used. or Broselow-Luten color Purple if available.or Broselow-Lutenif color Purple gnesaemia, many hypokalemia, cardiac drugs. rate is 220 – the patient’s the age inyears.220 – rate is SSM EMS Protocols hic (multiple shaped) Tachycardia: hic (multiple 0.09 seconds): ≤ 0.09 seconds): PHILIPS ≥ 1 J/kg, 2 J/kg rapid, weak pulse Pediatric Tachycardia Pediatric underlying heart disease / cardiacdiseaseunderlyingcardiomyopathy.long QT syndrome surgery / heart / / Breath holding. Blowing a glove into a balloon. Have to occludeobstructedovernot carefulfaceupper theMay put a bag of ice water straw. Infants: half of the the airway. SVT with aberrancy. VT: Uncommon in children. Rates may vary from near no minute.250 beats / typicallyRate is150 to Associated with long QT syndrome, hypoma Sinuswaves tachycardia:R-R wa present.P Variable usually minute.180 beats / < ( QRS narrow have a will with SVT children 90 % of > SVT: deteriorateMay quicklyVT. to Respiratory distress / failure. with or without / poor hypotension. perfusion Signs of shock Altered Mental Status Sudden collapse with R waves not variable. Usually abrupt onset. Infants usually > 220 beats / minute. Children usually > 180 beats / minute. Atrial Flutter / Fibrillation PEDIATRIC manufacturer Torsades de Pointes / Polymorp Separating the child fromcaregiver thethe child's clinical condition. worsenmay 10 kg Pediatricpadsin children < should be used Vagal Maneuvers: Narrow Complex TachycardiaNarrow ( Wide Complex Tachycardia ( Serious Signs and Symptoms: and Signs Serious Recommended Exam: Mental Status, Skin, Neck, Lu Generally, the maximum sinus tachycardia Continuous pulse oximetry is required for all SVT Patients if available. Documentrhythm changes all with monitor strips and Monitor for respiratory depression and hypotension Cardioversion dose        Pearls      Pediatric Cardiac Protocols Section 2016 max 60 mL/kg NO NO Patient still symptomatic? 20 mL/kg IV / IO Normal Saline Bolus Epinephrine 1:10,000 Foreign body Foreign Secretions Infectionepiglotitis) (croup, Protocol(s) Repeat every 3 – 5 minutes as indicated 0.01 mg/kg IV / IO (Max 1 mg) Pediatric Airway Arrest Protocol Respiratory failure (dehydration) Hypovolemia Congenitaldisease heart Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis Simultaneously utilize Simultaneously Repeat asneeded Pediatric Cardiac Simultaneously utilize Simultaneously YES YES Differential          of shock? P Pediatric Diabetic Protocol Severe signs contacting Medical Control Medical contacting Notify destination and consider Notify NO YES YES 94 % ≥

2 NO YES SSM EMS Protocols Adequate? Decreased heart rate Delayed capillary refill or cyanosis Mottled, coolskin Hypotension or arrest Altered levelof consciousness Procedure Symptomatic bradycardia? Airway Patent nous Access Protocol Cardiac Monitor Heart Rate < 60?      Signs and Symptoms Signs and maintain SpO Supplemental oxygen to Identify underlying cause Oxygenation / Ventilation Blood Glucose Analysis Blood Glucose 0.1 mg/kg IV / IO 0.1 mg/kgIV / Midazolam or

Ve NO Universal Patient Care Protocol may repeat once in 3 -5 (max total dose 5 mg) P B Pediatric Bradycardia Pediatric Cardiac Pacing Procedure Max total dose 150 mcg (max initial dose 75 mcg) Consider sedation Fentanyl 2 mcg/kg IV / IO bolus Consider minutes if needed 0.2 mg/ kg IntraNasal (max dose 2.5 mg) May repeat0.5 mcg/kgevery 5 minas needed Shock Exit to Protocol P hypotension Toxicology Toxicology Poor perfusion Poor Symptoms include: Follow Pediatric Follow Suspected Beta- Channel Blocker altered mental status Past medical history medical Past exposure body Foreign arrest or distress Respiratory Apnea Possible toxic or poison exposure disease Congenital Medication (maternal or infant) Blocker or Calcium Appropriate Protocol(s) History        Pediatric Cardiac Protocols Section 2016 in bradycardic patients with shock. with patients bradycardic in SSM EMS Protocols early for drug dosages if applicable. , HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro Extremities, Abdomen, Lungs, Back, Heart, HEENT, Skin, , Pediatric Bradycardia Pediatric Use pre-made Drug dosage reference The majority of pediatric arrests are due to airway problems. Most maternal medications pass through breast milk to the infant. Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia. Transcutaneous pacing should be considered available. when patients pediatric for appropriate pads of use the require pacing transcutaneous requiring patients Pediatric The minimum Atropine dose for any patient is 0.1 mg IV, due to paradoxical effects at extremely low doses. Recommended Exam: Mental Status         Pearls Pediatric Cardiac Protocols Section 2016

Protocol(s) Exit to Protocol Pediatric Pediatric Airway Simultaneously utilize Simultaneously Allergic Reaction Congestiveheart failure Asthma Anaphylaxis Aspiration effusion Pleural Pneumonia embolus Pulmonary Pericardial tamponade Toxic Exposure iac patient. Differential          NO YES ongenital card precise past medical history. 94 % ≥

2 NO YES Access Protocol ema may vary depending on the underlying cause and may Anaphylaxis? Airway Patent Pulse Oximetry Cardiac Monitor Allergic Reaction care of the pediatriccare of c Ventilations adequate Ventilations maintain SpO Oxygenation adequate? Supplemental oxygen to 12 Lead ECG Procedure Capnography Procedure SSM EMS Protocols contacting Medical Control Medical contacting Venous Infant: Respiratory distress, poor feeding, lethargy, weightgain, +/- cyanosis distress, Respiratory Child/Adolescent: bilateral rales, apprehension, orthopnea, jugular vein distention (rare), pink, frothysputum, peripheral edema, diaphoresis, chest pain Hypotension, shock Notify destination and consider Notify spiratory, Cardiac, Skin, Neuro P B Transport to Specialty a Pediatric Center Signs/Symptoms    Position child with head of bed in up-position (25-40°) congenital heart defect, obtain a YES Flexing hips with support under knees so that they are bent90° B mcg/kg IV / IO. Titrate to systolicage specific blood pressure. Pediatric Pulmonary Edema / CHF Edema Pulmonary Pediatric

NO Exit to known CHF? History / Signs / / Signs History Morphine Sulfate: 0.1 mg/kg IV / IO for patients having a “tet spell.” Max single dose 5 mg/dose. Fentanyl: 1 mcg/kg IV / IO. Max single dose 50 mcg. Dopamine 2 – 20 < 1 month: Tetralogy of Fallot, Transposition of the great arteries, Coarctation ofthe aorta. 6 months:2 – Ventricularseptal defects Atrioseptal(VSD), defects(ASD). Any age: Myocarditis, Pericarditis, SVT, heart blocks. with crackles with crackles / rales / Symptoms consistent Appropriate Protocol with respiratory distress distress respiratory with Most children with CHF have a Congenital heart disease varies by age: include the following with consultation as needed by Medical Control: Contact Medical Control as needed early in the Recommended exam: Mental status, Re Congenital Heart Disease Chronic Lung Disease Congestiveheart failure history medical Past Do not assume all wheezing is pulmonary, especially in a cardiac child. Treatment of Congestive Failure Heart / Pulmonary ed Universal Patient CareProtocol     Pearls History       Pediatric Medical

Section Table of Contents

Pediatric Airway Pediatric Medical Protocols Section Pediatric Pharmacologically Assisted Intubation Pediatric Failed Airway Pediatric Hypotension/Shock Pediatric Altered Mental Status Pediatric Respiratory Distress Pediatric Allergic Reaction/Anaphylaxis Pediatric Seizure Pediatric Overdose/Toxic Injestion

Pediatric Diabetic Pediatric Vomiting/Diarrhea Pediatric Pain Control

SSM EMS Protocols 2016 Pediatric Airway

Universal Patient Care Protocol Supplemental oxygen Assess Respiratory Rate, Effort, Oxygenation Goal oxygen saturation YES Is Airway / Breathing Adequate? ≥ 94% NO Exit to Basic Maneuvers First Appropriate Protocol -open airway chin lift / jaw thrust -nasal or oral airway -Bag-valve mask (BVM) B Spine Motion Restriction Protocol if indicated Consider Altered Mental Status Protocol

Airway Foreign Body B NO Airway Patent? Obstruction Procedure

YES Pediatric Medical Protocols Section P Direct laryngoscopy BVM and supplemental O2 to maintain Breathing / Oxygenation NO YES B EtCO2 of 35-45 mmHg Complete Obstruction, Support needed? Unable to Clear? and/or NO SpO2 of ≥ 94% YES Exit to Monitor /Reassess Exit to Pediatric Supplemental Oxygen BVM / Oxygen Pharmacologically Effective? Pediatric Failed if indicated YES Airway Protocol Assisted Intubation Exit to Protocol Appropriate Protocol NO

Tension Pneumothorax? Unable to Ventilate NO and Oxygenate ≥ 90% Gag reflex YES during or after one (1) YES or more unsuccessful present? Chest Decompression intubation attempts . P NO Procedure Anatomy inconsistent with continued attempts. B Pediatric BIAD Procedure Oral-Tracheal Intubation P NO Two (2) unsuccessful Procedure BVM / Oxygen attempts by most Effective? experienced EMT-P YES Intubation NO sucessful? YES Continuously monitor bag compliance B Ventilation rate to maintain Consider Sedation EtCO2 35 – 45 mmHg Midazolam and an SpO2 of ≥ 94% 0.2 mg/ kg IntraNasal or 0.1 mg/kg P IV / IO (max dose 2.5 mg) may repeat once in 3 -5 minutes if needed (max total dose 5 mg) Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Pediatric Medical Protocols Section 2016 90% or ≥ between 35 and between of 35-40 mmHg. of 2 2 endotracheal tube past the teeth ven in absence of trauma) to better lse oximetryvalues of lse oximetry in the mid 80s post-the mid lse oximetry in rway measures instead of using a BIAD or Intubation. Intubation. or of using a BIADrway measures instead of age or any patientwho can be measuredor of age within racheal/ movespatientusedshould tube during all be t intubations.someworsenThis maycases. view in should only be done to maintain a EtCO maintain to done be only should r minute. Goal rate should maintain EtCO maintain rate should Goal minute. r BVM with continuous pu continuous with BVM SSM EMS Protocols with clinical condition (e.g. pu passing the laryngoscope blade passing the blade or laryngoscope eal tube well and consider c-collar (e

) is mandatory for the constant monitoring of all patients with any of all monitoring the constant mandatory for ) is 2 y be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for y be 25 20 Age, 30 for Neonates, for Toddlers, for School Pediatric Airway Pediatric ients who maintain a gag reflex. or inserted into the nasal passage. stabilization Manual placement.endot maintain ETT of transfers. airway device. Document results. 45; AVOID HYPERVENTILATION. Gastric tube placementGastric tube be shouldperformedall intubated in patients. It is important to secure the endotrach Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful. BURP maneuver may be used to assist with difficul Adolescentspe 8-12the normal Adult rate of Hyperventilation in deteriorating head trauma Do not attempt intubation in pat Ventilatory rate should rate should Ventilatory generall when the patient is appropriately oxygenated and of this protocol,secureFor the purposespatient is appropriatelyoxygenated whenairway is a the ventilated. attempt is defined as intubation An If an effective airway is being maintained by maintained airway is If an being effective Continuous capnography (EtCO capnography Continuous For this protocol, pediatric is defined as < 12 years < as pediatric is defined protocol,For this the Broselow-Lutentape. stable/improving values consistent stable/improving values drowning), it is acceptable to continue with basic ai            Pearls  Pediatric Pharmacologically Assisted Intubation

Patient is < 10 years of age? Exit to NO Adult Pharmacologically YES Assisted Intubation CHECKLIST Protocol Complete pre-intubation checklist P Ensure that all equipment is working Venous Access Protocol and available.  Suction B Baseline neurologic exam  Broslow Tape  BIAD and/or materials for surgical airway (> 12 y/o) Spine Motion Restriction Protocol  All equipment for Oral Tracheal B if indicated Intubation  Pulse oximetry  End tidal capnography Patient suspected of having: YES head injury, or intracranial hemmorage? Lidocaine 1.5 mg/kg IV / IO P NO Ideally given 1 min. prior to intubation Pediatric Medical Protocols Section Midazolam 0.1 mg/kg IV / IO P followed by Fentanyl 1 mcg/kg IV / IO

B Capnography Procedure

Pre-oxygenate the patient B with 100% oxygen and assist ventilations with BVM

Are respirations < 8 and gag reflex absent? NO YES

Oral Tracheal Intubation Procedure BURP maneuver, if indicated P Consider BIAD Procedure if unsuccessful first attempt

ET tube passed Auscultate over stomach Unable to ventilate B and oxygenate after the first NO vocal chords under YES then lung fields unsuccessful intubation attempt direct visualization? AND Capnography Procedure Anatomy inconsistent with B continued attempts Properly secure airway OR Avoid hyperventilation Two (2) unsuccessful attempts by most experienced EMT-P. Ventilate to maintain: Midazolam 0.1 mg/kg IV / IO Max dose 5 mg SpO of 90-99% P B 2 if indicated, bucking or biting AND/OR tube Exit to EtCO2 of 35-45 mmHg Adult Failed Airway Protocol Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Pediatric Pharmacologically Assisted Intubation

Always weigh the risks and benefits of endotracheal intubation in the field against transport. All prehospital endotracheal intubations are to be considered high risk. If ventilation / oxygenation is adequate, transport may be the best option. The most important airway device and the most difficult to use correctly and effectively is the Bag Valve Mask (not the laryngoscope).

Few prehospital airway emergencies cannot be temporized or managed with proper BVM techniques.

Difficult Airway Assessment

Difficult BVM Ventilation‐MOANS: Difficult Mask seal due to facial hair, anatomy, blood or secretions / trauma; Obese or late pregnancy; Age > 55; No teeth (roll gauze and place between gums and cheeks to improve seal); Stiff or increased airway pressures (Asthma, COPD, Obese, Pregnant).

Difficult Laryngoscopy‐LEMON: Look externally for anatomical distortions (small mandible, short neck, large tongue); Evaluate 3‐3‐2 Rule (Mouth open should accommodate 3 patient fingers, mandible to neck junction should accommodate 3 patient fingers, chin‐neck junction to thyroid prominence should accommodate 2 patient fingers); Mallampati (difficult to assess in the field); Obstruction / Obese or late pregnancy; Neck mobility. Pediatric Medical Protocols Section Difficult BIAD‐RODS: Restricted mouth opening; Obstruction / Obese or late pregnancy; Distorted or disrupted airway; Stiff or increased airway pressures (Asthma, COPD, Obese, Pregnant);

Difficult Cricothyrotomy / Surgical Airway (> 12 y / o)‐SHORT: Surgery or distortion of airway; Hematoma over lying neck; Obese or late pregnant; Radiation treatment skin changes; Tumor overlying neck.

Trauma: Utilize in‐line cervical stabilization during intubation, BIAD or BVM use. During intubation or BIAD the cervical collar front should be open or removed to facilitate translation of the mandible / mouth opening.

Pearls  Contact medical control before using the Pharmacologically Assisted Intubation Protocol if the patient is stable.

 Continuous waveform capnography (EtCO2) is mandatory for the monitoring of all patients with a BIAD or ET tube. Document results.  If an effective airway is being maintained by BVM and/or basic airway adjuncts (e.g. nasopharyngeal airway) with continuous pulse oximetry values of ≥ 90% or values expected based on pathophysiologic condition with otherwise reassuring vital signs (e.g. pulse oximetry of 85% with otherwise normal vitals in a post-drowning patient), it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. Consider CPAP as indicated by protocol and patient condition.  For the purposes of this protocol a secure airway is achieved when the patient is receiving appropriate oxygenation and ventilation.  An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage.

 An appropriate ventilatory rate is one that maintains an EtCO2 of 35-45. Avoid hyperventilation.  Paramedics should use a BIAD if oral-tracheal intubation is unsuccessful.  Maintain C-spine immobilization for patients with suspected spinal injury.  Cricoid pressure is no longer routinely recommended. BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) may assist with difficult intubations.  Gastric tube placement should be considered in all intubated patients if available or time allows.  It is important to secure the endotracheal tube well and consider c-collar (in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers.

SSM EMS Protocols 2016 Pediatric Medical Protocols Section 2016 90% of ≥ 2 SpO 35 – 45 mmHg 2 EtCO maintain Ventilation rate to maintain Continue Ventilation / Oxygenation YES B 2 94%)? ≥ NO NO NO Enter from Adequate? successful? Airway Protocol Significant Facial Significant Call for additional resources if available if resources appropriate for clinical clinical for appropriate Airway BIAD procedure Oxygenation / Ventilation maintains adequate SpO Airway: BIAD Procedure Capnography Procedure condition (usually BVMwith adjunctive airway contacting Medical Control Medical contacting Trauma / Swelling / Distortion? PlaceOral/ or Nasal and Airway Notify destination and consider Notify P B B SSM EMS Protocols NO YES YES YES 90% during ≥

90% ≥ Pediatric Failed Airway Failed Pediatric of 2 OR OR attempts . SpO or equipment 35 – 45 mmHg 2 90 % ≥

experienced EMT-P. 2 Exit to focus on BVM skills EtCO maintain Re-position, Re-attempt, SpO Ventilation rate to maintain Continue BVM / BVM to maintain Two (2) unsuccessful attempts by most Continue Ventilation / Oxygenation Supplemental oxygen Supplemental Oxygen Appropriate Protocol Anatomy inconsistent with continued attempts. P B NO MORE THAN TWO (2) ATTEMPTS TOTALNO MORE THAN TWO or after one (1) or more unsuccessful intubation B Each attempt should include change inapproach Unable to Ventilate and Oxygenate Pediatric Failed Airway Pediatric Medical Protocols Section

Pearls  For this protocol, pediatric is defined as less than 12 years of age or any patient which can be measured within the Broselow-Luten tape.  Capnometry (color) or capnography is mandatory with all airway management. Document results.

 Continuous capnography (EtCO2) is mandatory with BIAD or endotracheal tube use.  If an effective airway is being maintained by BVM with continuous pulse oximetry values of ≥ 90% or stable/ improving values appropriate to clinical condition (e.g. values in the mid 80s with a post-drowning patient), it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation.  For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation.  An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage.  Ventilatory rate should generally be 30 for Neonates, 25 for Toddlers, 20 for School Age, and for Adolescents the normal Adult rate of 8-12 per minute. The goal rate maintains an EtCO2 between 35 and 45 and avoid hyperventilation.

 Hyperventilation in deteriorating head trauma should only be done to maintain a pCO2 of 30-35.  If first intubation attempt fails, make an adjustment and then try again: Different laryngoscope blade; Gum Elastic Bougie; Different ETT size; Change cricoid pressure; Apply BURP; Change head positioning  Paramedics should consider using a BIAD if oral-tracheal intubation is unsuccessful.  Cricoid pressure and BURP maneuver may be used to assist with difficult intubations. They may worsen view in some cases.  Gastric tube placement should be considered in all intubated patients.  It is important to secure the endotracheal tube well and consider c-collar (even in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers.

SSM EMS Protocols 2016 Pediatric Medical Protocols Section , 2016

(sepsis, consider in cardiogenic (PE, tamponade) Pediatric if indicated (dehydration, GI bleed) GI (dehydration, Diabetic Protocol 70 + 2 x Age) 70 + 2 x Age) 70 + 2 x Age) ≥ ≥ ≥ Hypovolemic Cardiogenic Septic Neurogenic Anaphylactic NO (SBP (SBP (SBP Shock Trauma Infection Dehydration Congenitaldisease heart or Toxin Medication , Obstructive Max dosetotal 60 mL/kg

consider the presence of pulmonary to effect age appropriate BP: to effect age appropriate BP: edema; utilize Dopamine early: Differential       Hypovolemic For non-cardiogenic shock, Repeat to effect age appropriate BP: Dopamine 2 – 20 mcg/kg/min IV / IO Dopamine 2 – 20 mcg/kg/min IV / IO Normal Saline Bolus 20 mL/kg IV / IO vasopressors after 60 mL/kg fluid bolus: shock; Caution with excess fluids Cardiogenic (CHF), Distributive anaphylaxis) Consider P

contacting Medical Control Medical contacting Access Protocol Notify destination and consider Notify Pediatric Procedure Consider Protocol Was trauma involved? Cardiac monitor if indicated other Anaphylaxis or Blood Glucose Analysis Analysis Blood Glucose Venous SSM EMS Protocols Restlessness, confusion, weakness Dizziness Tachycardia Hypotension (Late sign) Pale, cool, clammy skin Delayed capillary refill Dark-tarry stools Pediatric Airway Protocol(s) Universal Patient CareProtocol P B Signs and Symptoms Signs and        Type of Type of Shock: History, Exam and Circumstances often suggest

, Neurogenic (Pneumothorax) YES ONLY after 60 mL/kg (bleeding) Hemostatic Agent Exit to 70 + 2 x Age) 70 + 2 x Age) Pediatric Hypotension / Shock Hypotension Pediatric Protocol ≥ ≥ Pediatric if indicated Procedure and/or Obstructive Obstructive

, Multiple Trauma consider early use of (SBP (SBP Wound Care Procedure Max total dose 60 mL/kg

vasopressors Hypovolemic to effect age appropriate BP: fluid bolus and patient is peri-arrest. is patient and bolus fluid Repeat to effect age appropriate BP: Dopamine 2 – 20 mcg/kg/min IV / IO Tourniquet Normal Saline Bolus 20 mL/kg IV / IO Spine Restriction Protocol Motion Chest Decompression-Needle Procedure (spinal injury) Blood loss loss Blood loss Fluid Vomiting Diarrhea Fever Infection Consider Consider P B History       Pediatric Hypotension / Shock Pediatric Medical Protocols Section

Pearls  Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro  Lowest normal blood pressure by age: < 31 days: > 60 mmHg. 31 days to 1 year: > 70 mmHg. Greater than 1 year: 70 + 2 x age in years.  Consider all possible causes of shock and treat per appropriate protocol. Majority of decompensation in pediatrics is airway related.  Decreasing heart rate and hypotension occur late in children and are signs of imminent cardiac arrest.  Shock may be present with a normal blood pressure initially.  Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation.  Consider all possible causes of shock and treat per appropriate protocol.  Hypovolemic Shock; Hemorrhage, trauma, GI bleeding, or pregnancy-related bleeding.  Cardiogenic Shock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventrical / septum / valve / toxins.  Distributive Shock: Sepsis Anaphylactic Neurogenic: Hallmark is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins  Obstructive Shock: Pericardial tamponade. Pulmonary embolus. Tension pneumothorax. Signs may include hypotension with distended neck veins, tachycardia, unilateral decreased breath sounds or muffled heart sounds.

 Acute Adrenal Insufficiency: State where body cannot produce enough steroids (glucocorticoids / mineralocorticoids.) May have primary adrenal disease or more commonly have stopped a steroid like prednisone. Usually hypotensive with nausea, vomiting, dehydration and / or abdominal pain. If suspected EMT-P should give Methylprednisolone 2 mg/kg IV / IO (Maximum 125mg).

SSM EMS Protocols 2016 Pediatric Medical Protocols Section 2016

Exit to Exit to as indicated Protocol Pediatric Hypoxia infection) seizure, stroke, CNS (trauma, Thyroid (hyper hypo) / Shock (septic-infection, metabolic, traumatic) Diabetes (hyper / hypoglycemia) Toxicological Acidosis / Alkalosis Environmental exposure Electrolyte abnormatilities Psychiatric disorder Exit to Exit to Protocol Protocol Pediatric Exit to Protocol Appropriate Pediatric if indicated Differential           Hypo / Hyperthermia Pediatric Diabetic Hypotension / Shock Hypotension / Cardiac / ArrhythmiaCardiac Protocol Overdose / Toxic Ingestion SSM EMS Protocols Decrease in mentation mentation baseline in Change Decrease in Blood sugar Cool, diaphoreticskin sugar Blood in Increase Warm, dry, skin, fruity breath, of signs respirations, Kussmaul dehydration Fever/Febrile , HEENT, Skin, Heart, , HEENT, Skin, Lungs,Heart, Abdomen, Neuro Back, Extremities, YES YES YES YES        Signs and Symptoms Signs and Pediatric Altered Mental Status Mental Altered Pediatric NO NO NO Hypo / Procedure Procedure Signs of if indicated if indicated Signs of OD / Cardiac monitor Signs of shock Hyperthermia? Poor perfusion? Poor Venous Access Protocol toxicology related? Blood Glucose Analysis Blood Glucose contacting Medical Control Medical contacting 12 Lead EKG Procedure Notify destination and consider Notify Carboxyhemoglobin Monitoring Pediatric Airway Protocol(s) Recommended Exam: Mental Status Pay careful attention to the head exam for signs of bruising or other injury. Be aware of altered mental status as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or Glucagon Consider alcohol, prescription drugs, illicit drugs and over the counter preparations as a potential etiology. Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure. Potential ingestion Trauma Lethargy sleeping / feeding in Changes Diabetes Recent illness Irritability Past medical history medical Past Medications

Universal Patient Care Protocol Spine Motion Restriction Protocol P B Pearls       P        History   B Pediatric Medical Protocols Section YES 2016

NO Protocol(s) Exit to Nebulizer Protocol STRIDOR Pediatric Improving? Pediatric Airway Pediatric May repeat x 3 2 mg/kg IV / IO Simultaneously utilize 0.01 mg / kg IM as indicated 1 mg in 2 mL NS Max0.3 mg dose Max125 dose mg Allergic Reaction Epinephrine 1:1000 Epinephrine 1:1000 Methylprednisolone Repeat as needed x 3 Airway Protocol(s) Albuterol Nebulizer 2.5 mg P P P P Asthma / Reactive Airway Disease Aspiration body Foreign infection airway or lower Upper Congenitaldisease heart OD/ Toxic ingestion / CHF Anaphylaxis Trauma NO Differential         YES NO Lung Exam Signs / Symptoms YES YES Nebulizer Anaphylaxis? Airway Patent Improving? Max2 g dose Allergic Reaction or Reaction Allergic 40 mg/kg IV / IO Over 20 minutes, 1 mg in 2 mL NS Ventilations adequate Ventilations Oxygenation adequate? Magnesium Sulfate Epinephrine 1:1000 SSM EMS Protocols P Universal Patient Care Protocol contacting Medical Control Medical contacting Wheezing / Stridor / Crackles / Rales Nasal Flaring Retractions / / Grunting Increased Heart Rate AMS Anxiety / Distractability Attentiveness Cyanosis Poor feeding Sputum / Frothy JVD Hypotension NO Notify destination and consider Notify Signs and Symptoms           NO WHEEZING 94 % 94 ≥

Pediatric Respiratory Distress Respiratory Pediatric 2 NO YES Improving? Improving? 2 mg/kg IV / IO Cardiac Monitor Max125 dose mg Ipratropium 0.5 mg Methylprednisolone

Repeat as needed x 3 Repeat as needed x 3 maintain SpO Supplemental oxygen to 12 Lead ECG Procedure Albuterol Nebulizer 2.5 mg Capnography Procedure P Time of onset Time of Possibility of foreign body Past Medical History Medications Fever / Illness Sick Contacts History of trauma History / possibility of choking IngestionOD / Congenitaldisease heart Venous Access Protocol P YES P B History           Pediatric Medical Protocols Section . 2016 no wants to treatment. Also consider saline compliance and care. compliance on of comfort. They will protect their airway by their body bacterial, with fever, rapid onset, possible stridor, patient ed to evaluate protocol 92 % after first beta agonist ≤ in the patient with respiratory distress. . Airway manipulation may worsen the condition. SSM EMS Protocols , HEENT, Skin, Neck, Heart, Lungs, Abdomen, Neuro Extremities, Pediatric Respiratory Distress Respiratory Pediatric bolus of 20 mL/kg in pediatric patients in respiratory distress; these patients are often dehydrated. Do not force a child into a position, allow them to assume positi Recommended Exam: Mental Status Items in Red Text are key performance measures us Pulse oximetry should be monitored continuously position. The most important component of respiratory distress is airway control. Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respond to beta-agonists Consider IV access when Pulse oximetry remains Consider Epinephrine if patient < 18 months and not responding to initial beta-agonist treatment. Croup typically affects children < 2 years of age.Bronchodilaters are ineffective. It is viral, possible fever, gradual onset, is noted. Epiglottitis typically affects children > 2 years of age. It is sit up to keep airway open, drooling is common In patients using levalbuterol (Xopenex) you may substitute the patient’s levalbuterol for Albuterol in the protocol.  Pearls      EMT-B may administer Albuterol if patient already prescribed and may assist with patient medication.     Pediatric Allergic Reaction / Anaphylaxis

History Signs and Symptoms Differential  Onset and location  Itching or hives  Urticaria (rash only)  Insect sting or bite  Coughing / wheezing or respiratory  Anaphylaxis (systemic effect)  Food allergy / exposure distress  Shock (vascular effect)  Medication allergy / exposure  Chest or throat constriction  Angioedema (drug induced)  New clothing, soap, detergent  Difficulty swallowing  Aspiration / Airway obstruction  Past medical history / reactions  Hypotension or shock  Vasovagal event  Medication history  Edema  Asthma / COPD / CHF

Universal Patient Care Protocol Supplemental oxygen to maintain B SpO2 ≥ 94 % P Venous Access Protocol

Assess Symptom Severity

SEVERE Pediatric Medical Protocols Section

MILD MODERATE Assist patient with their prescribed B Epinephrine Auto-Injector Assist patient with their prescribed B Epinephrine Auto-Injector Pediatric Airway Protocol(s) if indicated Diphenhydramine 1 mg / kg max dose 50 mg Consider IV / IO / IM Epinephrine 1:1000 P Epinephrine 1:1000 0.01 mg / kg IM max 0.3 mg Famotidine 1 mg / kg 0.01 mg / kg IM max 0.3 mg Use autoinjector if available IV / IO max dose 40mg Use autoinjector if available Repeat in 5 min if no Repeat in 5 min if no improvement improvement Diphenhydramine Diphenhydramine 1 mg / kg max dose 50 mg Monitor and Reassess 1 mg / kg IV / IO / IM IV / IO / IM B for Worsening Signs and if not already given Symptoms P Albuterol Nebulizer 2.5 mg Albuterol Nebulizer 2.5 mg P +/- Ipratropium 0.5 mg +/- Ipratropium 0.5 mg Repeat as needed x 3 Repeat as needed x 3 if indicated if indicated Famotidine 1 mg / kg Symptoms stable NO Famotidine 1 mg / kg IV / IO max dose 40 mg or improving? IV / IO max dose 40 mg Methylprednisolone Methylprednisolone YES 2 mg/kg IV / IO 2 mg/kg IV / IO max dose 125 mg max dose 125 mg

Symptoms stable YES or improving? NO Cardiac Monitoring with pulse oximetry and end Normal Saline Bolus tidal EtCO2 (if available) Simultaneously utilize 20 mL / kg IV / IO Indicated for Moderate Airway Protocol(s) P and Severe Reactions Repeat as needed Max 60 mL / kg

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Pediatric Medical Protocols Section 2016 r to administering any r For pediatric patients, patients, pediatric For rity before or during rity yspnea, hypoxia) or yspnea, hypoxia) or ) with normal blood pressure ) withpoor hypotension and medications like Prinivil / Zestril WELL, based on age, prio d is swelling involving the face, lips or airway lips the face, d is swelling involving be administered in prio epi-pen”) may be used. Either may repeatedbe for ephrine may require IV epinephrine administration ephrine may require IV that should be administered in acute anaphylaxisadministered that should be espiratory (wheezing, d espiratory (wheezing, d ld receive a 12 lead ECG and should be continually present due to poor perfusion. due to perfusion. poor present th normal blood pressure and perfusion. ed Albuterol and Epinephrine Auto-injector. are worsening 5 minutes after the first dose. a SBP >70 + (age in years x 2) mmHg. years x (age in >70 + a SBP ausea, vomiting, abdominal pain ausea, vomiting, abdominal pain lethal multisystem allergic reaction. SSM EMS Protocols lay administration of epinephrine. lay administration in patients taking blood pressure in Use an autoinjector if available to deliver epinephrine. autoinjector if available to Use an Pediatric Allergic Reaction Allergic Pediatric Flushing, hives, itching, erythema wi Flushing, hives, itching, Flushing, hives, itching, erythema plus r gastrointestinal symptoms (n and perfusion. Flushing, hives, itching, erythema plus r gastrointestinal symptoms (n perfusion. Skin symptoms may be not Mild symptoms: symptoms: Mild Moderate symptoms: Severe symptoms: (lisinopril)-typically end in -il. po medication for respiratory distress. respiratory po medication for The shorter the onset from exposure symptoms to the more severe the reaction. EMT-B may assist patientsprescrib with their Patients with moderate and severe reactions shou Fluids titrated and Medication Fluids to maintain al symptoms and have no rash / symptomsgastrointestinwith only respiratoryreactions have no rash and al and may occur Allergic skin involvement. seenAngioedema isreactionssevere in moderate an to de this should NOT but monitored, by IV push or epinephrine infusion. epinephrine or push IV by PILLS SWALLOW CONSIDER THE ABILITY TO CHILD’S Symptom Severity Classification: structures. This can also be seen Anaphylaxis unresponsive to repeat doses of IM epin Anaphylaxisdoses of to repeat unresponsive attempts at IV or IO access. To increase patient safety, 0.3mg dose (“ the 0.15mg or jr”) dose (“epi-peneither severe symptoms that have not improved or (Moderate/ Severe Symptoms.) IM Epinephrine should Epinephrine is the drug of choice and the first drug drug the first choice and of the drug is Epinephrine Recommended Exam: Mental Status, Heart, Skin, Lungs Anaphylaxis is acutean and potentially            Pearls   Pediatric Medical Protocols Section 2016

5 mg 4 mg 94 % ≥

2 or Procedure Protect patient Cardiac Monitor nous Access Protocol Max initialdose: 2 mg Max total dose: 4 mg Status Epilepticus? Protocol if indicated after 2-3 minutesifneeded Max initialdose: Max initialdose: maintain SpO YES May repeat initial dose once Pregnancy 20> Weeks Supplemental oxygen to if indicated Blood Glucose Analysis Blood Glucose Diazepam rectal: 0.5 mg/kg Lorazepam 0.1 mg/kg IV / IO / IM Spine Motion Restriction Loosen any constrictive clothing Midazolam 0.2 mg/kg Intranasal Ve ActiveSeizure in Knownor Suspected Exit to Obstetrical Emergency Protocol Emergency Obstetrical to Exit Simple Febrile seizure Febrile Simple Infection or Toxin Medication trauma, Head failure Respiratory or Hypoxia Hypoglycemia Metabolic abnormality / acidosis Tumor

P B Pediatric Airway Protocol(s) NO Differential        YES 4 mg or P Rectal: 0.5 mg/kg Max initialdose: after 2-3 minutes if needed Max total dose:Max total 0.4 mg/kg May repeat initial dose once Diazepam 0.2 mg/kg IV / IO or Pediatric if indicated arrival onscene? Consider Pediatric Reassess if indicated Monitor and and Monitor Actively Seizing upon Diabetic Protocol PostictalState Altered Mental Status Protocol

SSM EMS Protocols Administer only one of the following medications: Administer only one of the Universal Patient Care Protocol Fever; hot, dry skin activity Seizure Incontinence Tongue trauma Rash rigidity Nuchal Altered mental status NO Signs and Symptoms Signs and        or NO Pediatric Seizure Pediatric YES Max initialdose: 5 mg Max total dose: 5 mg after 2-3 minutesifneeded May repeat initial dose once 94 % ≥

Midazolam 0.2 mg/kg Intranasal 2 Midazolam 0.1 mg/kg IV / IO / IM YES Procedure if indicated Awake, Alert Cardiac Monitor seizure activity? contacting Medical Control Medical contacting Protocol if indicated simple febrile seizure Notify destination and consider Notify maintain SpO Patient begins to have Monitor and Reassess and Monitor Normal Mental Status? Mental Normal Supplemental oxygen to Blood Glucose Analysis Blood Glucose Protect patient, observe for Spine Motion Restriction Loosen any constrictive clothing Fever, Sick contacts Prior history of seizures Medication compliance Recent head trauma Whole body vs unilateral seizure activity Single/multiple Duration, Congenital Abnormality Venous Access Protocol B P B History        NO Pediatric Medical Protocols Section

2016 ol compliance and care compliance ol used to evaluate protoc SSM EMS Protocols T, Heart, Lungs, Extremities, Neuro Pediatric Seizure Pediatric Simple Febrile Seizures are most common in ages 6mos – 5 years. They are by definition generalized seizures with no medication. Midazolam 0.2 mg/kg (Maximum 5 mg) Intranasal is effective in termination of seizures. Do not delay Intranasal administration with difficult IV or IO access. IM is preferred over IO. Addressing the ABCs and verifying blood glucose is as important as stopping the seizure. Be prepared to assist ventilations especially if a benzodiazepine is used. Avoiding hypoxemia is extremely important. In an infant, a seizure may be the only evidence of a closed head injury. Status epilepticus is defined as ortwo more successive seizures without a period of consciousness or recovery. This is a true transport. and treatment, control, airway rapid requiring emergency Assess for possibility of occult trauma and substance abuse, overdose or ingestion / toxins. Monitor for hypotension and utilize continuous waveform capnography to monitor for respiratory depression associated with any controlled substance. seizure history in the setting of any grade of fever, with an otherwise normal neurologic and physical exam and recent history. It may be reasonable to observe these seizures, while treating fever with acetaminophen and passive cooling measures (i.e. undressing), for up to five minutes. Any seizure confirmed to last for more than five minutes should be treated with Recommended Exam: Mental Status, HEEN Items in Red Text are key performance measures          Pearls  Pediatric Medical Protocols Section 2016 OD Exit to Carbon Cyanide / Pediatric

Monoxide / IV / IO / IM Carbon Monoxide Cyanide Protocol Cyanide max 2 mg as indicated dose. respiratory status respiratory st CONCIOUSNESS Airway Protocol(s) 1 Shock Protocol Naloxone 0.1 mg/kg, Appropriate Simultaneously utilize NOT GIVEN TO RESTORE Pediatric Hypotension / Naloxone is titrated to adequate IntraNasal route is preferred for P Exit to severity arms WMD / WMD Nerve Tricyclic antidepressants Acetaminophen Depressants Stimulants Anticholinergic medications Cardiac Solvents, Alcohols, Cleaning agents Insecticides (organophosphates) Agent Protocol Follow symptom Organophosphate NO YES Differential         NO

0.09 0.09 rination; ≥ I Upset; U G mEq/kg NO NO QRS YES YES Sodium seconds 0.09 sec Tricyclic ≥ Bicarbonate Age Specific Hypotension? Cardiac monitor Potential Cause 1 mEq/kg IV / IO every 5 minutes if Repeat 1 Repeat acrimation, Maximum 50 mEq Antidepressant OD QRS remains QRS remains L uscle Twitching Carboxyhemoglobin Altered Mental Status? Monitoring Procedure M Adequate Respirations / 12 Lead EKG Procedure Oxygenation / Ventilation P SSM EMS Protocols contacting Medical Control Medical contacting Serious Symptoms / Symptoms Venous Access Protocol Notify destination and consider Notify

efecationDiarrhea, / P B increased, loss of control, D Abdominalcramping, pain / Emesis, Mental status changes Hypotension / hypertension Decreased respiratory rate Tachycardia, dysrhythmias Seizures Salivation,

or

YES Signs and Symptoms Signs and       OD (max 3g) (max 1g) Over 10 minutes 20 mg/kg IV / IO 60 mg/kg IV / IO Calcium Chloride or

Calcium Gluconate P Calcium ChannelBlocker Dopamine Procedure If no improvement 4195 Procedure Pediatric Overdose / Toxic Ingestion / Toxic Overdose Pediatric as indicated IF Needed 2 – 20 mcg/kg/min IV / IO Cardiac: External Pacing Cardiac: External Exit to Appropriate Missouri Poison Control 314-268- Pediatric Diabetic Altered Mental Status OD 5 mg Blood Glucose Analysis Blood Glucose IV / IO P Glucagon Maximum 0.1 mg/kg mg/kg 0.1 Ingestion or suspected ingestion of potentially toxic substance Substance ingested,route, quantity Time of Ingestion is important Reason (suicidal, accidental, criminal) Available medications in home history, medical Past medications, pastpsychiatric history Beta Blocker Universal Patient Care Protocol History       P B Pediatric Medical Protocols Section 2016 Abdomen, Extremities, Neuro - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x age)mmHg ough appropriate county Haz Mat Response Team. contain 2 mg of SSM EMS Protocols us, Skin, HEENT, Heart, us, Skin, HEENT, Lungs,Heart, y weapons. Bring bottles, contents, emesis to ED. dysrhythmias and mental status changes initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure increased HR, increased temperature, dilated pupils, mental status changes decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils non-specific respirations, decreased temperature, decreased BP, decreased HR, decreased increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils increased HR, increased BP, increased temperature, dilated pupils, seizures pupils, dilated temperature, increased BP, increased HR, increased nausea, coughing, vomiting, and mental status changes Pediatric Overdose / Toxic Ingestion / Toxic Overdose Pediatric : Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal Renal later. occur may status mental altered and Tachypnea vomiting. and pain abdominal of consist signs Early : Recommended Exam: Mental Stat Insecticides: Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has an Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month and 11 years and older > 90 mmHg. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid death. to status mental alert from progression Acetaminophen: Aspirin dysfunction, liver failure, and or cerebral edema among other things can take place later. Depressants: Stimulants: Anticholinergic: Solvents: Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. Nerve Agent Antidote kits can be obtained thr Atropine and 600 mg of pralidoxime in an autoinjector for self administration or patient care. These kits may be available as Destruction. Mass of Weapons for preparedness domestic the of part Contact Missouri Poison Control Center for guidance. (314-268-4195) Cardiac Medications: Pearls                Pediatric Diabetic

History Signs and Symptoms Differential  Past medical history  Altered mental status  Alcohol / drug use  Medications  Combative / irritable  Toxic ingestion  Recent blood glucose check  Diaphoresis  Trauma; head injury  Last meal  Seizures  Seizure  Abdominal pain  CVA  Nausea / vomiting  Altered baseline mental status.  Weakness  Dehydration  Deep / rapid breathing

Universal Patient Care Protocol

Blood Glucose Analysis Procedure B Supplemental oxygen to maintain SpO2 ≥ 94 % Cardiac Monitor P Pediatric Medical Protocols Section Blood Glucose if indicated < 80 mg / dL

Awake, PO Blood Glucose Blood Glucose NO tolerant? 80 – 200 mg / dL > 200 mg / dL YES Monitor blood Consider glucose B Oral Glucose Solution every 15 minutes P Venous Access Protocol If age appropriate Exit to Appropriate Protocol Dehydration with Improving? NO no evidence of YES NO CHF/ fluid P Venous Access Protocol overload? YES NO IV successful? YES Normal Saline Bolus 20 mL/kg IV / IO Glucagon 0.1 mg/kg IM P Repeat as needed to effect Max dose 1 mg <6 years old (<20 kg): P age appropriate SBP Repeat every 15 minutes to Blood Glucose <70 mg/dL Maximum 60 mL/kg keep blood glucose > 80 mg / dL Dextrose 10% 5cc/kg IV / IO May repeat bolus prn P >6 years old (>20 kg): Dextrose 10% 10 grams (100 cc) IV / IO bolus Continue infusion of D10, titrate blood glucose to >80 mg/dL Return to baseline Monitor and reassess mental status? P YES every 10 minutes NO

Exit to Pediatric Altered Mental Monitor and reassess Notify destination and consider Status Protocol P every 5 minutes contacting Medical Control

SSM EMS Protocols 2016 Pediatric Medical Protocols Section 2016 60 cc 70 cc 80 cc 90 cc 15 cc 20 cc 25 cc 30 cc 40 cc 50 cc 100 cc 100 cc VOLUME

swallow or protectswallow their airway. or Bolus DOSE 6 grams 7 grams 8 grams 9 grams 2 grams 3 grams 4 grams 5 grams 10 grams 1.5 grams 2.5 grams 10 grams initial IV eart, Lungs, Abdomen, Back, Neuro Extremities, eart, Lungs, Abdomen, titrate blood glucose to >80 mg / dL Continue infusion ofDextrose 10%, in 250 cc bag 250 in 6 kg 8 kg 3 kg 4 kg 5 kg 20 kg 10 kg 12 kg 14 kg 16 kg 18 kg SSM EMS Protocols >20 kg WEIGHT patientsthat are not able to mia my not respond to glucagon. Pediatric Diabetic Pediatric ̴6 years ̴3 years ̴4 years ̴5 years ̴3 months ̴6 months ̴1 months ̴2 months > 6 years > 6 years ̴< 1 month ̴12 months ̴18-24 months Approximate age Dextrose 10% comes packaged as 25 grams (0.1 gram/cc) of Dextrose of Dextrose gram/cc) (0.1 as 25 grams packaged comes 10% Dextrose Do not administer oral glucose to not administer oral glucose Do controlQualitychecks should be maintained per manufacturers glucometers. recommendation forall RecommendedH Exam:Skin, Mental HEENT, Status, Patients with prolonged hypoglyce   Pearls   Pediatric Medical Protocols Section 2016 NO 70 + 2 x Age Exit to Pediatric ≥ if indicated Protocol Pediatric Improving? Ondansetron Max4 mg dose Diabetic Protocol n, Back, Extremities, 20 mL / kg IV / IO SBP Normal Saline Bolus Maximum 60 mL / kg Venous Access Protocol Hypotension / Shock Hypotension / Do not give if age <3mos 0.2 mg/kg ODT / IV / IO / IM Repeat to effect age appropriate BP: YES

YES CNS (IncreasedCNS pressure, headache, or hemorrhage) trauma tumor, Drugs Appendicitis Gastroenteritis disorders Renal or GI Diabetic Ketoacidosis influenza) (pneumonia, Infections Electrolyte abnormalities P Differential         severe, very unlikely to be significantly s / Symptomss / 1 month - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x 70 + > - 10 years 70 mmHg, 1 1 year > month - 1 Pyloric stenosis, bowel obstruction, and CNS processes Procedure Protocol Pediatric Pain Control hydration is almost always increased heart rate. perfusion, shock? Hypotension, poor Simultaneously utilize Simultaneously s) all often present with isolated vomiting. Blood Glucose Analysis Blood Glucose Serious SignSerious contacting Medical Control Medical contacting Notify destination and consider Notify SSM EMS Protocols B Universal Patient Care Protocol YES Pain Distension Constipation Diarrhea Anorexia Fever Cough, Dysuria NO Signs and Symptoms Signs and         YES Pediatric Vomiting / Diarrhea Vomiting Pediatric NO NO Access Protocol Improving? Ondansetron Max dose 4 mg Abdominal Pain? 20 mL / kg IV / IO Normal Saline Bolus Do not give if age < 3 mos 0.2 mg / kg ODT / IV / IO / IM Venous P P Tachycardia increasesTachycardia as dehydration becomes more Recommended Abdome Mental Exam:HEENT, Neck, Heart, Lungs, Status,Skin, Neuro Heart Rate: One of the first clinical signs of de if heart rate is close dehydrated to normal. 60 mmHg, days > Age specific0 – 28 blood pressure or increasedtumors,(bleeding, CSF pressure age) mmHg and 11 years older and > 90 mmHg. Beware of only vomiting (i.e. no diarrhea) in children. Age Time of last meal Last bowel movement / emesis Improvement or worsening with activityfood or Other sick contacts PastMedical History Past Surgical History Medications history Travel diarrhea or Emesis Bloody Pearls     History           Pediatric Medical Protocols Section 2

2016 SpO 94 % 94 ≥

2 OR SpO YES Consider sedation? to attempt show signs of of signs show Severe Does the patient Moderate Continuously monitor Narcan 0.4 mg IV / IO maintain

Supplemental oxygen to Capnography Procedure Narcan 0.8 mg IntraNasal respiratory status with with status respiratory Venous Access Protocol Venous Access - open airway chin lift / jaw thrust - nasal airway - bag - valve mask (BVM) Max initial dose 75 mcg Per the specific protocol specific the Per Musculoskeletal (abdominal) Visceral Cardiac Respiratory / Pleural Neurogenic Renal (colic) P Fentanyl 2 mcg/kg IntraNasal P B NO

Differential        P YES ecific complaint

mcg/kg

dose st Enter from OR NO Assess pain severity of maximum of maximum Cardiac Monitor Morphine 0.1 mg/kg comfort unless sedation? contraindicated Fentanyl 0.5 Allow for position position for Allow show signs of of signs show every 5 minutes as needed SSM EMS Protocols Use combination of pain scale, Does the patient every 10 minutes as needed Severity (pain scale) Severity (pain Quality (sharp, dull, etc.) Radiation Relationmovement, respiration to Increased with palpationofarea until improvement. until improvement. Monitor and Reassess and Monitor Protocol based on sp Protocol based on Consider

10 minutes after 1 Signs and Symptoms Signs and      Maximummg 10 total dose circumstances, MOI, injury or illness severity Maximummcg150 total dose minutes following narcotic dose contacting Medical Control Medical contacting May repeat May repeat Vital signs and pain scale every 5 Notify destination and consider Notify IV / IO / IM

IV / IO / IM P P Pediatric Pain Control Pain Pediatric

ss Protocol Mild If indicated every 5 minutes Maximum 1000mg Monitor and Reassess Reassess and Monitor Venous Acce Acetaminophen15 mg/kg PO Age Location Duration Severity (1 - 10) If child use Wong-Baker faces scale history medical Past Medications Drug allergies History         P B Pediatric Medical Protocols Section 2016 eded to assess pain ment PainProcedure) scale (0-7 yrs) as ne as scale (0-7 yrs) sedation such as open fractures or fracture deformities. ts less than 10kg se the adult pain control protocol, realizing that the adult e and post IV or IM medication delivery and at disposition. FLACC score (see Assess (see score FLACC SSM EMS Protocols opioids to patien ces (4-16yrs) or FLACC 5 minutes post, and at disposition with all pain medications. atus, Area of Pain, Neuro include hypotension, head injury, distress.or respiratory

Pediatric Pain Control Pain Pediatric is also weight-based. This protocol applies patientsto less than 12 years of age or who can bemeasured on the Broselow-Luten tape. If a patient is larger than tape, the Broselow-Luten you may u For children use Wong-Baker faces scale or the USE EXTREME CAUTION in administering USE EXTREME CAUTION in administering pain control protocol Pain severity (0-10) is a vital sign to be recorded pr Recommended Exam: Mental St Vital signs should be obtained pre, Contraindications to Opioid use All patients who receive IM or IV medications must be observed 15 minutes for drug reaction. need may who patients for PO medications any administer not Do fa (> 9 yrs), Wong-Baker Numeric Use     Pearls       Trauma/Environmental

Section Table of Contents

CDC Trauma Guidelines Spinal Motion Restriction Traumatic Arrest Trauma/Environmental Protocols Section Adult Multiple Trauma Pediatric Multiple Trauma Adult Head Trauma Pediatric Head Trauma Eye Injury Extremity Trauma Crush Syndrome Thermal Burns Chemical/Electric Burns Blast Injury Drowning/Submersion Injury Hypothermia Hyperthermia Bites/Envenomations

SSM EMS Protocols 2016 CDC Trauma Guidelines

FIGURE 2. Guidelines for field triage of injured patients — United States, 2011

Measure vital signs and level of consciousness

Step One Glasgow Coma Scale ≤13 Systolic Blood Pressure (mmHg) <90 mmHg Respiratory rate <10 or >29 breaths per minute* (<20 in infant aged <1 year), or need for ventilatory support Transport to a trauma No center.† Steps One and Two attempt to identify the most seriously injured Assess anatomy Yes patients. These patients of injury should be transported preferentially to the highest level of care within Step Two§ • All penetrating injuries to head, neck, torso and extremities proximal to elbow or knee the de ned trauma system. • Chest wall instability or deformity (e.g., flail chest) • Two or more proximal long-bone fractures • Crushed, degloved, mangled, or pulseless extremity • Amputation proximal to wrist or ankle • Pelvic fractures • Open or depressed skull fracture • Paralysis

No

Assess mechanism of injury and evidence of high-energy impact

Step Three§ • Falls — Adults: >20 feet (one story is equal to 10 feet) — Children¶: >10 feet or two or three times the height of the child Transport to a trauma • High-risk auto crash center, which, depending — Intrusion,** including roof: >12 inches occupant site; >18 inches any site upon the de ned trauma Yes — Ejection (partial or complete) from automobile system, need not be the — Death in same passenger compartment highest level trauma — Vehicle telemetry data consistent with a high risk of injury center.§§ • Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact†† • Motorcycle crash >20 mph

No

Assess special patient or system considerations

Step Four • Older adults¶¶ — Risk of injury/death increases after age 55 years — SBP <110 might represent shock after age 65 years — Low impact mechanisms (e.g. ground level falls) might result in severe injury Transport to a trauma • Children center or hospital capable — Should be triaged preferentially to pediatric capable trauma centers of timely and thorough evaluation and initial • Anticoagulants and bleeding disorders Yes — Patients with head injury are at high risk for rapid deterioration management of potentially • Burns serious injuries. Consider — Without other trauma mechanism: triage to burn facility*** consultation with medical — With trauma mechanism: triage to trauma center*** control. • Pregnancy > 20 weeks • EMS provider judgment

No

Transport according to protocol†††

MMWR / January 13, 2012 / Vol. 61 / No. 1 Trauma/Environmental Protocols Section 2016 If indicated Procedure Procedure Pain Protocol Assessment: Pain Sensation q 5 min. Sensation Default is Any doubt Spinal Motion Restriction Reassess Pulse, Motor, and always immobilize always immobilize B B B

YES YES YES Exit to Appropriate Protocol YES YES YES YES NO NO NO or SSM EMS Protocols Inability to questions? intoxication? YES distract the patient of drug or alcohol Any injury thatmight from a c-spine injury? a c-spine from communicate? Repeats Repeats communicate? Reasonable suspicion AND NO NO NO NO Spinal Motion Restriction Motion Spinal the spine? palpatation? Procedure Procedure Spinal pain or or pain Spinal altered level of consciousness? tenderness upon motor weakness) Blunt trauma (e.g., numbnessor NO Anatomic deformity of of deformity Anatomic Neurologic complaint? complaint? Neurologic Spinal Examination Not Required Circumstance that may warrant Assessment: Adult / Peds. Assessment: / Adult Entry from appropriate protocolEntry from spinal motionrestriction consideration High Energy Impact? Spinal Immobilization B Document exclusion criteria in ePCR Spinal Motion Restriction Trauma/Environmental Protocols Section

This protocol is based on the official position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma regarding emergency medical services spinal precautions and the use of the long backboard.

Pearls  Recommended Exam: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro  Consider immobilization in any patient with arthritis, cancer, dialysis or other underlying spinal or bone disease.  The decision to NOT implement spinal immobilization in a patient is the responsibility of the paramedic solely.  In very old and very young, a normal exam may not be sufficient to rule out spinal injury.  Significant mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes and may indicate the need for spinal immobilization.  Range of motion should NOT be assessed if patient has midline spinal tenderness.  If a long backboard is withheld, document exclusion criteria in patient’s ePCR.  Spinal Motion Restriction Guidelines: 1. Long spine boards (LSB) have both risks and benefits for patients and have not been shown to improve outcomes. The best use of the LSB may be for extricating the unconscious patient, or providing a firm surface for compressions. However, several devices may be appropriate for patient extrication and movement, including the scoop stretcher and soft body splints. 2. Utilization of the LSB should be judicious, and occur in consideration of the individual patient’s benefit vs. risk. 3. Patients for whom immobilization on a backboard is not necessary include those with all of the following: - Normal level of consciousness (Glasgow Coma Score [GCS] 15) - No spine tenderness or anatomic abnormality - No neurologic findings or complaints - No distracting injury - No intoxication 4. Patients with penetrating trauma and no evidence of spinal injury do not require spinal immobilization. Patients who are ambulatory at the scene of blunt trauma in general do not require immobilization via LSB, but may require cervical collar and spinal precautions. 5. Whether or not a LSB is utilized, spinal precautions are STILL VERY IMPORTANT in patients at risk for spinal injury. Adequate spinal precautions may be achieved by placement of a hard cervical collar and ensuring that the patient is secured tightly to the stretcher, ensuring minimal movement and patient transfers, and manual in-line stabilization during any transfers.

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016

Exit to BP: 70 + 2 x Age) ≥ Appropriate Protocol Normal Saline or (SBP Bolus 20 mL/kg IV / IO Max total dose 60 mL/kg

other Crystalloid Solution Repeat to effect age appropriate YES External hemorrhage Unstable bone long Displaced fracture(s) Hemothorax hemorrhage Intra-abdominal hemorrhage Retroperitoneal P Medical condition Medical preceding traumatic of arrest. event as cause Pneumothorax Tension Hypovolemic Shock       Differential:    YES

or

NO NO 90 ≥ Chest Injury? TO < 10 MIN Return of pulse? incompatible with life Known or Suspected LIMIT ON SCENE TIME Airway: BIAD Procedure Patient with injury obviously traumatic arrest in asystole? NO NO Universal Patient Care Protocol Spine Motion Restriction Protocol nous Access Protocol Maximum 2 L Pediatric patient? Normal Saline or YES B YES Bolus 500 mL IV / IO Repeat to effectSBP other Crystalloid Solution SSM EMS Protocols Ve Evidence ofEvidence penetrating trauma blunt trauma ofEvidence P P  Signs and Symptoms: Signs and  NO Procedure Traumatic Cardiac Arrest Cardiac Traumatic Consider Exit to scene. Bilateral Chest Decompression Protocol P Deceased Persons Persons Deceased TERMINATION OF EFFORTS contacting Medical Control Medical contacting Do not attempt resuscitation. Notify destination and consider Notify Contact law enforcement if not on P History: sufferedPatient who has traumatic injuryis and now pulseless  Traumatic Cardiac Arrest Trauma/Environmental Protocols Section

Pearls:  Injuries obviously incompatible with life include decapitation, massively deforming head or chest injuries, or other features of a particular patient encounter that would make resuscitation futile. If in doubt, place patient on the monitor.  Use medical cardiac arrest protocols if uncertainty exists regarding medical or traumatic cause of arrest.  As with all major trauma patients, transport should generally not be delayed for these patients.  Where the use of spinal immobilization interferes with performance of quality CPR, make reasonable efforts to manually limit patient movement.

SSM EMS Protocols 2016 Adult Multiple Trauma

History Signs and Symptoms Differential (Life threatening)  Time and mechanism of injury  Pain, swelling  Chest: Tension pneumothorax  Damage to structure or vehicle  Deformity, lesions, bleeding Flail chest, Hemothorax  Location in structure or vehicle  Altered mental status or Pericardial tamponade  Others injured or dead unconscious Open chest wound  Speed and details of MVC  Hypotension or shock  Intra-abdominal bleeding  Restraints / protective  Arrest  Pelvis / Femur / Spine fracture, cord injury equipment  Head injury (see Head Trauma)  Past medical history  Extremity fracture / Dislocation  Medications  HEENT (Airway obstruction)  Hypothermia

Universal Patient Care Protocol

Airway Protocol(s) if indicated B Spine Motion Restriction Trauma/Environmental Protocols Section Protocol Venous Access Protocol P Cardiac Monitor

Assess Vital signs Abnormal Normal Perfusion / GCS

Rapid Transport to appropriate destination using Adult Trauma and Burn Facility Limit Scene Time ≤ 10 minutes Provide Early Notification Wound Care: General Wound Care: General Procedure Procedure B Splinting Procedure Adult Head Injury Protocol B if indicated if indicated Adult Normal Saline Bolus 500 mL IV / IO Hypotension / Repeat Assessment: Adult Repeat to effect SBP ≥ 90 Shock Protocol Procedure Maximum 2 Liters if indicated Pain Control: Adult Protocol P P Chest Decompression-Needle if indicated Procedure Monitor and Reassess if indicated B Transport to appropriate Splinting Procedure Adult Trauma / Burn Facility if indicated B Repeat Assessment: Adult Procedure Pain Control: Adult Protocol P if indicated B Monitor and Reassess

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Adult Multiple Trauma Trauma/Environmental Protocols Section

Pearls  Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro  Items in Red Text are key performance measures used in the EMS Acute Trauma Care Toolkit  Transport Destination is chosen based on the EMS System Trauma Plan with EMS pre-arrival notification.  Scene times should not be delayed for procedures. These should be performed en route when possible. Rapid transport of the unstable trauma patient to the appropriate facility IS the goal.  Check PMS before and after stabilizing extremity fractures.  Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained ≥ 90%  Geriatric patients should be evaluated with a high index of suspicion. Often occult injuries are more difficult to recognize and patients can decompensate unexpectedly with little warning.  Mechanism is the most reliable indicator of serious injury.  In prolonged extrications or serious trauma, consider air transportation for transport times and the ability to give blood.  Do not overlook the possibility of associated domestic violence or abuse.

SSM EMS Protocols 2016 Pediatric Multiple Trauma

History Signs and Symptoms Differential (Life threatening)  Time and mechanism of injury  Pain, swelling  Chest: Tension pneumothorax  Damage to structure or vehicle  Deformity, lesions, bleeding Flail chest, Hemothorax  Location in structure or vehicle  Altered mental status or Pericardial tamponade  Others injured or dead unconscious Open chest wound  Speed and details of MVC  Hypotension or shock  Intra-abdominal bleeding  Restraints / protective  Arrest  Pelvis / Femur / Spine fracture, cord injury equipment  Head injury (see Head Trauma)  Past medical history  Extremity fracture / Dislocation  Medications  HEENT (Airway obstruction)  Hypothermia

Universal Patient Care Protocol

Pediatric Airway Protocol(s) B if indicated Trauma/Environmental Protocols Section Spine Motion Restriction Protocol Venous Access Protocol P Cardiac Monitor

Assess Vital signs Abnormal Normal Perfusion / GCS

Rapid Transport to appropriate destination using Pediatric Trauma and Burn Facility Limit Scene Time ≤ 10 minutes Provide Early Notification Wound Care: General Wound Care: General Procedure B Procedure Pediatric Head Injury Protocol Splinting Procedure if indicated B if indicated Normal Saline Pediatric Repeat Assessment: Pediatric Bolus 20 mL/kg IV / IO Hypotension / Procedure Repeat to effect age appropriate Shock Protocol Pain Control Protocol SBP ≥ 70 + 2 x Age if indicated P P Maximum 60 mL/kg if indicated Chest Decompression-Needle B Monitor and Reassess Procedure Transport to appropriate if indicated Pediatric Trauma / Burn Facility Splinting Procedure if indicated B Repeat Assessment: Pediatric Procedure Pain Control Protocol P if indicated B Monitor and Reassess

Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016 90% ≥ be performed be performed en route when possible. Rapid EMS Acute Trauma Care Toolkit the airway if pulse oximetry can be maintained SSM EMS Protocols t to the appropriate facility is the goal. Pain management for isolated injuries procedures. These should ormance measures used in the Pediatric Multiple Trauma Multiple Pediatric Items in Red Text are key perf Scene times should be not delayed for transport of the unstable trauma patien Bag valve mask is an acceptable method of managing Age specific blood pressure 0 – 28 days > 60 mmHg, 1 month - 1 year > 70 mmHg, 1 - 10 years > 70 + (2 x age)mmHg and 11 years and older > 90 mmHg. Consider Chest Decompression with signs of shock and injury to torso and evidence of tension pneumothorax. See Trauma Triage and Destination plan, or Adult Multiple Trauma Pearls, for Trauma Criteria Severe bleeding from an extremity not rapidly controlled with direct pressure may necessitate the application of a tourniquet. Do not overlook the possibility of child abuse. Pearls         Trauma/Environmental Protocols Section 2016 2 94 % ≥ 35 – 45 mmHg YES 35– 45 mmHg if indicated Maintain EtCO 2 Supplemental oxygen Monitor and Reassess and Monitor Maintain SpO2 Pupils / Posturing Brain Herniation Airway Protocol(s) EtCO per minutes to maintain B Hyperventilate 14 – 16 Breaths Unilateral or Bilateral Dilation of Skull fracture Brain injury (Concussion, Contusion, Hemorrhageor Laceration) Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse Able to Cough? Differential        NO YES 2 ss Protocol 8? 35 – 45 mmHg Maintain EtCO ≤ GCS Airway Protocol(s) SSM EMS Protocols B Record GCS contacting Medical Control Medical contacting Pain, swelling, bleeding Altered mental status Unconscious / failure distress Respiratory Vomiting Major traumatic mechanism of injury Seizure if indicated if indicated if indicated Notify destination and consider Notify Seizure Protocol Assess Mental Status Mental Assess Signs and Symptoms        Capnography Procedure Venous Acce Altered Mental Status Protocol Blood Glucose Analysis Procedure Blood Glucose Adult Multiple Trauma Protocol Spinal Motion Restriction Protocol Universal Patient Care Protocol Adult Head Trauma Head Adult NO P B DO NOT DO NOT 35 – 45 mmHg 2 Monitor and Reassess and Monitor Time of injury Time of Mechanism (blunt vs. penetrating) Loss of consciousness Bleeding history medical Past Medications Evidence for multi-trauma HYPERVENTILATE EtCO per minute to maintain Ventilate 8 – 10 Breaths History        B Adult Head Trauma Trauma/Environmental Protocols Section

Pearls  Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro  GCS is a key performance measure used in the EMS Acute Trauma Care Toolkit.  If GCS < 12 consider air / rapid transport as per protocol and policy  Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response).  Hypotension usually indicates injury or shock unrelated to the head injury and should be aggressively treated.  An important item to monitor and document is a change in the level of consciousness by serial examination.  Consider Restraints if necessary for patient’s and/or personnel’s protection per the Restraint Procedure.  Limit IV fluids unless patient is hypotensive.  Concussions are traumatic brain injuries involving any of a number of symptoms including confusion, LOC, vomiting, or headache. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP.

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section

or

2016

Pediatric if indicated Exit to Pediatric Diabetic Protocol Seizure Protocol Altered Mental Status Skull fracture Brain injury (Concussion, Contusion, Hemorrhage) Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Spinal injury Abuse Differential        YES

NO NO YES YES Protocol if indicated Hypotension Oxygenation? Seizure Activity? (SBP < 70 + 2 x Age) Adequate Ventilation / Isolated Head Trauma? Poor Perfusion / Shock? Obtain and Record GCS evaluate protocol compliance and care SSM EMS Protocols Venous Access Protocol Venous Access nd if GCS < 9 intubation should be anticipated. Pain, swelling, bleeding Altered mental status Unconscious / failure distress Respiratory Vomiting Major traumatic mechanism of injury Seizure Spinal Motion Restriction contacting Medical Control Medical contacting Notify destination and consider Notify Signs and Symptoms Signs and        Blood Glucose Analysis Procedure Blood Glucose Universal Patient CareProtocol us, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro P B YES NO NO Pediatric Head Trauma Head Pediatric Exit to Protocol Protocol(s) Protocol Pediatric Pediatric Airway Simultaneously utilize Simultaneously Simultaneously utilize Simultaneously Multiple Trauma GCS is a key performance measure used to If GCS < 12 consider/ air rapid transport a Hyperventilate the patient only if evidence herniationof (blown pupil, decorticate / decerebrate posturing, bradycardia, decreasing GCS). If hyperventilation is needed (35 / minute for infants <1 year and 25 / minute for children >1 year) EtCO2 should be maintained between 30 - 35 mmHg. Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively. An important item to monitor and document is a change in the level of consciousness by serial examination. Concussions are traumaticbrain injuries involvingofa number anyofsymptoms includingconfusion, LOC, vomiting, or headache. Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any should by a physician ASAP. be evaluated documented loss of consciousness Fluid resuscitation should be titrated to maintain at least a systolic BP of > 70 + 2 x the age in years. Recommended Exam: Mental Stat Time of injury Time of Mechanism (blunt vs. penetrating) Loss of consciousness Bleeding history medical Past Medications Evidence for multi-trauma         Pearls  History        Pediatric Hypotension / Shock Trauma/Environmental Protocols Section 2016 YES Physical trauma Physical Maximum 4 mg (when feasible) ODT / IV / IO / IM Rupture of Globe? Penetrating Trauma/ Assess visual acuity Assess orbital stability Assess orbital Ondansetron 0.2 mg/kg Do not give if age < 3mos Simultaneously utilize Simultaneously P Appropriate Protocol(s) B NO Mechanism? Abrasion/Laceration Globe rupture Retinal nerve damage/detachment burn/agentChemical/thermal of terror Orbital fracture Orbital compartment symdrome Neurological event Acute glaucoma Retinal artery occlusion NO  Differential:         Burn / chemical NO Procedure 314-268-4195 ry and need repeated assessmentsry ofvisual status. YES with normal saline es require emergent in-facility intervention. Cover unaffected eye unaffected Cover Eye(s) out of socket? Wound Care: Irrigation Wound Care: Irrigation Contact poison control Morgan Lens Procedure with available saline or water should raise suspicion of respiratory insult. Isolated to eye(s)? P B P B YES ma to eyes. Pads OK for unaffected eye. SSM EMS Protocols Pain, swelling, blood Deformity, contusion Visual deficit Leaking aqueous/vitreous humor Upwardlyeye fixed "Shooting" or "streaking" light Visible contaminants Rust ring Lacrimation esent even with severe eye injury.          Signs and Symptoms: Signs and Cover with saline gauze moistened Injury B Eye Injury / Complaint Injury Eye Nature? if indicated if indicated Pain / visual contacting Medical Control Medical contacting Pain Protocol Evaluate Pupils Cover Both Eyes Notify destination and consider Notify Assess Visual Acuity Complete Neuro Exam Complete Neuro Screen for Unrecognized Chemical/Agent Exposure Always cover both eyes to prevent further injury. Use shields, not for physical trau pads, objects. not remove impaled Do or compartment syndrom rupture Suspected globe Any chemicalface/eyestothermal the burn or inju or nerve of globe concern Orbital fractures raise Normal visual acuity can be pr Remove contact lens whenever possible. Normal visual acuity Medications Wound Contamination Medical History status Open vs. closedOpen vs. injury Involved chemicals/MSDS Time of injury/onset Blunt/penetrating/chemical Protocol Venous Access B Universal Patient CareProtocol P       Pearls:          History:   Trauma/Environmental Protocols Section 2016 Abrasion Contusion Laceration Sprain Dislocation Fracture Amputation Consider Differential        if indicated Procedure if indicated Age Appropriate Agent Procedure Hypotension / Age Appropriate Monitor and Reassess and Monitor Pain Control Protocol Shock Protocol(s) steriledressing soaked in normal Wound Care-Tourniquet Place container on ice if available. if ice on container Place Clean amputated part, wrap part in Wound Care – Hemostatic saline, place part in air tight container. Tourniquet Procedure FIRST. B P B B YES NO s. Consider antibiotics especially in cases in which YES and anyandespeciallytime is amputation; these critical in collapse scenarios), but only after providing other ions have a high incidence of vascular compromise.

ening hemorrhage: Considerening hemorrhage: Pain, swelling Deformity Altered sensation / motor function Diminished pulse / capillary refill Decreased extremity temperature within 6 hours from the time of injury.hoursthe time within 6 from s / Symptoms SSM EMS Protocols NO      Signs and Symptoms Signs and shock? if indicated Procedure Amputation? if indicated Splinting Procedure Bleeding Controlled by Controlled Bleeding Wound Care - General Serious SignSerious Direct Pressure / Dressings? Hypotension,perfusion, poor Extremity Trauma Extremity Protocol Venous Access Universal Patient Care Protocol P B YES if indicated Age Appropriate contacting Medical Control Medical contacting Monitor and Reassess and Monitor Pain Control Protocol Notify destination and consider Notify P B Type of injury Mechanism: crush / penetrating / amputation injury Time of Open vs. closed wound / fracture Wound contamination Medical history Medications Peripheral neurovascularis important status and shouldbe examined and recorded. Early antibiotic administrationbeneficial is fracture in open Recommended Exam:Neuro Mental Extremity, Status, transportcrush,delayed may (i.e. entrapment, be MCI, emergency care including hemorrhage control. Hip dislocations and knee and elbow fracture / dislocat Urgently transport any injury vascular with compromise Multiple casualtyobvious incidentlife threat or cases. withapparent extremity injuries. lossBloodbe concealed may or not Lacerations should be evaluatedrepair for   Pearls   History            Trauma/Environmental Protocols Section 2016 consider

NO NO 0.12 seconds 0.46 seconds ≥ ≥ Hypotension / 50 mEq IV / IO Midazolam 0.1-0.2 mg/kg Loss of P wave?

Peaked T Waves? T Peaked QT Entrapped > 1 hour? QRS Sodium Bicarbonate Age appropriate Peds: 1 mEq/kg IV / IO Monitor and Reassess and Monitor (max dose 2 mg total) Pain Control Protocol

IV / IO / IntraNasal / IM Monitor for fluid overload Immediately Prior to Extrication Give slowly over 2–3 minutes; In addition to Opioids, FOR THIS DRUG COMBINATION NO consider giving in divided doses and P Entrapment without crush syndrome crush significant without Entrapment Altered mental status PREPARE TO MANAGE THE AIRWAY PREPARE TO MANAGE AdultPeds and YES YES Differential    P

VF / VT? VF / rate nous Access Protocol Asystole / PEA if indicated Cardiac Monitor Age Appropriate Airway Protocol(s) 50 mEq IV / IO Over 3 minutes 12 Lead ECG Procedure Normal Saline Bolus Sodium Bicarbonate Peds: 20 mL/kg IV / IO Peds: 20 mg/kg IV / IO Peds: 1 mEq/kg IV / IO Ve 1 L then 500 mL/hr IV / IO consider separate IV lines 20 cc of Normal Saline or Calcium Chloride 1 g IV / IO SSM EMS Protocols seemaintenance Pearls for fluid and / or Flush IV line with a minimum of Universal Patient Care Protocol P B Protocol(s) as indicated YES P P Hypotension Hypothermia Abnormal ECG findings Pain Anxiety Considerappropriate age Multiple Trauma Protocol Signs and Symptoms Signs and      Hypothermia / Hyperthermia Crush Syndrome Trauma Syndrome Crush contacting Medical Control Medical contacting

Notify destination and consider Notify Exit to fluid rate 1 g IV / IO IV1 g as indicated 50 mEq IV / IO Over 3 minutes Cardiac Arrest Cardiac Arrest Age Appropriate Calcium Chloride Pulseless Arrest / Sodium Bicarbonate Normal Saline Bolus 20 cc of Normal Saline consider separate IV lines Peds: 20 mL/kg IV / IO Peds: 20 mg/kg IV / IO Peds: 1 mEq/kg IV / IO Arrhythmia Protocol(s)Arrhythmia of 1 L then 500 mL/hr IV / IO seemaintenance Pearls for Entrapped and crushed under heavyminutes> 30 load Extremity / body crushed Building collapse, trench collapse, industrial accident, pinned under heavy equipment or Flush IV line with a minimum P History    Crush Syndrome Trauma Trauma/Environmental Protocols Section

Pearls  Recommended exam: Mental Status, Musculoskeletal, Neuro  Scene safety is of paramount importance as typical scenes pose hazards to rescuers. Call for appropriate resources.  Avoid Ringers Lactate IV Solution due to potassium and potential worsening hyperkalemia  Hyperkalemia from crush syndrome can produce ECG changes described in protocol, but may also cause a bizarre, wide complex rhythm. Wide complex rhythms should also be treated using the VF/Pulseless VT Protocol.  Patients may become hypothermic even in warm environments.  Pediatric IV Fluid maintenance rate: 4 mL per first 10 kg of weight + 2 mL per second 10 kg of weight + 1 mL for every additional kg in weight.  The combination of opioids and benzodiazepines represents an increased level of anesthesia from either medication alone. This is the only protocol in which this combination of medications may be utilized without a direct order from medical control. There is a significant risk of airway compromise with this combination of medications; prepare to manage the airway prior to medication administration, administer supplemental oxygen, and EtCO2 waveform capnography must be in place prior to administration. If the patient is in a position in which you cannot adequately manage the airway, do not give this combination of medications.

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016

early Degree Burn rd /3 nd Cyanide Protocol Cyanide Carbon Monoxide / Monoxide Carbon Simultaneously utilize compromise Critical Burn Degree) blistering nd Burns with definitiveairway Burns with MultipleTrauma Trauma and Burn: Pharmacologically Pharmacologically Degree) painless/charred or

(Transport to a Burn Center) rd if indicated YES >15% TBSA 2 >15% TBSA Normal Saline Degree) red - painful(Don’t include Age appropriate Age appropriate st (More info below) Airway Protocol(s) Pain Control Protocol for upto the first 8 hours. 0.25 mL / kg ( x % TBSA) / hr Lactated Ringers if available Consider EMS Triage and Destination Plan Assisted Intubation Protocol Age appropriate in TBSA) Partial Thickness (2 Superficial (1 leathery skin injury Thermal injury Electrical – Chemical Radiation injury Blast injury Full Thickness (3 NO P B  Rapid Transport to appropriate destination using Differential       Degree Burn B Cyanide Exposure Cyanide Carbon Monoxide / rd /3 nd Serious Burn Serious Assess Burn / Concomitant Injury Severity SSM EMS Protocols (Transport to a Burn Center) Hypotension or GCS 13 or Less intubation for airway stabilization 5-15% TBSA 2 5-15% TBSA contacting Medical Control Medical contacting Suspected inhalationrequiring injuryor Burns, pain, swelling Dizziness Loss of consciousness Hypotension/shock Airway compromise/ distress could be indicated by hoarseness/wheezing Notify destination and consider Notify Thermal Burns Thermal Signs and Symptoms     

Degree Burn Degree rd if indicated if indicated /3 Procedure nd nous Access Protocol Normal Saline Minor Burn Age appropriate Age appropriate Constricting Items (More info below) Normotensive Pain Control Protocol for upto the first 8 hours. hands,perineum, or feet. Remove Rings, Bracelets / Multiple Trauma Protocol 1. Lactated Ringers preferred over Normal Saline. Use if available, if not change over once available. 2. Formula example; an 80 kg (196 lbs.) patient with 50% TBSA will need 1000 cc of fluid per hour. GCS 14 or Greater Dry Clean Sheet or dressings 0.25 mL / kg ( x % TBSA) / hr Lactated Ringers if available Burn Center for burns on the face, Carboxyhemoglobin Monitoring Ve Transport Facility of Choice; Consider Type of exposure (heat, gas, chemical) Inhalation injury Injury of Time Past medical history and Medications Other trauma Loss of Consciousness Tetanus/ status Universal Patient Care Protocol < 5% TBSA 2 < 5% TBSA P B No inhalation injury, Not Intubated, P B B History        Trauma/Environmental Protocols Section

2016

st th and 6 and th 5 th lue of identifyinga ) thickness ) thickness burns. rd degree burn from those of burn degree st ) or full (3 nd secondary to soft tissue referring to a burn that destroys referring to a burn that destroys referring to a burn that destroys th th th 4 the dermis and involves muscle the dermis and tissue. 5 penetratesdermis, tissue, muscle and involves tissue around the bone. 6 dermis, destroys muscle tissue, and tissue. bone or destroys penetrates Seldom do you find a complete isolated body part that is injured as describedin the Rule of Nines. More likely, it will be portions of one area, anapproximation portions of another, and needed.will be For the purpose of determining the extent injury,of serious differentiate the area with minimal or 1 partial (2 degree burns. There is significant debate burns. There degree va regarding the actual burn injury beyond that of the superficial, partial and full thickness burn at least at the level of emergent and primary care. For our work, all included are in Full Thickness burns. Other burn classificationsin general degree) burns degree) burns but do not include those in your TBSA estimate. burns Some texts will refer to 4  include: For the purpose of determining Total Body of burn,only includeSurface Area (TBSA) Partial and Full burns. Thickness Report superficialthe observation of other (1   Rule of Nines       art, Lungs, Abdomen, Extremities, Back, and Neuro Abdomen,and Lungs, Extremities,art, Back, degree burns, or degree burns, or rd or 3 nd SSM EMS Protocols e dangerous due to potent ial vascular compromise Thermal Burns Thermal

, perineum, or feet , perineum, or Estimate spotty areas of burn by using the size of the patient’s palm 1 as % degree burns > 5% TBSA for any age group, or rd > 5-15% total body surface area (TBSA) 2 circumferential burns of extremities, or electrical or lightning injuries, or suspicion of abuse or neglect, or inhalation injury, or chemical burns, or burns of face, hands 3 Recommended Exam: Mental Status, HEENT, Neck, He Green, Yellow and Red In severity burn do not apply to Startthe / JumpStart Triage System. Critical or Serious Burns: Require direct transport to a Burn Center. Local facility should be utilized only if critical interventions such as airway airway as such interventions critical if only utilized be should facility Local Center. Burn a to transport direct Require management are not possible in the field. Circumferential extremities burns to ar swelling. Burn patients are often trauma patients, evaluate for multisystem trauma. Assure whatever has caused the burn is no longer contacting the injury. (Stop the burning process!) Early intubation is required when the patient experiences significant inhalation injuries. If the patient requires airway management that cannot be achieved in the field, go to the nearest emergency department for stabilization prior to transfer to the Burn Center. Burn patients are prone to hypothermia - neverapply ice or cool the burn, must maintain normal body temperature. Evaluate the possibility of child abuse with children and burn injuries. Never administer IM pain injections to a burn patient. Pearls            Chemical and Electrical Burn

History Signs and Symptoms Differential  Type of exposure (heat, gas,  Burns, pain, swelling  Superficial (1st Degree) red - painful chemical)  Dizziness (Don’t include in TBSA)  Inhalation injury  Loss of consciousness  Partial Thickness (2nd Degree) blistering  Time of Injury  Hypotension/shock  Full Thickness (3rd Degree) painless/  Past medical history /  Airway compromise/distress could charred or leathery skin Medications be indicated by hoarseness/  Thermal injury  Other trauma wheezing / Hypotension  Chemical – Electrical injury  Loss of Consciousness  Radiation injury  Tetanus/Immunization status  Blast injury Assure Chemical Source is NOT Hazardous to Responders. Assure Electrical Source is NO longer in contact with patient before touching patient.

Universal Patient Care Protocol

YES Burn from a chemical source? NO Trauma/Environmental Protocols Section Decontamination B Procedure Exit to Patient in cardiac arrest? YES Age appropriate YES Patient in cardiac arrest? Cardiac Arrest NO Protocol(s) NO

Exit to B 12 Lead EKG Procedure Respiratory distress? YES Age appropriate Respiratory Distress Cardiac monitor P NO Protocol(s) Venous Access Protocol

Wound Care: Irrigation Procedure Exit to preferably Normal Saline for Age appropriate YES Symptomatic arrythmia? B 15 minutes Cardiac Arrest Protocol(s) Supplemental oxygen to NO maintain SpO2 ≥ 94 % Supplemental oxygen to maintain SpO2 ≥ 94 % Eye Involvement? YES Identify contact points B Attempt to identify then nature of NO Wound Care: Irrigation the electrical source (AC / DC,) the Morgan Lens Procedure P amount of voltage and the Normal Saline for 15 amperage the patient may have minutes been exposed to Age appropriate P Pain Control Protocol Venous Access Protocol if indicated P Age appropriate Pain Control Protocol if indicated

Exit to Age Appropriate Thermal Burn Protocol

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016 Do not refer to not refer to Do rigation using tap water. Extremities, Back, and point where the patient contacted the the amountthe amperage of voltage and the generally be full thickness. Flush the area as soon as possible with the not available, do not delay ir Heart, Lungs, Abdomen, source of the electrical shocksourcedisconnected. isof the obvious external burn from an electrical source, from an electrical burn obvious external the pply to the Start / JumpStart Triage System. solution using copiousfluids. amountsof during theelectrical shock. rally there will be two or more) A SSM EMS Protocols r or irregularityatrial including VT, VF, atrial fibrillation and / or heart . ient is grounded. Sites will grounded. ient is the electrical source (AC / DC,) / the electrical source (AC ensive internal damage not seen. damage not ensive internal Chemical and Electrical Burn Electrical and Chemical the patient may have been exposed to blocks. natureAttempt to identify thenof as entry and exit sites or wounds sites or as entry and exit CardiacAnticipate ventricula Monitor: DO NOT contact patient until you are certain the (gene points contact Attempt to locate source and a point(s)the pat where Refer to DecontaminationProcedure. howeverpreferred, if Water is Normal Saline or Sterile cleanest readily available water or saline Other water sources may be used based on availability. Contact poison control 314-268-4195 Electrical Burns: Recommended Exam: MentalNeck, Status, HEENT, Neuro Green, Yellow and Red not a In burn severity do Refer to Rule of Nines: Remember the extent of does not always reflect more ext not does Chemical Burns:  Pearls     Trauma/Environmental Protocols Section 2016 Exit to Protocol Degree) blistering nd Degree)painless/ Exit to Exit to Radiation Incident rd Protocol Degree) red - painful st Thermal Burn / Age Appropriate Trauma Protocol Crush Syndrome Chemical and Electrical Burn and Electrical Chemical YES (Don’t include in TBSA) Partial Thickness (2 Superficial (1 charred or leathery skin injury Thermal injury – Electrical Chemical Radiation injury Blast injury Full Thickness (3  Differential       YES YES NO NO NO Access Protocol if indicated Exposure? Radiation Burn or Burn Radiation Blast Lung Injury? NO NO Trauma Center Center Trauma

Resources are insufficient for all to be treated immediately? if indicated Exposure? if indicated if indicated Crush Injury? Cardiac monitor Electrical Burn or Burn Electrical Venous Universal Patient Care Protocol Spine Motion Restriction Protocol Age appropriate Age appropriate Thermal / Chemical / Rapid Transport to YES SSM EMS Protocols P Pain Control Protocol appropriate B Multiple Trauma Protocol contacting Medical Control Medical contacting YES Burns, pain, swelling Dizziness Loss of consciousness Hypotension/shock could compromise/distress Airway be indicated by hoarseness/ wheezing / Hypotension Notify destination and consider Notify P B Signs and Symptoms Signs and      Blast Injury / Incident / Injury Blast if indicated resources begin early Triage Protocol if indicated Airway Protocol Call for help / additional

Age appropriate Procedure Chest Decompression B Type of exposure (heat, gas, chemical) Inhalation injury Injury of Time / history medical Past Medications Other trauma Loss of Consciousness Tetanus/Immunization status P B History        Blast Injury / Incident

Nature of Device: Agent / Amount. Industrial Explosion. Terrorist Incident. Improvised Explosive Device. Consideration of Dirty Bomb or WMD. Activation of Haz-Mat is mandatory for decontamination and scene assessment. Method of Delivery: Incendiary / Explosive Nature of Environment: Open / Closed. Distance from Device: Intervening protective barrier. Other environmental hazards, Evaluate for: Blunt Trauma / Crush Injury / Compartment Syndrome / Traumatic Brain Injury / Concussion / Tympanic Membrane Rupture / Abdominal hemorrhage or Evisceration, Blast Lung Injury and Penetrating Trauma. Trauma/Environmental Protocols Section

Pearls  Types of Blast Injury: Primary Blast Injury: From pressure wave. Secondary Blast Injury: Impaled objects. Debris which becomes missiles / shrapnel. Tertiary Blast Injury: Patient falling or being thrown / pinned by debris. Most Common Cause of Death: Secondary Blast Injuries.  Triage of Blast Injury patients: Blast Injury Patients with Burn Injuries Must be Triaged using the Thermal / Chemical / Electrical Burn Destination Guidelines for Critical / Serious / Minor Trauma and Burns  Care of Blast Injury Patients: Blast Injury Patients with Burn Injuries Must be cared for using the Thermal / Chemical / Electrical Burn Protocols. Use Lactated Ringers (if available) for all Critical or Serious Burns.  Blast Lung Injury: Blast Lung Injury is characterized by respiratory difficulty and hypoxia. Can occur (rarely) in patients without external thoracic trauma. More likely in enclosed space or in close proximity to explosion. Symptoms: Dyspnea, hemoptysis cough, chest pain, wheezing and hemodynamic instability. Signs: Apnea, tachypnea, hypopnea, hypoxia, cyanosis and diminished breath sounds. Air embolism should be considered and patient transported prone and in slight left-lateral decubitus position. Blast Lung Injury patients may require early intubation but positive pressure ventilation may exacerbate the injury, avoid hyperventilation. Air transport may worsen lung injury as well and close observation is mandated. Tension pneumothorax may occur requiring chest decompression. Be judicious with fluids as volume overload may worsen lung injury.  Accident Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials.· Evaluate scene safety to include the source of the blast that may continue to spill explosive liquids or gases. Consider structural collapse / Environmental hazards / Fire.· Conditions that led to the initial explosion may be returning and lead to a second explosion. Patients who can, typically will attempt to move as far away from the explosive source as they safely can.  Intentional Explosions: Attempt to determine source of the blast to include any potential threat for particalization of hazardous materials. Greatest concern is potential threat for a secondary device. Evaluate surroundings for suspicious items; unattended back packs or packages, or unattended vehicles. If patient is unconscious or there is(are) fatality(fatalities) and you are evaluating patient(s) for signs of life: Before moving note if there are wires coming from the patient(s), or it appears the patient(s) is(are) lying on a package/pack, or bulky item, do not move the patient(s), quickly back away and immediately notify a law enforcement officer. If no indications the patient is connected to a triggering mechanism for a secondary device, expeditiously remove the patient(s) from the scene and begin transport to the hospital. Protect the airway and cervical spine, however, beyond the primary survey, care and a more detailed assessment should be deferred until the patient is in the ambulance. If there are signs the patient was carrying the source of the blast, notify law enforcement immediately and most likely, a law enforcement officer will accompany your patient to the hospital. Consider the threat of structural collapse, contaminated particles and / or fire hazards.

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016

NO Exit to Exit to Pulse? Protocol CPAP Procedure Protocol(s) Unresponsive Cardiac Arrest if indicated Age Appropriate Age appropriate Simultaneously utilize Respiratory Distress Hypothermia Protocol Age Appropriate Diabetic Protocol Contact Medical Control Consider YES Barotrauma Decompression sickness P Trauma Pre-existing medical problem (diving) Pressure injury Post-immersion syndrome YES Differential       YES 94 % ≥ NO

2 NO Access Protocol if indicated

Mental Status Exam Dyspnea / Dyspnea if indicated Dry patient Procedure Wheezing? Procedure Severe) Hypothermia? Systemic (moderate to Cardiac Monitor Active Warming Age Appropriate Airway Protocol(s) Mental Status Protocol Remove wet clothing maintain SpO Age Appropriate Altered Age Appropriate Alerted mental status Supplemental oxygen to 12 Lead EKG Procedure Blood Glucose Analysis Blood Glucose SSM EMS Protocols contacting Medical Control Medical contacting Venous Notify destination and consider Notify P B B Unresponsive Mental status changes Decreased or absent vital signs Vomiting Coughing, Wheezing,Rales, Rhonci,Stridor Apnea Signs and Symptoms Signs and       YES 94 % Drowning / Submersion Injury / Submersion Drowning ≥

ter regardless ter regardless 2 see Pearls if available if indicated Procedure NO Access Protocol Dyspnea / Dyspnea Dry patient Wheezing? Procedure Cardiac Monitor evaluation even if Awake and Alert Capnography Procedure Passive Warming Remove wet clothing Temperature Measurement Temperature maintain SpO Supplemental oxygen to Encourage transport and asymptomatic Submersion in wa of depth Possible history of trauma ie: diving board immersion of Duration Temperature of water or possibilityhypothermia of Degreeof water contamination Universal Patient Care Protocol Spine Motion Restriction Protocol Venous P B P B B History      Drowning / Submersion Injury Trauma/Environmental Protocols Section

Pearls  Recommended Exam: Trauma Survey, Head, Neck, Chest, Abdomen, Pelvis, Back, Extremities, Skin, Neuro  Ensure scene safety. Drowning is a leading cause of death among would-be rescuers.  Allow appropriately trained and certified rescuers to remove victims from areas of danger.  With cold water no time limit -- resuscitate all. These patients have an increased chance of survival.  Have a high index of suspicion for possible spinal injuries  Hypothermia is often associated with drowning and submersion injuries.  All victims should be transported for evaluation due to potential for worsening over the next several hours. Asymptomatic near-drowning victims should be observed 4 to 6 hours for development of symptoms.  If patient is insistent on refusing further care and transport contact medical control, considered a high-risk refusal.  With pressure injuries (decompression / barotrauma), consider transport to or availability of a hyperbaric chamber.  Post-drowning patients who are awake and cooperative but with respiratory distress may benefit from CPAP.

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016

Exit to Protocols See Pearls Arrest and Arrhythmia Age Appropriate

CardiacPulseless / if indicated Exit to Age Appropriate Diabetic Protocol Protocol Age Appropriate Stroke Head injury Spinal cord injury Hypotension/ Shock Sepsis Environmentalexposure Hypoglycemia CNS dysfunction Differential     NO if indicated NO YES Pulse? 70 + 2 x Age ≥ if indicated Procedure hypotensive? nous Access Protocol Maximum 2 L Patient remains 500 mL IV / IO Cardiac Monitor Age Appropriate Age Appropriate Airway Protocol(s) SBP Protocol MaximummL/kg 60 Monitor and Reassess and Monitor Normal Saline Bolus Altered Mental Status 12 Lead ECG Procedure Blood Glucose Analysis Blood Glucose Repeat to effect SBP > 90 Active Warming Procedure PED: Bolus 20 mL/kg IV / IO contacting Medical Control Medical contacting Repeat to effect Age appropriate Age effect to Repeat Ve Altered mental status / coma Cold, clammy Shivering Extremity pain or sensory abnormality Bradycardia Hypotension or shock Notify destination and consider Notify SSM EMS Protocols P B B B       Signs and Symptoms Signs and YES YES Hypothermia / Frostbite Hypothermia NO NO NO allow refreezing if available Procedure Procedure Procedure Passive Warming Dry / Warm Patient Remove wet clothing Patient unresponsive? Monitor and Reassess and Monitor Localized Cold Injury Wound Care: General Severe) Hypothermia? Systemic (moderate to DO NOT Rub Skin to warm DO NOT Temperature Measurement Temperature Exposure to decreased temperatures but may occur in normal temperatures / Medications history medical Past Drug use: Alcohol, barbituates Infections / Sepsis Length of exposure/ Wetness / Wind chill Age, very young and old Universal Patient CareProtocol B B      History  Hypothermia / Frostbite Trauma/Environmental Protocols Section

Pearls  Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro  Hypothermia categories: Mild 90° – 95° F ( 30° – 35° C) Moderate 82° – 90° F ( 28° – 32° C) Severe < 82° F ( < 28° C)  Mechanisms of hypothermia: Radiation: Heat loss to surrounding objects via infrared energy (60% of most heat loss.) Convection: Direct transfer of heat to the surrounding air. Conduction: Direct transfer of heat to direct contact with cooler objects (important in submersion.) Evaporation: Vaporization of water from sweat or other body water losses.  Contributing factors of hypothermia: Extremes of age, malnutrition, alcohol or other drug use.  If the temperature is unable to be measured, treat the patient based on the suspected temperature.  CPR: Severe hypothermia may cause cardiac instability and rough handling of the patient theoretically can cause ventricular fibrillation. This has not been demonstrated or confirmed by current evidence. Intubation and CPR techniques should not be withheld due to this concern. Intubation can cause ventricular fibrillation so it should be done gently by most experienced person. Consider the BIAD for initial airway Below 86° F (30° C) anti-arrythmics may not work and if given should be given at reduced intervals. Contact medical control for direction. Epinephrine / Vasopressin can be administered. Below 86° F (30° C) pacing should not be done. Consider withholding CPR if patient has organized rhythm or has other signs of life. Contact Medical Control. If the patient is below 86° F (30° C) then defibrillate 1 time if defibrillation is required. Deferring further attempts until more warming occurs is controversial. Contact medical control for direction. Hypothermia may produce severe bradycardia so take at least 45 second to palpate a pulse.  Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin. SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016 NO 70 + 2 x Age) Hypotension / ≥ ism (Storm) poor perfusion? if indicated if indicated MaximumL 2 Cardiac Monitor Hot, dry skin dry Hot, 1000 mL IV / IO if indicated Age Appropriate HEAT STROKE Age Appropriate Diabetic Protocol MaximummL/kg 60 (SBP Age Appropriate Airway Protocol(s) 12 Lead ECG Procedure Active cooling measures Repeat to effect SBP > 90 COLD Normal Saline Bolus PED: Bolus 20 mL/kg IV / IO Hypotension,/ Coma AMS Protocol Venous Access Repeat to effect Age appropriate Age effect to Repeat Altered Mental Status Protocol Fever (Infection) Fever Dehydration Medications Hyperthyroid Delirium tremens (DT's) tremens Delirium Heat cramps, exhaustion, stroke CNS lesions or tumors YES

High body temperature, usually > 104 P B Differential        YES Procedure Exit to 70 + 2 x age) ≥ cool environment as indicated Maximum 2 L 500 mL IV / IO Cardiac Monitor Remove tight clothing Age Appropriate Cool, moist skin Blood Glucose Analysis Analysis Blood Glucose Trauma Protocol(s) Maximum 60 mL/kg (SBP Monitor and Reassess and Monitor Normal Saline Bolus Passive coolingmeasures Remove from heat source to Hypotension / Shock / 12 Lead ECG Procedure HEAT EXHAUSTION Active cooling measures Repeat to effect SBP > 90 Altered mental status / coma Hot, dry or sweaty skin Hypotension or shock Seizures Nausea PED: Bolus 20 mL/kg IV / IO Assess Symptom Severity Hypotension / poor perfusion? Protocol Venous Access Elevated body temperature contacting Medical Control Medical contacting SSM EMS Protocols B Repeat to effect Age appropriate Age effect to Repeat Weakness, Anxious,Tachypnea Notify destination and consider Notify      Signs and Symptoms Signs and P B B Hyperthermia NO if available Procedure if indicated

HEAT CRAMPS Warm,skin moist PO Fluids as tolerated as PO Fluids Exit to Temperature Measurement Temperature Weakness, Muscle cramping Protocol Venous Access Age, very young and old Exposure to increased temperatures / or humidityand / Medications history medical Past Time and duration of exposure Poor PO intake, extreme exertion Fatigue and / or muscle cramping Seizure Activity? Seizure Protocol Normal to elevated body temperature Universal Patient CareProtocol B History       P B Hyperthermia Trauma/Environmental Protocols Section

Pearls  Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro  Extremes of age are more prone to heat emergencies (i.e. young and old). Obtain and document patient temperature if able.  Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol.  Cocaine, Amphetamines, and Salicylates may elevate body temperatures.  Sweating generally disappears as body temperature rises above 104° F (40° C).  Intense shivering may occur as patient is cooled.  Heat Cramps consists of benign muscle cramping to dehydration and is not associated with an elevated temperature.  Heat Exhaustion consists of dehydration, depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature.  Heat Stroke consists of dehydration, tachycardia, hypotension, temperature >104° F (40° C), and an altered mental status.

SSM EMS Protocols 2016 Trauma/Environmental Protocols Section 2016 Officer contact Control NO Document with Animal Contact and Animal bites: Exit to Exit to Protocol Protocol Appropriate Anaphylaxis Dog / Cat if indicated Human Bite Allergic Reaction / Trauma Protocol(s) Hypotension / Shock Splinting Procedure YES Transport? Extremity TraumaExtremity Protocol B Animal bite bite Animal Human bite (poisonous) bite Snake (poisonous) bite Spider Insect sting / bite (bee, wasp, ant, tick) Infection risk Rabies risk risk Tetanus YES YES Differential         if able NO NO Pain? Allergy / contacting Medical Control Medical contacting Snake Bite clothing / bands Anaphylaxis? Hypotension? Remove all jewelry Redness and Time and Redness Notify destination and consider Notify Serious Injury / DO NOT apply ICE Splinting Procedure from affected extremity Moderate / Severe a neutralposition Remove any constricting Mark Marginof Swelling / Elevate wound location to Identification of Animal B SSM EMS Protocols General Wound Procedure Care Rash, skin break, wound break, skin Rash, Pain, soft tissue swelling, redness Blood oozing from the bite wound infection of Evidence Shortness ofbreath, wheezing Allergic reaction,hives, itching Hypotension or shock Venous Access Protocol Universal Patient Care Protocol P B Signs and Symptoms Signs and        YES

or or

Bites and Envenomations and Bites if able PED: Spider Bite position bandsjewelry / Muscle Spasm Apply Ice Packs Bee / Wasp Sting Splinting Procedure Max total dose 5 mg over 2 to 3 minutesover 2 to over 2 to 3 minutesover 2 to 314-268-4195 Midazolam 0.1 mg/kg IV / IO Midazolam 0.5 – 2 mgIV / IO Appropriate Midazolam 5 mg IntraNasal / IM Remove any constricting clothing / Pain Protocol Elevate wound location to a neutral Missouri Poison Control Description or bring creature / photo with patient for identification Time, location, size of bite / sting Previous reactionto bite / sting Domestic vs. Wild Tetanus and Rabies risk Immunocompromised patient Type of bite / sting Midazolam 0.2 mg/kgIntraNasal/ IM Contact PoisonControl early       History  P B Special Response

Section Table of Contents Special Response ProtocolsSection

Triage CO Exposure Cyanide Exposure Scene Rehabilitation: General Scene Rehabilitation: Responder Active Shooter Nerve Agent Exposure Radiation Incident

SSM EMS Protocols 2016 Special Response Protocols Section 2016 red tag” red ” or “ ” or EXPECTANT DECEASED / (1) IMMEDIATE Secondary Triage Secondary (2) DELAYED (1) IMMEDIATE (1) IMMEDIATE (1) IMMEDIATE IMMEDIATE Evaluate Pediatrics FIRST FIRST Pediatrics Evaluate YES When Repeating Triage Process Triage Repeating When YES YES NO Adult patient? NO NO NO * Open Airway * Open Triage dial pulse absent (Adult) * Chest Decompression Adult LIFESAVING INTERVENTIONS (LSI): *Control Major Hemorrhage Pediatric SSM EMS Protocols minor injuries Peds < 15 or > 45 Obeys Commands Adult > 30 / minute Appropriate to AVPU (3) Ambulatory / Hold NO YES YES Pulse? pediatric Breathing? DO ANY OF THESE RESULT IN BREATHING? CONSIDER (1) IMMEDIATE No palpable pulse (Pediatric) pulse palpable No 5 Rescue Breaths Rescue 5 YES NO Cap Refill > 2 Sec or ra NO YES Rate? Walk? Able to Breathing? Respiratory If indicated * Open Airway Mental Status? CONSIDER LSI: CONSIDER Perfusion? * Chest Decompression who are patients in a MCI are automatically triage category “ category triage automatically in a MCI are patients * All infants are who Peds > 15 or < 45 *Control Major Hemorrhage Major *Control Adult < 30 / minute 30 / Adult < Radial pulse present Special Response Protocols Section 2016 cess Protocol NO Procedure symptoms? neurological YES Patient exhibiting and transport to ED cardiac / respiratory / / respiratory cardiac Capnography Monitoring 100% Oxygen by NRB mask NRB mask by Oxygen 100% Venous Ac P B NO YES SpCO > SpCO 15%? YES Differential byproductfire toxicof other- Effects cardiac event- Acute neurological- Acute event - Flu/GI illness intoxication - Acute - Diabetic Ketoacidosis non-toxic- Headache origin of Cyanide Exposure Protocol

contacting Medical Control Medical contacting Hypoxia / Hypoxia NO Notify destination Notify destination or consider if indicated Appropriate headache? See Pearls if indicated, considering products of combustion Exit to Diabetic Protocol Simultaneously utilize Symptoms of CO and / or may be readings 2 Recommend evaluation SpO and transport for any CO false exposed pregnant person. Appropriate Protocol(s) SSM EMS Protocols No treatment for CO exposure required* smoking seek smokers that Recommend cessation treatment. Recommend evaluation of home / work CO of presence for environment Signs and Symptoms - Altered mental status/dizziness - Headache, Nausea/Vomiting -Chest Pain/Respiratory distress - Neurological impairments - Vision problems/reddened eyes - Tachycardia/tachypnea - Arrhythmias, seizures, coma YES YES

NO NO a fire scene Carbon Monoxide Exposure Monoxide Carbon NO Procedure Procedure SpCO > 5%? SpCO Exit to if indicated Cardiac Monitor Protocol High Flow Oxygen Flow High If monitoring SpCO required* 12 Lead ECG Procedure Blood Glucose Analysis Blood Glucose signs or symptoms? signs Patient exhibiting any any exhibiting Patient Scene Rehabilitation responders at at responders Carboxyhemoglobin Monitoring Immediately Remove from Exposure Appropriate Trauma Protocols Appropriate Trauma Universal Patient Care Protocol No further medical evaluation of of evaluation medical further No P B B B History - Firefighter/Structure Fire victim - Suspected CO exposure - Suspected source/duration exposure - Age, possible pregnancy - Reason (accidental, suicidal) - Measured atmospheric levels - Past medical history, meds Carbon Monoxide Exposure Special Response ProtocolsSection

Pearls  Recommended exam: Neuro, Skin, Heart, Lungs, Abdomen, Extremities  Scene safety is priority.  Consider CO and Cyanide with any product of combustion.  Normal environmental CO level does not exclude CO poisoning.  Fetal hemoglobin has a greater attraction for CO than maternal hemoglobin. Females who are known to be or possibly pregnant should be advised that EMS-measured SpCO levels reflect the adult’s level, and that fetal COHb levels may be higher. Recommend Hospital evaluation for any CO exposed pregnant person.  The absence (or low detected levels of) of COHb is not a reliable predictor of firefighter or victim exposure to other toxic byproducts of fire.  In obtunded fire victims, consider Cyanide treatment protocol.  The differential list for CO Toxicity is extensive. Attempt to evaluate other correctable causes when possible.  If high levels of SpCO are detected do NOT pass the closer appropriate facility for one with a hyperbaric capabilities.  Chronic CO exposure is clinically significant; therefore advice on smoking cessation is important medical instruction.

SSM EMS Protocols Cyanide Exposure

History Signs and Symptoms Differential  Smoke inhalation  AMS  Diabetic related  Ingestion of cyanide  Malaise, weakness, flu like illness  Infection  Eating large quantity of fruit pits  Dyspnea  MI  Industrial exposure  GI Symptoms; N/V; cramping  Anaphylaxis  Trauma  Dizziness  Renal failure / dialysis problem  Reason: Suicide, criminal,  Seizures  Head injury / trauma accidental  Syncope  Co-ingestant or exposures  Past Medical History  Reddened skin  Time / Duration of exposure  Chest pain

Universal Patient Care Protocol

Safely remove patient from exposure B High risk for secondary exposure see Pearls

Adequate Appropriate Airway Protocol(s) Special Response ProtocolsSection NO ventilation/oxygenation? as indicated YES

SBP <90 Appropriate Age Specific VS YES Hypotension / Shock SBP < 70 + 2 x Age Protocol Poor Perfusion / Shock? NO

High Flow Oxygen Appropriate Appropriate B Blood Glucose Analysis Diabetic Protocol Trauma Protocol(s) Procedure if indicated if indicated Spinal Motion Restriction Protocol if indicated 12 Lead ECG Procedure B Carboxyhemoglobin Monitoring Procedure Venous Access Protocol CYANOKIT requires a separate IV line Venous Access Protocol for administration due to numerous P Cardiac Monitor incompatabilities If available on scene: P Hydroxocobalamin (CYANOKIT) High suspicion 5 grams IV / IO YES of cyanide exposure? infusion over 15 minutes Pediatric: 70mg/kg infusion NO over 15 min DO NOT DELAY TRANSPORT Continue Care Continue High Flow Oxygen B The initial dose may be repeated once Monitor and Reasses 15 minutes after the end of the first P infusion MAX total dose adults: 10 grams Peds: 5 grams Notify destination and consider contacting Medical Control

SSM EMS Protocols 2016 Special Response Protocols Section 2016 pervious materials. pervious tissue hypoxia occurs despite adequate oxygenationof the cardiovascular symptomsthe presence in of adequate garments made of im of garments made t, Lungs, Abdomen, Extremities. SSM EMS Protocols he diagnosis of cyanide poisoning. treating cyanide victims, personnel are at risk for are at risk for secondary exposure victims, personnel treating cyanide dless of pulse ox readings. e to an asymptomatic or mildly symptomatic patient, despite a history of exposure, gastric contents, skin and contaminated and clothing. Cyanide Exposure Cyanide of the CNS with or without

Significant impairment oxygenation and perfusion suggests t administer the antidot Do not who is awake and alert with normal, stable vitalalertandwho is awake signs. with normal, Cyanide impairs cellular energy production, so that blood. Consider CO and Cyanide with any product of combustion. CO poisoning.not excludeNormal level doesCO environmental Symptoms present with lower CO levels in pregnancy, children and the elderly. Continue high flow oxygen regar Recommended exam: Neuro, Skin, Hear Skin, Recommended exam: Neuro, Scene safety is priority. When When safety is priority. Scene and possible toxicity from Isolate potentiallyvomitus and clothing.contaminated transport. patient before of Consider decontamination wear protective personnel should Medical             Pearls Special Response Protocols Section 2016 Exit to Extend minutes Protocol another 10 Exit to Appropriate Rehabilitation urge transport Protocol Appropriate YES YES COLD STRESS Rehydration Techniques Active Warming Measures YES Active Warming Procedure Dry patient, place in warm area Hot packs to axilla and / or groin 12 – 32 oz Oral Fluid over 20 minutes Oral Rehydration may occur along with HR NO NO 110? Temp 100.6? ≥ ≥ B B YES 90 ≤ YES YES Discharge Individual from from Individual Discharge or NO NO General Rehabilitation Section Rehabilitation General Heat Reassess VS Reassess HR NO NO 110? Temp 100.6? Cold stress? Cold ≥ ≥ SSM EMS Protocols General Rehabilitation Section Rehabilitation General Respiratory rate < 8 or > 40 Systolic blood pressure YES Reassess individual after 20 Minutes in Cardiac complaint: signs / symptoms signs complaint: Cardiac Significant injury or medical complaint Universal Patient Care Protocol B Respiratory complaint: serious ssigns / symptoms ssigns serious complaint: Respiratory Scene Rehabilitation: General Rehabilitation: Scene 1. Patients logged into General Rehabilitation Documentation 2. VS Assessed / Recorded (If HR > 110 then obtain Temp) 3. Patients assessed for signs / symptoms 160 or ≥ B May be used for Special Events with Approval with Events Special for used be May 100 may need ≥ HEAT STRESS Active Cooling Measures Rehydration Techniques Active Cooling Procedure VITAL SIGN CAVEATS VITAL SIGN mist fans etc. for 10 – 20 Minutes immersion, cool shirts, cool 12 – 32 oz Oral Fluid over 20 minutes oral or IV hydration. IV or oral Oral Rehydration may occur along with appropriate treatment treatment appropriate should be treated using protocol beyond need for Injury / Illness / Complaint Temperature: increased have may Individuals temperature duringrehabilitation. extended rehabilitation.However this them prevent necessarily not does from returning to the event. Individuals with Systolic BP Diastolic BP Individuals at special events may have elevated blood pressure due to physical exertion and is not typically pathologic. Blood Pressure: Prone to inaccuracy on scenes. Must be interpreted in context. B B Scene Rehabilitation: General May be used for Special Events with Approval Special Response ProtocolsSection

Pearls  This protocol should be utilized for evaluating patrons of certain special events that may or may not otherwise meet the definition of a patient.  Paramedic on-scene has full authority in deciding when individuals meet the definition of a patient and/ or require further treatment or transport.  Regarding documentation under this protocol, individuals who are evaluated only at the rehabilitation center require a narrative-based patient log entry under one PCR for all of these individuals. However, if a patient receives ALS care more than over-the-counter medications and/or is transported to an emergency department, the patient requires a separate run number and full PCR like any other patient.  People taking anti-histamines, blood pressure medication, diuretics or stimulants are at increased risk for cold and heat stress.  Establish rehab location such that it provides shelter, privacy and freedom from smoke or other hazards.  For approved gatherings, other patient contact requirements may be determined at approval.

SSM EMS Protocols 2016 Special Response Protocols Section 2016 And Rehabilitation Protocol Rehabilitation conjunction with General consider transport May in use for responders Up to 2 L Important of additional rehabilitation; Cardiac monitor after 30 minutes No improvement Rehydration is Most Mandatory RestPeriod Normal Saline IV Bolus 12 Lead EKG Procedure Re-evaluate in 10 minutes Measurement Procedure Systolic BP is 100 or greater Until Pulse Rate is 110 or less Orthostatic Blood Presssure Venous Access Protocol P B Exit to contacting Medical Control Medical contacting Notify destination and consider Notify Appropriate Protocol(s) Capnography Procedure YES YES YES YES YES YES Consider B SSM EMS Protocols 100 100.6 160 ≥ ≥ ≥ NO Section if available Procedure Or NO NO NO NO NO Pulse oximetry if available see Pearls Reports for Procedure SPCO > 10 % Personnel logged into Carboxyhemoglobin from General General from Reassignment Monitoring Procedure Responder Rehabilitation Rehabilitation Responder Systolic BP Medicalcomplaint or injury? Diastolic BP Active Cooling or Warming Temperature Discharge Responder Responder Discharge Rehabilitation Section 20 MinuteRest Period Pulse oximetry < 90 % Respirations < 8 or > 40 Age Predicted Maximum Pulse Rate > 85 % NFPA between SCBA change-out B Temperature Measurement Temperature Universal Patient Care Protocol B Scene Rehabilitation: Responder Rehabilitation: Scene Firefighters should consume at least 8 ounces of fluid Remove: PPE Body Armor Chemical Suits SCBA Turnout Gear Otherequipment as indicated Special Response Protocols Section 2016 ants are at increased risk for cold 170 165 160 155 152 148 140 136 132 usually firefighters, on the scene of an incident. Maximum HeartRate in deciding when responders may return to duty. return to responders may in deciding when 51 -55 51 20 - 25 20 - 30 26 - 35 31 - 40 36 - 45 41 - 50 46 - 60 55 - 65 61 NFPA Age Predicted 85 % 85 Predicted Age NFPA law enforcement, rescue, EMS and training scenes. SSM EMS Protocols pressure medication, diuretics or stimul public safety responders, Scene Rehabilitation: Responder Rehabilitation: Scene This protocol is to be utilized for and heat stress. Rehabilitation Section is an integral function within the Incident Management System. Establish section such that it provides shelter, privacy and freedom from smoke, truck exhaust or other hazards. Rehabilitation officer should have full authority Utilize this protocol in conjunction with the rehab steps and guidance in the General Rehabilitation Protocol. May be utilized with adult responders on fire, Responders taking anti-histamines, blood Pearls        Special Response Protocols Section 2016 en possible, patients of similar of patients similar en possible, Delayed resources Immediate Triage Protocol resources are available available are resources untilsufficient transport Call for help / additional Establish treatment areas: collection point until scene secure NO Respond with law enforcement as a rescue team and develop a casualty a casualty develop and team rescue B then transport of trauma patients to non-trauma s as soon as possible with the projected number of projectedsoon as possible withas the s trauma center. Others may be considered for with SBP with SBP < 90 and / or obvious external trauma to 4 or assist with appropriatetransport destination. YES and scene Shooter detained immediately safe? SSM EMS Protocols d in the same EMS unit if needed. Wh Universal Patient Care Protocol Active Shooter Active YES NO to appropriate facility. for ambulatory patients. Rapidly transportall injuries Resources are insufficient for all to be treated immediately? >5 transport to multiple trauma centers to safe area in cold zone. Consider public transportation to alternative receiving facility 1-5 trauma patients – nearest trauma center Move all non-penetrating, ambulatory patients TAC or other Adhere to Adhere to Law Training Protocol Training Enforcement Enforcement MAC/ acuity should be transported in the same unit to should be transported acuity patients. Utilize the Incident Command System. Level 1 trauma centers can manage up to 5 penetrating trauma patients per hour trauma patients,5 penetrating consider multiple trauma centers. more than If If more than 30 patients require Level One trauma care, Make notification to Dispatch and all local hospital center local hospitalsbe required. may patientspatients, than 5 blast injury with more If I themore body surface Level areas should go to community hospital transport. transporte be may patients Multiple     Pearls:    Special Response Protocols Section 2016 Seizure Protocol Simultaneously utilize Simultaneously Arrest if available IV / IM / IO 3 Doses Rapidly3 Doses symptoms resolve symptoms Peds: 0.05 mg/kg Major Symptoms: Nerve agent exposure (e.g., VX, Soman, Sarin, etc.) Organophosphateexposure Mustard (e.g., exposure Vesicant etc.) Gas, Respiratory Irritant Exposure (e.g., Hydrogen Sulfide, etc.) Chlorine, Ammonia, (pesticide) YES Nerve Agent Kit IM as indicated Atropine 6 mg IV / IM / IO Differential     Repeat every 5 minutes until Venous Access Protocol NO Altered Mental Status, Seizures, Respiratory Distress, Respiratory Obtain history of exposure of history Obtain P Decontamination Procedure Observe for specific toxidromes B Seizure activity? Seizure NO if available IV / IM / IO 2 Doses Rapidly iosis / muscle twitching I Upset; Abdominal pain / cramping Resources are insufficient for rination; increased, loss of control efecationDiarrhea / symptoms resolve symptoms all to be treated immediately? Symptom Severity acrimation Peds:mg/kg 0.05 SSM EMS Protocols Minor Symptoms: Nerve Agent Kit IM L U D G Emesis M Seizure Activity Respiratory Arrest Salivation Universal Patient Care Protocol contacting Medical Control Medical contacting Atropine 2 mg IV / IM / IO Repeat every 5 minutes until Venous Access Protocol         Signs and Symptoms Signs and  Notify destination and consider Notify Respiratory Distress + SLUDGE P YES resources begin early symptoms. Exposure WMD) (includes Agent Nerve Triage Protocol Asymptomatic appropriate arm appropriate Every 15 minutes for Initiate treatment per Monitor and reassess and Monitor Call for help / additional Exposure to chemical, biologic, radiologic, or nuclear hazard Potential exposure to unknown substance/hazard with Farmer exposure to pesticide B History    B Special Response Protocols Section 2016 ilable atropine. e if patient weighs between 40 to 90 protective equipment. ts less than 7 years of age, 2 Nerve Agent ilable, use all ava SSM EMS Protocols less than 40 pounds (18 kg), 1 mg dos Pralidoxime (2-PAM) and Pralidoxime (2-PAM) 2 mg of Atropine. Nerve Agent Kits, or it is unava atus, Skin, HEENT, Heart, atus, Skin, HEENT, Lungs,Heart, Gastrointestinal, Neuro ttack, begin with 1 Nerve Agent Kit for patien Kit contains 600 mg of

Nerve Agent Exposure WMD) (includes Agent Nerve

Seizure Activity: Any benzodiazepine by any route is acceptable. For patients with major symptoms, there is no limit for atropine dosing. Consider a cardiac monitor for hypoxic patients receiving atropine as it may stimulate ventricular fibrillation. Carefully evaluate patients to ensure they not from exposure to another agent (e.g., narcotics, vesicants, etc.) The main symptom that the atropine addresses is excessive secretions so atropine should be given until drying of secretions is noted. In face of a bona fide a the Kits from 8 to 14 years of age, and 3 Nerve Agent Kits for patients 15 years of age and over. If Triage/MCI issues exhaust supply of Atropine dosing: 0.5 mg dose if patient is pounds (18 to 40 kg), and 2 mg dose for patients greater than 90 pounds (>40 kg). Each Follow local HAZMAT protocols for decontaminati on and use of personal Recommended Exam: Mental St           Pearls  Special Response Protocols Section 2016 Degree Burn rd Degree) blistering /3 nd nd Degree)painless/ rd Critical Burn? (may repeat as needed) compromise Degree) red - painful Wound Care – Irrigation Wound Care Morgan Lens Procedure st P transport to a Burn Center) Burns with definitiveairway Burns with MultipleTrauma (When reasonablyaccessible, >15% TBSA 2 (Don’t include in TBSA) Partial Thickness (2 Superficial (1 charred or leathery skin injury Thermal injury – Electrical Chemical Radiation injury Blast injury Full Thickness (3 YES  Differential      

Degree Burn rd Access Protocol NO /3 YES Exit to nd if indicated Procedure

Serious Burn? Serious nous Cardiac Monitor Pulse Present?

Age Appropriate Eye Involvement? Decontamination Airway Protocol(s) Ve Thermal Burn Protocol SSM EMS Protocols transport to a Burn Center) (When reasonablyaccessible, (15 min ideally with Normal Saline) Normal with ideally min (15 Hypotension or GCS 13 or Less ge Patients / Load and Go with Assessment / Treatment Enroute Universal Patient Care Protocol B intubation for airway stabilization Wound Care – Irrigation Procedure 5-15% TBSA 2 5-15% NO Burns, pain, swelling Dizziness Loss of consciousness Hypotension/shock could compromise/distress Airway be indicated by hoarseness/ wheezing / Hypotension P Suspected inhalationrequiring injuryor Assess/ Burn Concomitant Injury / Severity B Signs and Symptoms Signs and      Radiation Incident Radiation Degree Burn rd /3 nd Arrest / Scene Safety / Quantify and Tria Protocol(s) as indicated Normotensive Minor Burn? Age Appropriate GCS 14 or Greater Type of exposure (heat, gas, chemical) Inhalation injury Injury of Time / history medical Past Medications Other trauma Loss of Consciousness Tetanus/Immunization status Cardiac Arrest / Pulseless Age AppropriateArrhythmia < 5% TBSA 2 No inhalation injury, Not Intubated, History        Radiation Incident

Collateral Injury: Most all injuries immediately seen will be a result of collateral injury, such as heat from the blast, trauma from concussion, treat collateral injury based on typical care for the type of injury displayed.

Qualify: Determine exposure type; external irradiation, external contamination with radioactive material, internal contamination with radioactive material.

Quantify: Determine exposure (generally measured in Grays/Gy). Information may be available from those on site who have monitoring equipment, do not delay transport to acquire this information. Special Response ProtocolsSection

Pearls  Dealing with a patient with a radiation exposure can be a frightening experience. Do not ignore the ABC’s, a dead but decontaminated patient is not a good outcome. Refer to the Decontamination Procedure for more information.  Normal Saline or Sterile Water is preferred, however if not available, do not delay irrigation using tap water. Other water sources may be used based on availability. Flush the area as soon as possible with the cleanest readily available water or saline solution using copious amounts of fluids.  Three methods of exposure: External irradiation External contamination Internal contamination  Two classes of radiation: Ionizing radiation (greater energy) is the most dangerous and is generally in one of three states: Alpha Particles, Beta Particles and Gamma Rays. Non-ionizing (lower energy) examples include microwaves, radios, lasers and visible light.  Radiation burns with early presentation are unlikely, it is more likely this is a combination event with either thermal or chemical burn being presented as well as a radiation exposure. Where the burn is from a radiation source, it indicates the patient has been exposed to a significant source, (> 250 rem).  Patients experiencing radiation poisoning are not contagious. Cross contamination is only a threat with external and internal contamination.  Typical ionizing radiation sources in the civilian setting include soil density probes used with roadway builders and medical uses such as x-ray sources as well as radiation therapy. Sources used in the production of nuclear energy and spent fuel are rarely exposure threats as is military sources used in weaponry. Nevertheless, these sources are generally highly radioactive and in the unlikely event they are the source, consequences could be significant and the patient’s outcome could be grave.  The three primary methods of protection from radiation sources: Limiting time of exposure Distance from Shielding from the source  Dirty bombs ingredients generally include previously used radioactive material and combined with a conventional explosive device to spread and distribute the contaminated material.  Refer to Decontamination Procedure / WMD / Nerve Agent Protocol for dirty contamination events.  If there is a time lag between the time of exposure and the encounter with EMS, key clinical symptom evaluation includes: Nausea/ Vomiting, hypothermia/hyperthermia, diarrhea, neurological/cognitive deficits, headache and hypotension.

SSM EMS Protocols 20162012 Trauma/Environmental Protocols Section 2016 herapy, transplant patients. nd a complete Neck, Lung, Little reaction is noted initially but tissue necrosistissuenotedat Little reaction is initially but red streaksto wound. proximal over a few hours, muscular pain and severe abdominal y. About 25 % of snake bites are “dry” bites. SSM EMS Protocols xam if systemiceffectsare noted pain but very toxic. "Red on yellow - kill a fellow, red on black - venom lack." lack." - venom red on black a fellow, on yellow - kill "Red very toxic. pain but g, redness, drainage, fever, Bites and Envenomations and Bites Recommended of MentalExtremities (Location Exam: a injury), Status,Skin, Heart, Abdomen, Back, and Neuro e haveHuman bites higher infection normalanimal rates thanto due bites mouth bacteria. Carnivore bitesaremuchmore likely to become Rabies infected exposure.of andall have risk bites mayCat progressrapidly to infectionto due a specific bacteria (Pasteurella multicoda). Poisonoussnakesin this arearattlesnakethe pit viper family: andcopperhead. of are generally Very little rare: are bites snake Coral pain may develop (spider is black with red hourglass on belly). Brown Recluse spider bites are minimally painful to painless. sitebiteover developsthe of the next the (browndays few spider with fiddle back).shape on Evidence of infection: swellin Blackbut spider Widowbe minimallytend to painful, bites If no pain or swelling, envenomation is unlikel Immunocompromisedpatients are at an increased for risk infection: diabetes, chemot Consider contacting the Missouri Poison(314-268-4195).for guidance Control Pearls             Procedures Section

Section Table of Contents

Airway: CPAP Childbirth Airway: Foreign Body Obstruction Gastric Tube Insertion Airway: BIAD Restraints: Physical & Chemical Airway: Orotracheal Intubation Splinting Airway: Evaluating the Difficult Airway Spinal Examination Airway: Bougie Spinal Motion Restriction Airway: Nasotracheal Intubation Medication Administration Airway: Cricothyrotomy Intranasal Airway: Capnography Injections: Subcutaneous & Intramuscular Airway: Suctioning-Basic Venous Access: Extremity Airway: Suctioning-Advanced Venous Access: Intraosseous Airway: Trach Tube Change Venous Access: External Jugular Section Procedures Airway: Nebulizer Venous Access: Existing Catheters Airway: Respirator Operations Venous Access: Blood Draw Airway: Ventilator Operations Arterial Line Maintenance 12 Lead EKG Central Line Maintenance Code STEMI Activation Epidural Catheter Maintenance Cardiopulmonary Resuscitation (CPR) Accessing Central Venous Catheters (CVC) Defibrillation: Automated Ventricular Catheter Maintenance Defibrillation: Manual Wound Care: General Cardioversion Wound Care: Irrigation External Pacing Wound Care: Taser Probe Removal Assessment: Adult Wound Care: Hemostatic Dressing Assessment: Pediatric Wound Care: Tourniquet Pain Assessment and Documentation Warming Measures: Hypothermia Blood Glucose Analysis Cooling Measures: Hyperthermia Pulse Oximetry Decontamination Carboxy/Methemoglobin Monitoring Intra-Departmental Influenza Vaccination Orthostatic Blood Pressure Measurement Temperature Measurement Stroke Screening Reperfusion Checklist Chest Decompression

SSM EMS Procedures 2016 SSM Medical Direction Standard Procedure (Skill) Airway: CPAP

P EMT- P P

Clinical Indications for Continuous Positive Airway Pressure (CPAP) Use:

 CPAP is indicated in all patients whom inadequate ventilation is suspected and who have adequate mental status and respiratory drive to allow CPAP to function. This could be as a result of pulmonary edema, pneumonia, asthma, COPD, etc.

Clinical Contraindications for Continuous Positive Airway Pressure (CPAP) Use:

 Decreased mental status.  Facial features or deformities that prevent an adequate mask seal.  Excessive respiratory secretions.

Procedure:

1. Ensure adequate oxygen supply to ventilation device. 2. Explain the procedure to the patient. 3. Consider placement of a nasopharyngeal airway. 4. Place the delivery mask over the mouth and nose. Oxygen should be flowing through the device at this point. 5. Secure the mask with provided straps starting with the lower straps until minimal air leak occurs. 6. If the Positive End Expiratory Pressure (PEEP) is adjustable on the CPAP device adjust the PEEP beginning at 0 cmH20 of pressure and slowly titrate to achieve a positive pressure as follows:  5 – 10 cmH20 for Pulmonary Edema, Near Drowning, possible aspiration or pneumonia  3 – 5 cm H20 for COPD 7. Evaluate the response of the patient assessing breath sounds, oxygen saturation, and general appearance. Monitor for hypotension that is a side effect of CPAP 8. Titrate oxygen levels to the patient’s response. Many patients respond to low FIO2 (30-50%). 9. Encourage the patient to allow forced ventilation to occur. Observe closely for signs of complications. The patient must be breathing for optimal use of the CPAP device. 10. Document time and response on patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Foreign Body Obstruction

B EMT B Clinical Indications: P EMT- P P

 Sudden onset of respiratory distress often with coughing, wheezing, gagging, or stridor due to a foreign-body obstruction of the upper airway.

Procedure:

1. Assess the degree of foreign body obstruction  Do not interfere with a mild obstruction allowing the patient to clear their airway by coughing.  In severe foreign-body obstructions, the patient may not be able to make a sound. The victim my clutch his/her neck in the universal choking sign. 2. For an infant, deliver 5 back blows (slaps) followed by 5 chest thrusts repeatedly until the object is expelled or the victim becomes unresponsive. 3. For a child, perform a sub-diaphragmatic abdominal thrust (Heimlich Maneuver) until the object is expelled or the victim becomes unresponsive. 4. For adults, a combination of maneuvers may be required.  First, sub-diaphragmatic abdominal thrusts (Heimlich Maneuver) should be used in rapid sequence until the obstruction is relieved.  If abdominal thrusts are ineffective, chest thrusts should be used. Chest thrusts should be used primarily in morbidly obese patients and in the patients who are in the late stages of pregnancy. 5. If the victim becomes unresponsive, begin CPR immediately but look in the mouth before administering any ventilations. If a foreign-body is visible, remove it. 6. Do not perform blind finger sweeps in the mouth and posterior pharynx. This may push the object farther into the airway. 7. In unresponsive patients EMT-Paramedic level professionals should visualize the posterior pharynx with a laryngoscope to potentially identify and remove the foreign-body using Magil forceps. 8. Document the methods used and result of these procedures in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standards Procedure (Skill) Blind Insertion Airway Device (BIAD)

B EMT B Clinical Indications for Blind Insertion Airway Device (BIAD) Use: P EMT- P P

 Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport distances require a more advanced airway.  Appropriate intubation is impossible due to patient access or difficult airway anatomy.  Inability to secure an endotracheal tube in a patient who does not have a gag reflex where at least one failed intubation attempt has occurred.  Patient must be unconscious.  WARNING: This airway may not prevent aspiration of stomach contents!

Procedure: This procedure is the for the following SSM Medical Direction approved BIAD devices: King, Combitube and i-gel.

1. Pre-oxygenate and hyperventilate the patient. 2. Select the appropriate tube size for the patient. 3. Lubricate the tube if applicable. 4. Grasp the patient’s tongue and jaw with your gloved hand and pull forward. 5. Gently insert the device to the correct depth as specified by the manufacturer. 6. Inflate the pilot balloon per manufacturer specification for device utilized. 7. Ventilate the patient with a BVM device. 8. Auscultate for breath sounds and sounds over the epigastrium and look for the chest to rise and fall. 9. Confirm tube placement using end-tidal CO2 detector. 10. The airway should be monitored continuously through waveform capnography.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once a year.

SSM EMS Procedure 2016 SSM Medical Direction Standards Procedure (Skill) Airway: Orotracheal Intubation

P EMT- P P Clinical Indications:

 Inability to adequately ventilate a patient with a Bag Valve Mask or longer EMS transport distances require a more advanced airway.  An unconscious patient without a gag reflex who is apneic or is demonstrating inadequate respiratory effort.

Procedure:

1. Prepare, position and oxygenate the patient with 100% Oxygen. 2. Select proper ET tube (and stylette, if used), have suction ready. 3. Using laryngoscope, visualize vocal cords. (Use BURP to assist you). 4. Limit each intubation attempt to 30 seconds with BVM between attempts. 5. Visualize tube passing through vocal cords. 6. Confirm and document tube placement using an end-tidal CO2 monitoring or esophageal bulb device. 7. Inflate the cuff with 3-to10 cc of air; secure the tube to the patient’s face. 8. Auscultate for bilaterally equal breath sounds and absence of sounds over the epigastrium. If you are unsure of placement, remove tube and ventilate patient with BVM. 9. Apply waveform capnography monitor. After 3 ventilations, EtCO2 should be >10 mmHg or comparable to pre-intubation values. If < 10 mmHg, check for adequate circulation, equipment, and ventilatory rate. If EtCO2 remains < 10 mmHg without physiologic explanation, remove the ET Tube and ventilate by BVM. 10. Consider using a Blind Insertion Airway Device (BIAD) or Bougie if first intubation effort is unsuccessful. 11. Apply end tidal carbon dioxide monitor (waveform capnography) and record readings on scene, en route to the hospital, and at the hospital. 12. Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient’s teeth or lips on/with the patient care report (PCR). Document all devices used to confirm initial tube placement. Also document positive or negative breath sounds before and after each movement of the patient. 13. Place an NG or OG tube to clear stomach contents after the airway is secured with an ET tube, if time and resources permit. 14. The airway should be monitored continuously through waveform capnography.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once per year.

SSM EMS Procedure 2014 SSM Medical Direction Standards Procedure (Skill) Evaluating for the Difficult Airway Between 1 – 3% of patients who require endotracheal intubation have airways that make intubation difficult. Recognizing those patients who may have a difficult airway allows the paramedic to proceed with caution and to keep as many options open as possible. It also allows the paramedic to prepare additional equipment (such as a cricothyrotomy kit) that may not ordinarily be part of a standard airway kit. The pneumonic LEMON is useful in evaluating patients for signs that may be consistent with a difficult airway and should raise the paramedic’s index of suspicion.

Look externally External indicators of either difficult intubation or difficult ventilation include: presence of a beard or moustache, abnormal facial shape, extreme cachexia, edentulous mouth, facial trauma, obesity, large front teeth or “buck teeth”, high arching palate, receding mandible, short bull neck.

Evaluate 3-3-2 rule 3 fingers between the patient’s teeth (patient’s mouth should open adequately to permit three fingers to be placed between the upper and lower teeth) 3 fingers between the tip of the jaw and the beginning of the neck (under the chin) 2 fingers between the thyroid notch and the floor of the mandible (top of the neck)

Mallampati classification

A high Mallampati score (class 3 or 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea. In many ways it assesses the height of the mouth; the distance from the tongue base to the roof of the mouth, and therefore the amount of space in which there is to work.

Obstruction? Besides the obvious difficulty if the airway is obstructed with a foreign body, the paramedic should also consider other obstructers such as tumor, abscess, epiglottis, or expanding hematoma.

Neck Mobility Ask the patient to place their chin on their chest and to tilt their head backward as far as possible. Obviously, this will not be possible in the immobilized trauma patient.

SSM EMS Procedure 2016 SSM Medical Direction Standards Procedure (Skill) Airway: Endotracheal Tube Introducer (Bougie) Clinical Indications: P EMT- P P  Patients meet clinical indications for oral intubation  Initial intubation attempt(s) unsuccessful  Predicted difficult intubation

Contraindications:  Two attempts at orotracheal intubation (then utilize failed airway protocol)  Age less than eight (8) or ETT size less than 6.5 mm

Procedure: 1. Prepare, position and oxygenate the patient with 100% oxygen; 2. Select proper ET tube without stylet, test cuff and prepare suction; 3. Lubricate the distal end and cuff of the endotracheal tube (ETT) and the distal 1/2 of the Endotracheal Tube Introducer (Bougie) (note: Failure to lubricate the Bougie and the ETT may result in being unable to pass the ETT); 4. Using laryngoscopic techniques, visualize the vocal cords if possible using Sellick’s/BURP as needed; 5. Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized; 6. Once inserted, gently advance the Bougie until you meet resistance or “hold-up” (if you do not meet resistance you have a probable esophageal intubation and insertion should be reattempted or the failed airway protocol implemented as indicated); 7. Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie; 8. Gently advance the Bougie and loaded ET tube until you have hold-up again, thereby assuring tracheal placement and minimizing the risk of accidental displacement of the Bougie; 9. While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the Bougie passing the tube to its appropriate depth; 10. If you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn the bevel of the ETT posteriorly. If this technique fails to facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the ETT(this will require an assistant to maintain the position of the Bougie and, if so desired, advance the ETT); 11. Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie; 12. Confirm tracheal placement according to the intubation protocol, inflate the cuff with 3 to 10 cc of air, auscultate for equal breath sounds and reposition accordingly; 13. When final position is determined secure the ET tube, reassess breath sounds, apply continuous waveform end tidal (EtCO2) monitor, and record and monitor readings to assure continued tracheal intubation. Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once per year.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Nasotracheal Intubation

P EMT- P P Clinical Indications:  A spontaneously breathing patient in need of intubation (inadequate respiratory effort, evidence of hypoxia or carbon dioxide retention, or need for airway protection).  Rigidity or clenched teeth prohibiting other airway procedures.  Patient must be 12 years of age or older.

Contraindication:  Contraindicated in

Procedure: 1. Premedicate the patient with nasal spray. 2. Select the largest and least obstructed nostril and insert a lubricated nasal airway to help dilate the nasal passage. 3. Preoxygenate the patient and lubricate the tube. The use of a BAAM device is recommended. 4. Remove the nasal airway and gently insert the tube keeping the bevel of the tube toward the septum. 5. Continue to pass the tube listening for air movement and visualizing vapor condensation in the ETT tube. 6. Gently and evenly advance the tube through the glottic opening on the inspiration. This facilitates passage of the tube and reduces the incidence of trauma to the vocal cords. 7. Upon entering the trachea, the tube may cause the patient to cough, buck, strain, or gag. Do not remove the tube! This is normal, but be prepared to control the cervical spine and the patient, and be alert for vomiting. 8. Auscultate for bilaterally equal breath sounds and absence of sounds of the epigastrium. Observe for symmetrical chest expansion. The 15mm adapter usually rests close to the nostril with proper positioning. 9. Inflate the cuff with 5-10 cc of air. 10. Confirm tube placement using end-tidal CO2 monitoring: Apply waveform capnography monitor. After 3 ventilations, EtCO2 should be >10 mmHg or comparable to pre-intubation values. If < 10 mmHg, check for adequate circulation, equipment, and ventilatory rate. If EtCO2 is still < 10 mmHg without physiologic explanation, remove the ET Tube and ventilate by BVM. 11. Secure the tube. 12. Reassess airway and breath sounds after transfer to the stretcher and during transport. These tubes are easily dislodged and require close monitoring and frequent reassessment. 13. Document the procedure, time, and result (success) on / with the patient care report (PCR). 14. It is required that the airway be monitored continuously via waveform capnography and pulse oximetry. 15. Complete and submit appropriate airway form.

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Surgical – Cricothyrotomy

Clinical Indications: P EMT- P P  Failed Airway Protocol  Management of an airway when standard airway procedures cannot be performed or have failed in a patient > 12 years old.

Procedure: 1. Have suction and supplies available and ready. Don personal protective equipment. 2. Locate the cricothyroid membrane utilizing anatomical landmarks. 3. Prep the area with an antiseptic swab (Betadine). 4. Attach a 5-cc syringe to an 18G - 1 & 1/2-inch needle. 5. Insert the needle (with syringe attached) perpendicularly through the cricothyroid membrane with the needle directed posteriorly. 6. During needle insertion, gentle aspiration should be applied to the syringe. Rapid aspiration of air into the syringe indicates successful entry into the trachea. Do not advance the needle any further. Attach forceps and remove syringe. 7. With the needle remaining in place, make a 1-inch vertical incision through the skin and subcutaneous tissue above and below the needle using a scalpel. Using blunt dissection technique, expose the cricothyroid membrane. This is a bloody procedure. The needle should act as a guide to the cricothyroid membrane. 8. With the needle still in place, make a horizontal stabbing incision approx. 1/2 inch through the membrane on each side of the needle. Remove the needle. 9. Using (skin hook, tracheal hook, or gloved finger) to maintain surgical opening, insert the cuffed tube into the trachea, or Bougie (advance until resistance is felt) then cuffed tube over Bougie. (Tube from the cric kit or a #6 endotracheal tube is usually sufficient). 10. Inflate the cuff with 5-10cc of air and ventilate the patient while manually stabilizing the tube. 11. All of the standard assessment techniques for insuring tube placement should be performed (auscultation, chest rise & fall, end-tidal CO2 detector, etc.) Esophageal bulb devices are not accurate with this procedure. 12. Secure the tube. 13. If available, apply continuous waveform end tidal capnography (EtCO2) and record readings on scene, en route to the hospital, and at the hospital. 14. Document ETT size, time, result (success), and placement location by the centimeter marks either at the patient’s teeth or lips on/with the patient care report (PCR). Document all devices used to confirm initial tube placement and after each movement of the patient. 15. Consider placing an NG or OG tube to clear stomach contents after the airway is secured. 16. It is required that the airway be monitored continuously through waveform capnography and pulse oximetry.

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Capnography- Continuous Waveform

P EMT- P P Clinical Indications:

 Capnography will be used when available with the use of all invasive airway procedures including endotracheal, nasotracheal, cricothyrotomy, or Blind Insertion Airway Devices (BIAD).  Capnography will be used when possible with CPAP.  Capnography will be used on all patients treated with magnesium and/or epinephrine for respiratory distress.  Capnography will be used on any patient exhibiting any signs of sedation after controlled substance administration.

Procedure:

1. Attach capnography sensor to the BIAD, endotracheal tube, or any other oxygen delivery device, including bag-valve mask and nasal cannula. 2. Note CO2 level and waveform changes. These will be documented on each respiratory failure cardiac arrest, or respiratory distress patient. 3. The capnography sensor will remain in place with the airway and be monitored throughout the pre-hospital care and transport. 4. Any loss of CO2 detection or waveform indicates an airway problem and should be documented. Use systematic approach when documenting any loss’s or failures. 5. The capnography sensor will be monitored as procedures are performed to verify or correct the airway problem. 6. Document the procedure and results on/with the Patient Care Report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Suctioning-Basic

B EMT B Clinical Indications: P EMT- P P

 Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient who cannot maintain or keep the airway clear.

Procedure:

1. Ensure suction device is in proper working order with suction tip in place. 2. Preoxygenate the patient as is possible. 3. Explain the procedure to the patient if they are coherent. 4. Examine the oropharynx and remove any potential foreign bodies or material which may occlude the airway if dislodged by the suction device. 5. If applicable, remove ventilation devices from the airway. 6. Use the suction device to remove any secretions, blood, or other substance. 7. The alert patient may assist with this procedure. 8. Reattach ventilation device (e.g., bag-valve mask) and ventilate or assist the patient 9. Record the time and result of the suctioning in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Suctioning-Advanced

P EMT- P P Clinical Indications:

 Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient currently being assisted by an airway adjunct such as a nasotracheal tube, endotracheal tube, Combitube, tracheostomy tube, or a cricothyrotomy tube.

Procedure:

1. Ensure suction device is in proper working order. 2. Preoxygenate the patient as is possible. 3. Attach suction catheter to suction device, keeping sterile plastic covering over catheter. 4. Using the suprasternal notch and the end of the airway into the catheter will be placed as guides, measure the depth desired for the catheter (judgment must be used regarding the depth of suctioning with cricothyrotomy and tracheostomy tubes). 5. If applicable, remove ventilation devices from the airway. 6. With the thumb port of the catheter uncovered, insert the catheter through the airway device. 7. Once the desired depth (measured in #4 above) has been reached, occlude the thumb port and remove the suction catheter slowly. 8. A small amount of Normal Saline (10 ml) may be used if needed to loosen secretions for suctioning. 9. Reattach ventilation device (e.g., bag-valve mask) and ventilate the patient. 10. Document time and result in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Tracheostomy Tube Change

P EMT- P P Clinical Indications:

 Presence of Tracheostomy site.  Urgent or emergent indication to change the tube, such as obstruction that will not clear with suction, dislodgement, or inability to oxygenate/ventilate the patient without other obvious explanation.

Procedure:

1. Have all airway equipment prepared for standard airway management, including equipment of orotracheal intubation and failed airway. 2. Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (e.g., if the patient has a # 6.0 Shilley, then have a 6.0 and a 5.5 tube). 3. Lubricate the replacement tube(s) and check the cuff. 4. Remove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to preoxygenate the patient as much as possible. 5. Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages. 6. If applicable, deflate the cuff on the tube. If unable to aspirate air with a syringe, cut the balloon off to allow the cuff to lose pressure. 7. Remove the tracheostomy tube. 8. Insert the replacement tube. Confirm placement via standard measures except for esophageal detection (which is ineffective for surgical airways). 9. If there is any difficultly placing the tube, re-attempt procedure with the smaller tube. 10. If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal intubation (as per protocol). More difficulty with tube changing can be anticipated for tracheostomy sites that are immature – i.e., less than two weeks old. Great caution should be exercised in attempts to change immature tracheotomy sites. 11. Document procedure, confirmation, patient response, and any complications in the PCR.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment for this skill should include direct observation at least once per certification cycle.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway – Nebulizer Inhalation Therapy

P EMT- P P Clinical Indications:

 Patients experiencing bronchospasm.

Procedure:

1. Gather the necessary equipment. 2. Assemble the nebulizer kit. 3. Instill the premixed drug (such as Albuterol or other approved drug) into the reservoir well of the nebulizer. 4. Connect the nebulizer device to oxygen at 4 - 6 liters per minute or adequate flow to produce a steady, visible mist. 5. Instruct the patient to inhale normally through the mouthpiece of the nebulizer. The patient needs to have a good lip seal around the mouthpiece. 6. The treatment should last until the solution is depleted. Tapping the reservoir well near the end of the treatment will assist in utilizing all of the solution. 7. Monitor the patient for medication effects. This should include the patient’s assessment of his / her response to the treatment and reassessment of vital signs, ECG, and breath sounds. 8. Assess and document peak flows before and after nebulizer treatments. 9. Document the treatment, dose, and route on/with the patient care report (PCR). 10. EMT-B may only assist only assist with giving patient's their prescribed medications.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Respirator Operation

P EMT- P P Clinical Indications:

 Transport of an intubated patient

Procedure:

1. Confirm the placement of tube as per airway protocol. 2. Ensure adequate oxygen delivery to the respirator device. 3. Preoxygenate the patient as much as possible with bag-valve mask. 4. Remove BVM and attach tube to respiration device. 5. Per instructions of device, set initial respiration values. For example, set an inspiratory: expiratory ratio of 1:4 (for every 1 second of inspiration, allow 4 seconds and expiration) with a rate of 12 to 20. 6. Assess breath sounds. Allow for adequate expiratory time. Adjust respirator setting as clinically indicated. 7. It is required that patients on a transport ventilator should be monitored continuously through capnography and pulse oximetry. The ventilatory rate should adjusted to maintain a pulse oximetry of 90-99% (or as high as possible up to 99%) while maintaining

a EtCO2 of 30-35 mmHg. 8. If any worsening of patient condition, decrease in oxygen saturation, or any question regarding the function of the respirator, remove the respirator and resume bag-valve mask ventilations. 9. Document time, complications, and patient response on the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Airway: Ventilator Operation

P EMT- P P Clinical Indications:

 Management of the ventilation of a patient during a prolonged or interfacility transport of an intubated patient.

Procedure:

1. Transporting personnel should review the operation of the ventilator with the treating personnel (physician, nurse, or respiratory therapy) in the referring facility prior to transport if possible. 2. All ventilator settings, including respiratory rate, FiO2, mode of ventilation, and tidal volumes should be recorded prior to initiating transport. Additionally, the recent trends in oxygen saturation experienced by the patient should be noted. 3. Prior to transport, specific orders regarding any anticipated changes to ventilator settings as well as causes for significant alarm should be reviewed with the referring medical personnel as well as medical control. 4. Once in the transporting unit, confirm adequate oxygen delivery to the ventilator. 5. Frequently assess breath sounds to assess for possible tube dislodgment during transfer. 6. Frequently assess the patient’s respiratory status, noting any decreases in oxygen saturation or changes in tidal volumes, peak pressures, etc. 7. Note any changes in ventilator settings or patient condition in the PCR. 8. Consider placing an NG or OG tube to clear stomach contents. 9. It is required that the airway be monitored continuously through waveform capnography and pulse oximetry. 10. If any significant change in patient condition, including vital signs or oxygen saturation or there is a concern regarding ventilator performance/alarms, remove the ventilator from the endotracheal tube and use a bag-valve mask with 100% O2. Contact medical control immediately.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) 12 Lead ECG and CODE STEMI Activation Clinical Indications: B EMT B  Suspected cardiac patient  Suspected tricyclic overdose P EMT- P P  Electrical injuries  Syncope

Procedure: 1. Assess patient and monitor cardiac status. 2. Administer oxygen as patient condition warrants. 3. If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after treatment, perform a 12 Lead ECG. 4. Prepare ECG monitor and connect patient cable with electrodes. 5. Enter the required patient information (patient name, etc.) into the 12 lead ECG device. 6. Expose chest and prep as necessary. Modesty of the patient should be respected. 7. Apply chest leads and extremity leads using the following landmarks:  RA - Right arm  LA - Left arm  RL - Right leg  LL - Left leg  V1 - 4th intercostal space at right sternal border  V2 - 4th intercostal space at left sternal border  V3 - Directly between V2 and V4  V4 - 5th intercostal space at midclavicular line  V5 - Level with V4 at left anterior axillary line  V6 - Level with V5 at left midaxillary line 8. Patient should be placed in the supine position (or as near to it as the patient can tolerate) before acquiring the 12 Lead ECG. 9. Instruct patient to remain still. 10. Press the appropriate button to acquire the 12 Lead ECG. 11. If the monitor detects a problem, such as loose leads, bad connection, noisy data, the problem should be addressed and a new 12 lead acquired. 12. Once acquired, transmit the 12 Lead ECG data to the receiving hospital. 13. Contact the receiving hospital to give report and notify them that a 12 Lead ECG has been sent. 14. Monitor the patient while continuing with the treatment protocol. 15. Download monitor data (if available) and attach a copy of the 12 lead to the patient care report (PCR). 15 Leads are highly suggested in Chest Pain Patients 16. Document the procedure, time, and results in the PCR. 17. Go to the next page for procedures regarding suspected STEMI

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure Page 1 2016 SSM Medical Direction Standard Procedure (Skill) EMS CODE STEMI: Cath Lab Activation Clinical Indications: P EMT- P P  Suspected ST-Elevation MI (STEMI), based on patient condition and ECG

Procedure:

1. Transmit diagnostic 12‐lead ECG to receiving hospital. 2. Obtain the following information before your radio call in:  Patient age and gender  Patient cardiologist and preferred STEMI hospital (if present)  Clinical presentation, history, symptoms that suggest this is an acute cardiac event  What are the 2 or more anatomically contiguous leads with 1 + mm ST elevation, (SEE CHEST PAIN PROTOCOL for STEMI localization tool)  Is there a LBBB not known to be old?  Absence or presence of Left Ventricular Hypertrophy (LVH).  Absence or presence of profound tachycardia (heart rate >129).  Absence or presence of pacemaker activity.  Was the patient resuscitated from cardiac arrest but does not have obvious STEMI?

3. If patient has 1+ mm of ST elevation in two anatomically contiguous leads and none of the characteristics in red above, call a CODE STEMI to the hospital. If any of the characteristics in red are present do NOT call “Code STEMI.” Instead, transmit the 12‐lead for physician consultation; be sure to communicate the need for physician consult due to concern for possible STEMI.

4. Give your standard radio call‐in including the following information:  This is EMS (unit #) en route with a CODE STEMI patient, ETA (X) minutes.  The 12‐lead (has been/could not be) transmitted.  Clinical presentation suggesting acute event: Chest Pain, Shortness of Breath, diaphoresis, etc.  (X) mm of ST segment elevation are present in leads (X,Y…), with reciprocal depression in (X,Y…) (SEE CHEST PAIN PROTOCOL FOR LOCALIZATION TOOL) OR patient was resuscitated from V‐fib / VTach arrest and now has evidence of STEMI.  There is (or is not) LVH noted.  The patient has no pacemaker (or no pacer spikes are present).  (He/She) is a patient of Dr. (X) (or has no cardiologist).  Provide patient’s name and DOB if requested (Not a HIPAA Issue).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure Page 2 2016 SSM Medical Direction Standard Procedure (Skill) Cardiopulmonary Resuscitation (CPR) Clinical Indications: B EMT B  Basic life support for the patient in cardiac arrest P EMT- P P Procedure: 1. Within 10 seconds, assess the patient’s level of responsiveness, (shake and shout), assess for normal breathing, and check pulse. 2. If the patient is not breathing normally, check for carotid pulse in adults and older children, brachial pulse for infants. If no pulse or if you are unsure if there is a pulse, begin chest compressions based on chart below: Age Location Depth Rate

Over sternum, between nipples Infant 1.5 inches At least 100/minute (inter-mammary line), 2-3 fingers

Over sternum, just At least 100/minute cephalad from Child 2 inches (3 compressions xyphoid process, Every 2 seconds) heel of one hand

Over sternum, just cephalad from At least 100/minute Adult xyphoid process, At least 2 inches (3 compressions hands with Every 2 seconds) interlocked fingers 3. If patient is an adult, go to step 5. In a pediatric patient, with 2 rescuers, a 15:2 ratio of compressions and ventilations should be given until an advanced airway is placed. Then ventilate at a rate of 8 – 10 breaths per minute. Proceed to Pediatric arrest protocol. 4. Chest compressions and ventilations should be given at a 30:2 ratio until an advanced airway is placed. Then ventilate at a rate of 8 – 10 breaths per minute after advanced airway procedure, and continue compressions. Proceed to Cardiac Arrest Protocol. 5. If an advanced airway is in place, continuous waveform capnography (EtCO2) readings of < 10 mmHg is an indication to try to improve compressions. If there is an abrupt increase in EtCO2 readings this may be an indicator of a return of spontaneous circulation (ROSC). 6. Chest compressions should be provided in an uninterrupted manner. Only brief interruptions (< 5 seconds) are allowed for rhythm analysis, defibrillation, and procedures. 7. Document the time and procedure in the Patient Care Report (PCR). Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. A current Professional Healthcare Basic Life Support (BLS) Provider card shall be maintained. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Defibrillation: Automated

B EMT B Clinical Indications: P EMT- P P  Patients in cardiac arrest (pulseless, non-breathing).  Age < 8 years, use Pediatric Pads, if available.

Contraindication:

 Pediatric patients who are so small that the pads cannot be placed without touching one another.

Procedure:

1. If multiple rescuers available, one rescuer should provide uninterrupted chest compressions while the AED is being prepared for use. 2. Apply defibrillator pads per manufacturer recommendations. Based on 2010 guidelines, place pads preferably in AP or AL position when implanted devices (pacemakers, AICDs) occupy preferred pad positions and attempt to avoid placing directly over device. 3. Remove any medication patches on the chest and wipe off any residue. 4. If necessary, connect defibrillator leads: white to the anterior chest pad and the red to the posterior pad. 5. Activate AED for analysis of rhythm. 6. Stop CPR and clear the patient for rhythm analysis. Keep interruption in CPR as brief as possible. 7. Defibrillate if appropriate by depressing the “shock” button. Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient prior to defibrillation. The sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic defibrillators will determine the correct joules accordingly. 8. Begin CPR (chest compressions and ventilations) immediately after the delivery of the defibrillation. 9. After 2 minutes of CPR, analyze rhythm and defibrillate if indicated. Repeat this step every 2 minutes. 10. If “no shock advised” appears, perform CPR for two minutes and then reanalyze. 11. Transport and continue treatment as indicated. 12. Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation. 13. If pulse returns follow the Post Resuscitation Protocol.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once a year.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Defibrillation: Manual

P EMT- P P Clinical Indications:

 Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia

Procedure:

1. Ensure that Chest Compressions are adequate and interrupted only when absolutely necessary. 2. Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation. 3. After application of an appropriate conductive agent if needed, apply defibrillation hands free pads (recommended to allow more continuous CPR) or paddles to the patient’s chest in the proper position:  Paddles: right of sternum at 2nd ICS and anterior axillary line at 5th ICS  Pads: anterior-posterior position  For patients with implanted pacers/defibrillators, paddles or pads can be in AP or AL positions. The presence of implanted pacers/defibrillators should not delay defibrillation. Attempt to avoid placing paddles or pads directly above device. 4. Set the appropriate energy level: dose ADULT 150J, 150 J, 200 J 200J, 300J, 360J 120J, 150J, 200J PEDIATRIC 2 J/KG, 4 J/KG, 10 J/KG 2 J/KG, 4 J/KG, 10 J/KG 2 J/KG, 4 J/KG, 10 J/KG manufacturer PHILIPS PHYSIO ZOLL 5. Charge the defibrillator to the selected energy level. Continue chest compressions while the defibrillator is charging. 6. If using paddles, assure proper contact by applying 25 pounds of pressure on each paddle. 7. Hold Compressions, assertively state, “CLEAR” and visualize that no one, including yourself, is in contact with the patient. 8. Deliver the countershock by depressing the discharge button(s) when using paddles, or depress the shock button for hands free operation. 9. Immediately resume chest compressions and ventilations for 2 minutes. After 2 minutes of CPR, analyze rhythm and check for pulse only if appropriate for rhythm. 10. Repeat the procedure every two minutes as indicated by patient response and ECG rhythm. 11. Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once per year.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Cardioversion Clinical Indications: P EMT- P P  Unstable patient with a tachydysrhythmia (rapid atrial fibrillation, supraventricular tachycardia, ventricular tachycardia)  Patient is not pulseless (the pulseless patient requires unsynchronized cardioversion, i.e., defibrillation)

Procedure:

1. Ensure the patient is attached properly to a monitor/defibrillator capable of synchronized cardioversion. 2. Have all equipment prepared for unsynchronized cardioversion / defibrillation if the patient fails synchronized cardioversion and the condition worsens. 3. Consider the use of pain or sedating medications. 4. Set energy selection to the appropriate setting.

Cardioversion dose 100J, 150 J, 200 J 200J, 300J, 360J 75J, 120J, 150J, 200J Consider starting at 150J for E Series ADULT Atrial flutter 50J, 100J, 150J Atrial flutter/SVT 70J, 120J, 150J, 200J PEDIATRIC 1 J/KG, 2 J/K 1 J/KG, 2 J/K 2 J/KG manufacturer PHILIPS PHYSIO ZOLL

5. Set monitor/defibrillator to synchronized cardioversion mode. 6. Make certain all personnel are clear of patient. 7. Press and hold the shock button to cardiovert. Stay clear of the patient until you are certain the energy has been delivered. NOTE: It may take the monitor/defibrillator several cardiac cycles to “synchronize”, so there may a delay between activating the cardioversion and the actual delivery of energy. 8. Note patient response and perform immediate unsynchronized cardioversion/defibrillation if the patient’s rhythm has deteriorated into pulseless ventricular tachycardia / ventricular fibrillation, follow the procedure for Defibrillation: Manual. 9. If the patient’s condition is unchanged, repeat steps 2 to 8 above, using escalating energy settings. 10. Repeat until maximum setting or until efforts succeed. Consider discussion with medical control if cardioversion is unsuccessful after 2 attempts. 11. Monitor for hypotension and utilize continuous waveform capnography to monitor for respiratory depression associated with midazolam. 12. Note procedure, response, and time in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the local EMS System. Assessment should include direct observation at least once per year, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Cardiac: External Pacing

P EMT- P P Clinical Indications:

 Patients with symptomatic bradycardia (less than 60 per minute) with signs and symptoms of inadequate cerebral or cardiac perfusion such as:  Chest pain  Hypotension  Pulmonary edema  Altered mental status, confusion, etc.  Ventricular ectopy  In asystole, pacing must be done early to have any chance of effectiveness.  In PEA, where the underlying rhythm is bradycardic and reversible causes have been treated.

Procedure:

1. Attach standard four-lead monitor. 2. Apply defibrillation/pacing pads to chest and back:  One pad to left mid chest next to sternum  One pad to mid left posterior chest next to spine. 3. Select pacing option on monitor unit. 4. Adjust heart rate to 70 BPM for an adult and 100 BPM for a child. 5. Note pacer spikes on EKG screen. 6. Slowly increase output until capture of electrical rhythm on the monitor. 7. If unable to capture while at maximum current output, stop pacing immediately. 8. If capture observed on monitor, check for corresponding pulse and assess vital signs. 9. Consider the use of sedation or analgesia if patient is uncomfortable. 10. Monitor for hypotension and utilize continuous waveform capnography to monitor for respiratory depression associated with midazolam. 11. Document the dysrhythmia and the response to external pacing with ECG strips in the PCR.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once a year.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Assessment: Adult

B EMT B Clinical Indications: P EMT- P P

 Any patient requesting a medical evaluation that is too large to be measured with a Broselow - Luten Resuscitation Tape.

Procedure:

1. Scene size-up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by-stander safety, and initiate patient/caregiver interaction. 2. Initial assessment includes a general impression as well as the status of a patient’s airway, breathing, and circulation. 3. Assess need for critical interventions and assess overall priority of patient. 4. Assess mental status (e.g., AVPU) and disability (e.g., GCS). Perform baseline set of vital signs. 5. Perform a focused history and physical based on patient’s chief complaint. Complete pain assessment. 6. Complete critical interventions before performing a complete secondary exam (e.g. SAMPLE). Complete ongoing sets of vital signs as directed by protocol. 7. Maintain an on-going assessment throughout transport; to include patient response/possible complications of interventions, need for additional interventions, and assessment of evolving patient complaints/conditions. 8. Document all findings and information associated with the assessment, performed procedures, any administration of medications, and patient’s response to interventions on the PCR.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Assessment: Pediatric

B EMT B Clinical Indications: P EMT- P P

 Any child that can be measured with the Broselow-Luten Resuscitation Tape.

Procedure:

1. Scene size-up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by-stander safety, and patient/caregiver interaction. 2. Assess patient using the pediatric triangle of ABCs:  Airway and appearance: speech/cry, muscle tone, inter-activeness, look/gaze, movement of extremities  Work of breathing: absent or abnormal airway sounds, use of accessory muscles, nasal flaring, body positioning  Circulation to skin: pallor, mottling, cyanosis 3. Establish spinal immobilization if there is suspicion of spinal injury. 4. Establish responsiveness appropriate for age (AVPU, GCS, etc.). 5. Color code using Broselow - Luten tape. 6. Assess disability (pulse, motor function, sensory function, pupillary reaction). 7. Perform a focused history and physical exam. Recall that pediatric patients easily experience hypothermia and thus should not be left uncovered any longer than necessary to perform an exam. 8. Record vital signs (Generally, BP > 3 years of age, cap refill < 3 years of age). For young children, the need for BP measurement should be determined on a case-by-case basis considering the provider’s rapport with the child and the child’s clinical condition. Blood pressure measurement is not required for all patients, but should be measured if possible, especially in critically ill patients in whom blood pressure measurement may guide treatment decisions. 9. Include , allergies, medications, past medical history, last meal, and events leading up to injury or illness (SAMPLE) where appropriate. 10. Treat chief complaint as per protocol(s).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Pain Assessment and Documentation Clinical Indications: B EMT B  Any patient with pain. Definitions: P EMT- P P  Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.  Pain is subjective (whatever the patient says it is). Procedure: 1. Initial and ongoing assessment of pain intensity and character is accomplished through the patient’s self report. 2. Pain should be assessed and documented in the PCR during initial assessment, before starting pain control treatment, and with each set of vitals. 3. Pain should be assessed using the appropriate approved scale. 4. Three pain scales are available: the 0 – 10, the Wong - Baker "faces", and the FLACC.  0 – 10 Scale: the most familiar scale used by EMS for rating pain with patients. It is primarily for adults and is based on the patient being able to express their perception of the pain as related to numbers. Avoid coaching the patient; simply ask them to rate their pain on a scale from 0 to 10, where 0 is no pain at all and 10 is the worst pain ever.  Wong – Baker “FACES” scale: this scale is primarily for use with pediatrics but may also be used with geriatrics or any patient with a language barrier. The faces correspond to numeric values from 0-10. This scale can be documented with the numeric value.

From Hockenberry MJ, Wilson D, Winkelstein ML: Wong's Essentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p. 1259. Used with permission. Copyright, Mosby.  FLACC scale: this scale has been validated for measuring pain in children with mild to severe cognitive impairment and in pre-verbal children (including infants).

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Blood Glucose Analysis

B EMT B Clinical Indications: P EMT- P P

 Patients with suspected hypoglycemia (diabetic emergencies, change in mental status, bizarre behavior, etc.)

Procedure:

1. Gather and prepare equipment. 2. Blood samples for performing glucose analysis can be obtained through a finger-stick or when possible simultaneously with intravenous access. 3. Place correct amount of blood on reagent strip or site on glucometer per the manufacturer's instructions. 4. Time the analysis as instructed by the manufacturer. 5. Document the glucometer reading and treat the patient as indicated by the analysis and protocol. 6. Repeat glucose analysis as indicated for reassessment after treatment and as per protocol. 7. Perform Quality Assurance on glucometers at least once every 7 days, if any clinically suspicious readings are noted, and/or as recommended by the manufacturer and document results in the log.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Pulse Oximetry

B EMT B Clinical Indications: P EMT- P P

 Patients with suspected hypoxemia.

Procedure:

1. Apply probe to patient’s finger or any other digit as recommended by the device manufacturer. 2. Allow machine to register saturation level. 3. Record time and initial saturation percent on room air if possible on/with the patient care report (PCR). 4. Verify pulse rate on machine with actual pulse of the patient. 5. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary. 6. Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia. 7. In general, normal saturation is 97-99%. Below 92-94%, suspect a respiratory compromise, which may or may not be a chronic condition (e.g. COPD). 8. Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data provided by the device. 9. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain. Supplemental oxygen is not required if the oxyhemoglobin saturation is > 94%. If there are obvious signs of ischemia, heart failure, dyspnea, or hypoxia, goal is to maintain saturation 90-99% depending on patient condition. 10. Factors which may reduce the reliability of the pulse oximetry reading include but are not limited to:  Poor peripheral circulation (blood volume, hypotension, hypothermia)  Excessive pulse oximeter sensor motion  Fingernail polish (may be removed with acetone pad)  Carbon monoxide bound to hemoglobin  Irregular heart rhythms (atrial fibrillation, SVT, etc.)  Jaundice  Placement of BP cuff on same extremity as pulse ox probe.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Carboxy/Methemoglobin Monitoring

B EMT B Clinical Indications: P EMT- P P

 Persons with suspected or known exposure to carbon monoxide or substance likely to produce methemoglobin.

Procedure:

1. Apply probe to patient’s ring finger on non-dominant hand or any other digit as recommended by the device manufacturer. If near strobe lights, cover the finger to avoid interference and/or move away from lights if possible. Where the manufacturer provides a light shield it should be used. 2. Allow machine to register percent circulating carboxyhemoglobin or methemoglobin values. 3. If the manufacturer recommends then the carboxyhemoglobin / methemoglobin is taken 3 times and the values are averaged out to obtain the mean percentage of carboxyhemoglobin / methemoglobin level. 4. Record levels in patient care report or on the scene rehabilitation form. 5. Verify pulse rate on machine with actual pulse of the patient. 6. Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading, monitor patients for a few minutes as oxygen saturation can vary. 7. Document percent of carboxyhemoglobin or methemoglobin values every time vital signs are recorded during therapy for exposed patients. 8. Use the pulse oximetry feature of the device as an added tool for patient evaluation. Treat the patient, not the data provided by the device. Utilize the relevant protocol(s) for guidance. 9. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings, such as chest pain. 10. Factors which may reduce the reliability of the reading include:  Poor peripheral circulation (blood volume, hypotension, hypothermia  Excessive external lighting, particularly strobe/flashing lights  Excessive pulse oximeter sensor motion.  Fingernail polish (may be removed with acetone pad)  Irregular heart rhythms (atrial fibrillation, SVT, etc.)  Jaundice  Placement of BP cuff on same extremity as pulse ox probe.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Orthostatic Blood Pressure Measurement

B EMT B Clinical Indications: P EMT- P P

 Patient situations with suspected blood, fluid loss, or dehydration with no indication for spinal immobilization. Orthostatic vital signs are not routinely recommended.  Patients > 8 years of age, or patients larger than the Broselow - Luten tape  Orthostatic Vital Signs are not sensitive nor specific for volume loss / dehydration and may induce syncope in some cases. Assessment of orthostatic vital signs are not routinely recommended. Local Medical Director should indicate and educate on situations where they may be helpful.

Procedure:

1. Gather and prepare standard sphygmomanometer and stethoscope. 2. With the patient supine, obtain pulse and blood pressure. 3. Have the patient sit upright. 4. After 30 seconds, obtain blood pressure and pulse. 5. If the systolic blood pressure falls more than 30 mmHg or the pulse rises more than 20 bpm, the patient is considered to be orthostatic. 6. If a patient experiences dizziness upon sitting or is obviously dehydrated based on history or physical exam, formal orthostatic examination should be omitted and fluid resuscitation initiated. 7. If you do perform a standing orthostatic blood pressure, extreme caution is necessary of you and your patient’s environment, it may be inappropriate of the clinical setting.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Temperature Measurement

B EMT B Clinical Indications: P EMT- P P

 Monitoring body temperature in a patient with suspected infection, hypothermia, hyperthermia, or to assist in evaluating resuscitation efforts.

Procedure:

1. For adult patients that are conscious, cooperative, and in no respiratory distress, an oral temperature is preferred (steps 2 to 4 below). For infants or adults that do not meet the criteria above, a rectal temperature may be performed (steps 5 to 7 below). Tympanic temperature measurement is also acceptable, as is esophageal temperature probe in the setting of induced hypothermia; refer to manufacturer’s instructions for these devices as necessary, and follow to the Gastric Tube Insertion procedure (Paramedic Only) to effect placement of the esophageal probe. 2. To obtain an oral temperature, ensure the patient has no significant oral trauma and place the thermometer under the patient’s tongue with appropriate sterile covering. 3. Have the patient seal his or her mouth closed around thermometer. 4. If using an electric thermometer, leave the device in place until there is indication an accurate temperature has been recorded (per the “beep” or other indicator specific to the device). If using a traditional thermometer, leave it in place until there is no change in the reading for at least 30 seconds (usually 2 to 3 minutes). Proceed to step 9. 5. Prior to obtaining a rectal temperature, assess whether the patient has suffered any rectal trauma by history and/or brief examination as appropriate for patient’s complaint. 6. To obtain a rectal temperature, cover the thermometer with an appropriate sterile cover, apply lubricant, and insert into rectum no more than 1 to 2 cm beyond the external anal sphincter. 7. Follow guidelines in step 5 above to obtain temperature. 8. Record time, temperature, method (oral, rectal, tympanic, esophageal), and scale (C° or F°) in Patient Care Report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Stroke Screen: Modified SSM Pre-hospital

B EMT B Clinical Indications: P EMT- P P

 Suspected Stroke Patient

Procedure:

1. Assess and treat suspected stroke patients as per protocol. 2. The SSM Prehospital Stroke Screen form should be completed for all suspected stroke patients (see appendix). There are six screening criteria items on the form- see below for SSM Code Stroke-specific modifications. 3. Screen the patient for the following criteria:  For the utilization of this screen in the SSM Code Stroke, there is no age cutoff; consider any age patient as “yes” for possible stroke.  For the utilization of this screen in the SSM Code Stroke, there must be no history of seizure within the last 24 hours.  New onset of neurologic symptoms in last 8 hours.  For the utilization of this screen in the SSM Code Stroke, there is no ambulatory requirement; i.e. patients non-ambulatory at baseline can screen “yes” for possible stroke.  Blood glucose between 60-400 4. The final criterion consists of performing a patient exam looking for facial droop, unilateral grip weakness/absence, or unilateral arm weakness. One of these exam components must be positive to answer “yes” on the screening form. 5. If all of the SSM Code Stroke screening criteria are met (“yes” to all criteria, including at least one exam component OR if unknown), OR if the patient has slurred speech not related to alcohol or toxic ingestion or cannot talk, follow the SSM Code Stroke Plan and alert the receiving hospital of a possible stroke patient as early as possible. 6. All sections of the SSM Code Stroke form must be completed. 7. The completed SSM Code Stroke form should be attached or documented in the PCR.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM CODE STROKE CHECKLIST Date: Unit#: Lead Medic: ❐ EMS Agency: Incident#: EMS Onscene Time: Gender: Female Male Patient Name: DOB: SS#: Witness Name: #: Home #: Closest Relative: Cell #: Home #: (if different) CINCINNATI STROKE SCALE (FAST) (✓ If Abnormal) F—(face) FACIAL DROOP: Have patient smile or show teeth (look for asymmetry). Normal: Both sides of the face move equally or not at all. Abnormal: One side of the patient’s face droops. A—(arm) MOTOR WEAKNESS: Arm drift (close eyes, extend arms, palms down). Normal: Remain extended equally, drifts equally, or does not move at all. Abnormal: One arm drifts down as compared with the other. S—(speech): “You can’t teach an old dog new tricks” (repeat phrase). Normal: Phrase is repeated clearly and correctly. Abnormal: Words are slurred (dysarthria) or abnormal (aphasia) or no speech. T—TIME OF SYMPTOM ONSET: LAST TIME SEEN NORMAL:______LAST TIME SEEN NORMAL TIME: Date: ______Time: ______EVALUATION Glucose ______mg/dL SaO2______% Unable to obtain last time seen normal TREATMENT Head Elevation greater than 30 degree (unless hypotensive) IV x's 2 - 18 gauge preferred Blood draws with Code Stroke Bag and blood tubes labeled. If SpO2 is less than 92%, administer 2L/min nasal cannula If unable to maintain SpO2 > 92%, administer high-flow O2, consider intubation! CODE STROKE called to St. Marys or St. Clare Health Center! Assess Blood Glucose, Treat if below 60mg/dl STROKE ALERT CRITERIA YES NO Time of onset < 12 hours? ANY “abnormal” finding on examination? Deficit NOT likely due to head trauma? Blood glucose > 60 mg/dL? If answer is YES to ALL Code Stroket criteria, call a CODE STROKE to St. Marys or St. Clare Health Center and transport the patient urgently!

Hospital destination: Time Code Stroke called: SSM Medical Direction Standard Procedure (Skill) Reperfusion Checklist

B EMT B Clinical Indications: P EMT- P P

Rapid evaluation of a patient with suspected acute stroke to:  Determine eligibility and potential benefit from fibrinolysis.  Rapid identification of patients who are not eligible for fibrinolysis and may require interventional therapy.

Procedure: 1. Follow the appropriate protocol for the patient’s complaint to assess and identify an acute condition which could potentially benefit from fibrinolysis. If a positive finding is noted on the following assessment, proceed to step 2.  Perform the modified SSM Pre-hospital Stroke Screen to identify an acute stroke

2. Complete the Reperfusion Check Sheet to identify any potential contraindications to fibrinolysis.

Systolic Blood Pressure greater than 180 mm Hg Diastolic Blood Pressure greater than 110 mm Hg Right vs. Left Arm Systolic Blood Pressure difference of greater than 15 mm Hg History of structural Central Nervous System disease (age >= 18, history of aneurysm or AV- malformation, tumors, masses, hemorrhage, etc.) Significant closed head or facial trauma within the previous 3 months Recent (within 6 weeks) major trauma, surgery (including laser eye surgery), gastrointestinal bleeding, or severe genital-urinary bleeding Bleeding or clotting problem or on blood thinners CPR performed greater than 10 minutes Currently Pregnant Serious Systemic Disease such as advanced/terminal cancer or severe liver or kidney failure.

3. If an acute Stroke is suspected by exam, activate the EMS SSM Code Stroke Plan. 4. Record all findings in the Patient Care Report (PCR).

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Chest Decompression

P EMT- P P Clinical Indications:

 Patients who are peri-arrest with have clinical signs of shock, and at least one of the following signs:  Jugular vein distention.  Tracheal deviation away from the side of the injury (often a late sign).  Absent or decreased breath sounds on the affected side.  Hyper-resonance to percussion on the affected side.  Increased resistance when ventilating a patient.  In patients with penetrating trauma to the chest or upper back, or gunshot wound to the neck or torso, who are in respiratory distress, a weak or absent radial pulse may be substituted for blood pressure measurement as above; signs of tension pneumothorax listed above may also be present.  Patients in traumatic arrest with chest or abdominal trauma for whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above.

Procedure:

1. Don personal protective equipment (gloves, eye protection, etc.). 2. Administer high flow oxygen. 3. Identify and prep the site:  Locate the second intercostal space in the mid-clavicular line on the same side as the pneumothorax.  Prepare the site with providone-iodine ointment or solution. 4. Insert the catheter (14 gauge for adults) into the skin over the third and direct it just over the top of the rib (superior border) into the interspace. 5. Advance the catheter through the parietal pleura until a “pop” is felt and air or blood exits under pressure through the catheter, then advance catheter only to chest wall. 6. Remove the needle, leaving the plastic catheter in place. 7. Secure the catheter hub to the chest wall with dressings and tape. 8. Consider placing a finger cut from an exam glove over the catheter hub. Cut a small hole in the end of the finger to make a flutter valve. Secure the glove finger with tape or a rubber band. (Note – don’t waste much time preparing the flutter valve; if necessary control the air flow through the catheter hub with your gloved thumb.)

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation once per year.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Childbirth

B EMT B Clinical Indications: P EMT- P P

 Imminent delivery with crowning.

Procedure:

1. Don personal protective equipment (gloves, eye protection, etc.). Delivery should be controlled so as to allow a slow controlled delivery of the infant. This will prevent injury to the mother and infant. 2. Support the infant’s head as needed. 3. Check the umbilical cord surrounding the neck. If it is present, slip it over the head. If unable to free the cord from the neck, double clamp the cord and cut between the clamps. 4. Suction the airway with a bulb syringe. 5. Grasping the head with hands over the ears, gently pull down to allow delivery of the anterior shoulder. 6. Gently pull up on the head to allow delivery of the posterior shoulder. 7. Slowly deliver the remainder of the infant. 8. Clamp the cord 2 inches from the abdomen with 2 clamps and cut the cord between the clamps. 9. Record APGAR scores at 1 and 5 minutes. 10. Follow the Newly Born Protocol for further treatment. 11. The placenta will deliver spontaneously, usually within 5 minutes of the infant. Do not force the placenta to deliver. 12. Massaging the uterus may facilitate delivery of the placenta and decrease bleeding by facilitating uterine contractions. 13. Continue rapid transport to the hospital. SCORE SIGN 0 1 2 1 min. 5 min. Heart rate Absent < 100 > 100

Respiratory rate Absent Weak, irregular Good, crying

Muscle tone Flaccid Arms and legs flexed Well flexed

Reflex irritability No response Grimace Cough or sneeze

Skin color Blue, pale Hands and feet blue Completely pink

TOTAL SCORE Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by the SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Gastric Tube Insertion

P EMT- P P Clinical Indications:

 Gastric decompression in intubated patients.

Procedure:

1. Estimate insertion length by superimposing the tube over the body from the nose to the stomach. 2. Flex the neck if not contraindicated to facilitate esophageal passage. 3. Liberally lubricate the distal end of the tube and pass through the patient’s nostril along the floor of the nasal passage. Do not orient the tip upward into the turbinates. This increases the difficulty of the insertion and may cause bleeding. 4. In the setting of an intubated patient or a patient with facial trauma, oral insertion of the tube may be considered or preferred after securing airway. 5. Continue to advance the tube gently until the appropriate distance is reached. 6. Confirm placement by injecting 20cc of air and auscultate for the swish or bubbling of the air over the stomach. Additionally, aspirate gastric contents to confirm proper placement. 7. Secure the tube. 8. Decompress the stomach of air and food either by connecting the tube to suction or manually aspirating with the large catheter tip syringe. 9. Document the procedure, time, and result (success) on/with the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Restraints: Physical & Chemical

B Basic B Clinical Indications: P Paramedic P

 Any patient who may harm himself, herself, or others may be gently restrained to prevent injury to the patient or crew. This restraint must be in a humane manner and used only as a last resort. Other means to prevent injury to the patient or crew must be attempted first. These efforts could include reality orientation, distraction techniques, or other less restrictive therapeutic means. Physical or chemical restraint should be a last resort technique.

Procedure:

1. Attempt less restrictive means of managing the patient. 2. Request law enforcement assistance. 3. Ensure that there are sufficient personnel available to physically restrain the patient safely. 4. Restrain the patient in a lateral or supine position. No devices such as backboards, splints, or other devices will be on top of the patient. The patient will never be restrained in the prone position. 5. The patient must be under constant observation by the EMS crew at all times. This includes direct visualization of the patient as well as cardiac and pulse oximetry monitoring. 6. The extremities that are restrained will have a circulation check at least every 15 minutes. The first of these checks should occur as soon after placement of the restraints as possible. This MUST be documented on the PCR. 7. Documentation on/with the patient care report (PCR) should include the reason for the use of restraints, the type of restraints used, and the time restraints were placed. Use of the Restraint Checklist is highly recommended. 8. Paramedic Skill: In general, chemical restraints (i.e. medication(s) given under the Behavioral Protocol) should be utilized whenever physical restraints are utilized. If the above actions are unsuccessful, or if the patient is resisting restraints, consider further medication per protocol or contact medical control. Chemical restraint should be considered early. 9. If a patient is restrained by law enforcement personnel with handcuffs or other devices EMS personnel can not remove, a law enforcement officer must accompany the patient to the hospital in the transporting EMS vehicle.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Splinting

B EMT B Clinical Indications: P EMT- P P  Immobilization of an extremity for transport, due to suspected fracture, sprain, or injury.  Immobilization of an extremity for transport to secure medically necessary devices such as intravenous catheters

Procedure:

1. Assess and document pulses, sensation, and motor function prior to placement of the splint. If no pulses are present and a fracture is suspected with significant deformity present, consider reduction any long prior to placement of the splint. Generally field reduction should be avoided (except femoral traction splint); simply splinting may restore pulses. Consider contacting medical control for advice if extended scene time is expected and an extremity is pulseless. 2. Remove all clothing from the extremity. 3. Select a site to secure the splint both proximal and distal to the area of suspected injury, or the area where the medical device will be placed. 4. Do not secure the splint directly over the injury or device. 5. Place the splint and secure with Velcro, straps, or bandage material (e.g., kling, kerlex, cloth bandage, etc.) depending on the splint manufacturer and design. 6. Document pulses, sensation, and motor function after placement of the splint. If there has been a deterioration in any of these 3 parameters, remove the splint and reassess. 7. If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, the following procedure may be followed for placement of a femoral traction splint:  Assess neurovascular function as in #1 above.  Place the ankle device over the ankle.  Place the proximal end of the traction splint on the posterior side of the affected extremity, being careful to avoid placing too much pressure on genitalia or open wounds. Make certain the splint extends proximal to the suspected fracture. If the splint will not extend in such a manner, reassess possible involvement of the pelvis.  Extend the distal end of the splint at least 6 inches beyond the foot.  Attach the ankle device to the traction crank.  Twist until moderate resistance is met.  Reassess alignment, pulses, sensation, and motor function. If there has been deterioration in any of these 3 parameters, release traction and reassess. 8. Document the time, type of splint, and the pre and post assessment of pulse, sensation, and motor function in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Spinal Examination

B EMT B Clinical Indications: P EMT- P P

 Suspicion of spinal/neurological injury  Provider decision to utilize the Spinal immobilization Clearance protocol

***This procedure details the spinal examination process and must be used in conjunction with the Spinal Immobilization Clearance protocol. It is not intended as a replacement for that protocol or procedure.***

Procedure: 1. Explain to the patient the actions that you are going to take. Ask the patient to immediately report any pain, and to answer questions with a “yes” or “no” rather than shaking the head. 2. With the patient’s spine supported to limit movement, begin palpation at the base of the skull at the midline of the spine. 3. Palpate the vertebrae individually from the base of the skull to the bottom of the sacrum. 4. On palpation of each vertebral body, look for evidence of pain and ask the patient if they are experiencing pain. If evidence of pain along the spinal column is encountered, the patient should be immobilized. 5. If the capable patient is found to be pain free, ask the patient to turn their head first to one side (so that the chin is pointing toward the shoulder on the same side as the head is rotating) then, if pain free, to the other. If there is evidence of pain the patient should be immobilized. 6. With the head rotated back to its normal position, ask the patient to flex and extend their neck. If there is evidence of pain the patient should be immobilized.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Spinal Motion Restriction

B EMT B Clinical Indications: P EMT- P P  Need for spinal motion restriction as determined by protocol; consider the following guidelines:  Long spine boards (LSB) have both risks and benefits for patients and have not been shown to improve outcomes. The best use of the LSB may be for extricating the unconscious patient, or providing a firm surface for compressions. However, several devices may be appropriate for patient extrication and movement, including the scoop stretcher and soft body splints.  Utilization of the LSB should occur in consideration of the individual patient’s benefit vs. risk.  Patients who should be immobilized with a LSB include: blunt trauma and distracting injury, intoxication, altered mental status, or neurologic complaint (e.g. numbness or weakness), and non- ambulatory blunt trauma patients with spinal pain, tenderness, or spinal deformity.  Patients with penetrating trauma and no evidence of spinal injury do not require spinal immobilization. Patients who are ambulatory at the scene of blunt trauma in general do not require immobilization via LSB, and may or may not require c-collar and spinal precautions.  Whether or not a LSB is utilized, spinal precautions are STILL VERY IMPORTANT in patients at risk for spinal injury. Adequate spinal precautions may be achieved by placement of a hard cervical collar and ensuring that the patient is secured tightly to the stretcher, ensuring minimal movement and patient transfers, and manual in-line stabilization during any transfers.

Procedure: 1. Gather a backboard or other appropriately-sized device and C-collar as indicated. 2. Explain the procedure to the patient; assess and record extremity neuro status & distal pulses. 3. Place the patient in an appropriately sized C-collar while maintaining in-line stabilization of the C-spine by a second provider. Stabilization should not involve traction or tension but rather maintaining the head in a neutral, midline position while the first provider applies the collar. 4. Once the collar is secure, the second rescuer should still maintain position to ensure stabilization (the collar is helpful but will not do the job by itself.) 5. If indicated, place the patient on a long spine board with the log-roll technique if the patient is supine or prone. For the patient in a vehicle or otherwise unable to be placed prone or supine, place him or her on a backboard by the safest method available that allows maintenance of in-line spinal stability. 6. Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is secured to the backboard, the second rescuer may release manual in-line stabilization. 7. NOTE: Spinal precautions may be achieved by many appropriate methods. See above and the Spinal Immobilization protocol. In addition, some patients, due to size or age, will not be able to be immobilized through in-line stabilization with standard devices and C-collars. Never force a patient into a non-neutral position to immobilize him or her. Manual stabilization may be required during transport. Special situations (athletes in full shoulder pads and helmet) may remain immobilized with helmet and pads in place. 8. Assess and record extremity neuro status and distal pulses post-procedure. If worse, remove any immobilization devices and reassess. Document time of the procedure in the PCR.

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (skill) Medication Administration

P EMT- P P OBJECTIVE: Standardize the administration of medications in the pre-hospital setting. STANDARD:  EMS personnel shall operate within their respective scope of practice pertaining to the administration of medications in the pre-hospital setting.  Administration of the correct type and quantity of medications is imperative to ensure the safety of the patients served. PROCEDURE: Prior to administering each medication, personnel shall ensure the following: A. Right Patient 1. Confirm the patient is the correct recipient of the intended medication. This shall include obtaining pertinent patient history (when/where possible), including current medications being taken by the patient and any known allergies/sensitivities to medications B. Right Medication 1. Correct medication by name. 2. Correct indications are present. 3. Confirmation that no contraindications are present. 4. Valid date range (medication is not expired). 5. Confirmation of no tamper. Ensure the medication vessel has not been compromised. C. Right Dose 1. Correct dosage of each medication to be administered. 2. Correct concentration of each medication to be administered. D. Right Route 1. Correct route of each medication to be administered. 2. Correct site for injections. 3. Appropriate flushing of IV tubing between medications, when applicable. E. Right Time 1. Correct time to administer each medication pursuant to indications. 2. Correct time intervals between each medication and between repeated doses.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Intranasal (IN) Medication Administration

P EMT- P P Clinical Indications:

 When medication administration is necessary and the medication must be given via the IN route or as an alternative route in selected medications.

Procedure:

1. The only medications that are approved for IN administration are the following:  Fentanyl  Glucagon  Ketamine  Midazolam  Naloxone 2. Receive and confirm medication order or perform according to standing orders. 3. Prepare equipment and medication, expelling air from the syringe. 4. Explain the procedure to the patient and reconfirm patient allergies. 5. The only site for IN administration is the nasal cavities.  Use the highest concentrated form of medication as possible (do not dilute).  Divide total administration amount between both nostrils.  Volume should not exceed 1mL per nostril. 6. Attach atomizing device to syringe. 7. Place tip of device against nostril, aiming slightly up and outward.  May have to place a hand on patient’s occiput area for stabilization. 8. Briskly compress the syringe plunger to deliver half of the medication into the nostril. 9. Move to the other nostril and repeat steps 5-7. 10. Monitor the patient for desired therapeutic effects as well as any possible side effects. 11. Document the medication, dose, route, and time on/with the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Injections: Subcutaneous and Intramuscular

P EMT- P P Clinical Indications:

 When medication administration is necessary and the medication must be given via the SQ (not auto-injector) or IM route or as an alternative route in selected medications.

Procedure:

1. Receive and confirm medication order or perform according to standing orders. 2. Prepare equipment and medication expelling air from the syringe. 3. Explain the procedure to the patient and reconfirm patient allergies. 4. The most common site for subcutaneous injection is the arm.  Injection volume should not exceed 1 cc. 5. The possible injection sites for intramuscular injections include the arm, buttock and thigh.  Injection volume should not exceed 1 cc for the arm  Injection volume should not exceed 2 cc in the thigh or buttock. 6. The thigh should be used for injections in pediatric patients and injection volume should not exceed 1 cc. 7. Expose the selected area and cleanse the injection site with alcohol. 8. Insert the needle into the skin with a smooth, steady motion SQ: 45-degree angle IM: 90-degree angle skin pinched skin flattened 9. Aspirate for blood 10. Inject the medication. 11. Withdraw the needle quickly and dispose of properly without recapping. 12. Apply pressure to the site. 13. Monitor the patient for the desired therapeutic effects as well as any possible side effects. 14. Document the medication, dose, route, and time on/with the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Venous Access: Extremity Clinical Indications: P EMT- P P  Any patient where intravenous access is indicated (significant trauma, emergent or potentially emergent medical condition). Procedure: 1. Saline locks may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the ALS professional. 2. Paramedics can use intraosseous access where threat to life exists as provided for in the Venous Access-Intraosseous procedure. 3. Use the largest catheter bore necessary based upon the patient’s condition and size of veins. 4. Fluid and setup choice is preferably: • Lactated Ringers with a macro drip (10 gtt/cc) for burns • Normal Saline with a macro drip (10 gtt/cc) for medical conditions, trauma or hypotension • Normal Saline with a micro drip (60 gtt/cc) for medication infusions 5. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles. 6. Connect IV tubing to the solution in a sterile manner. Fill the drip chamber half full and then flush the tubing bleeding all air bubbles from the line. 7. Place a tourniquet around the patient’s extremity to restrict venous flow only. 8. Select a vein and an appropriate gauge catheter for the vein and the patient’s condition. 9. Prep the skin with an antiseptic solution. 10. Insert the needle with the bevel up into the skin in a steady, deliberate motion until the bloody flashback is visualized in the catheter. 11. Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle into the proper container without recapping. 12. Draw blood samples when appropriate. 13. Remove the tourniquet and connect the IV tubing or saline lock. 14. Open the IV to assure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated. Rates are preferably: • Adult: KVO: 60 cc/hr. (1 gtt/ 6 sec for a macro drip set) • Pediatric: KVO: 30 cc/hr. (1 gtt/ 12 sec for a macro drip set) If shock is present: • Adult: 500 cc fluid boluses repeated as long as lungs are dry and BP < 90. Consider a second IV line. • Pediatric: 20 cc/kg blouses repeated PRN for poor perfusion. 15. Cover the site with a sterile dressing and secure the IV and tubing. 16. Label the IV with date and time, catheter gauge, and name/ID of the person starting the IV. 17. Document the procedure, time and result (success) on/with the patient care report (PCR). Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Venous Access: Intraosseous

P P Clinical Indications: EMT- P  Patients where rapid, regular IV access is unavailable with any of the following:  Cardiac arrest.  Multisystem trauma with severe hypovolemia and/or a significantly burned patient with no IV access.  Severe dehydration with vascular collapse and/or loss of consciousness.  Respiratory failure / respiratory arrest.  Any other immediately life-threatening, peri-arrest clinical condition in which IV access is unobtainable. When in doubt, contact a senior medical authority ( medical control) for advice.

Contraindications:  Fracture proximal to proposed intraosseous site.  History of Osteogenesis Imperfecta  Current or prior infection at proposed intraosseous site.  Previous intraosseous insertion or joint replacement at the selected site.

Procedure: 1. Don personal protective equipment (gloves, eye protection, etc.). Proximal humerus is preferred. 2. Identify anteromedial aspect of the proximal and distal tibia, proximal humerus head. The proximal tibia insertion location will be 1-2 cm (2 finger widths) below this. If this site is not suitable identify the anterior medial aspect of the distal tibia (2 cm proximal to the medial malleolus). Proximal humerus is also an acceptable insertion site for patients > 40 Kg, lateral aspect of the humerus, 2 cm distal to the greater tuberosity. 3. Prep the selected site with providone-iodine ointment or solution. 4. For manual pediatric devices, hold the intraosseous needle at a 60 to 90 degree angle, aimed away from the nearby joint and epiphyseal plate, twist the needle handle with a rotating grinding motion applying controlled downward force until a “pop” or “give” is felt indicating loss of resistance. Do not advance the needle any further. 5. For the EZ-IO intraosseous device, hold the intraosseous needle at a 60 to 90 degree angle, aimed away from the nearby joint and epiphyseal plate, power the driver until a “pop” or “give” is felt indicating loss of resistance. Do not advance the needle any further. Utilize the larger needle for the proximal humerus. The smallest needle is only intended for use in neonatal patients. 6. Remove the stylette and place in an approved sharps container. 7. Attach a syringe filled with at least 5 cc NS; aspirate bone marrow for manual devices only, to verify placement; then inject at least 5 cc of NS to clear the lumen of the needle. 8. Attach the IV line and adjust flow rate. A pressure bag may assist with achieving desired flows. 9. Stabilize and secure the needle with dressings and tape. 10. You may administer 20-40 mg (2-4 cc) of 2% Lidocaine in conscious adult patients (0.5-1 mg/kg for pediatric patients) who are not allergic to Lidocaine who experience infusion-related pain. 11. Following the administration of any IO medications, flush the IO line with 10 cc of IV fluid. 12. Document the procedure, time, and result (success) on/with the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction. Assessment should include direct observation at least once per year.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Venous Access: External Jugular Access

P EMT- P P Clinical Indications:

 External jugular vein cannulation is indicated in a critically ill patient > 8 years of age who requires intravenous access for fluid or medication administration and in whom an extremity vein is not obtainable. Consider IO access in addition to or instead of an EJ attempt.  External jugular cannulation may be attempted initially in life threatening events where no obvious peripheral site is noted.

Procedure:

1. Place the patient in a supine Trendelenburg (feet above the head) position. This helps distend the vein and prevents air embolism. 2. Turn the patient’s head toward the opposite side if no risk of cervical injury exists. 3. Prep the site as per peripheral IV site. 4. Align the catheter with the vein and aim toward the same side shoulder. 5. Compressing the vein lightly with one finger above the clavicle, puncture the vein midway between the angle of the jaw and the clavicle and cannulate the vein in the usual method. 6. Attach the IV and secure the catheter avoiding circumferential dressing or taping. 7. Document the procedure, time, and result (success) on/with the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Venous Access: Existing Catheters

P EMT- P P Clinical Indications:

 Inability to obtain adequate peripheral access.  Access of an existing venous catheter for medication or fluid administration.  Central venous access in a patient in cardiac arrest.

Procedure:

1. Clean the port of the catheter with alcohol wipe. 2. Using sterile technique, withdraw 5-10 ml of blood and discard syringe in sharps container. 3. Using 5cc of normal saline, access the port with sterile technique and gently attempt to flush the saline. 4. If there is no resistance, no evidence of infiltration (e.g., no subcutaneous collection of fluid), and no pain experienced by the patient, then proceed to step 4. If there is resistance, evidence of infiltration, pain experienced by the patient, or any concern that the catheter may be clotted or dislodged, do not use the catheter. 5. Begin administration of medications or IV fluids slowly and observe for any signs of infiltration. If difficulties are encountered, stop the infusion and reassess. 6. Record procedure, any complications, and fluids/medications administered in the Patient Care Report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Venous Access: Blood Draw

P EMT- P P Clinical Indications:

 This procedure shall ONLY be utilized for ACUTE STROKE patients to facilitate expeditious care at the hospital.  This procedure is for patients being transported to St. Clare or St. Mary’s Health Centers.  If the acute stroke patient is being transported to another facility that accepts pre-hospital drawn blood, follow the directions included in that hospital’s acute stroke blood draw kit.

Procedure:

1. Utilize universal precautions. 2. Select vein and prep as usual. Have all supplies ready prior to initiating the IV stick. 3. Select appropriate blood-drawing devices (Vacutainer holder, adapter, lab tubes). 4. Place a venous tourniquet and insert the IV needle-catheter device into the skin. Advance the catheter and leave the tourniquet in place for drawing blood. 5. Attach the Vacutainer adapter and device to the catheter hub. Draw blood by pushing the lab tubes onto the needle inside the Vacutainer, blood should flow easily into the lab tube. Allow to fill until flow ceases. Both tubes need to be full. 6. Draw in this order: 1st White top tube. Does NOT need to be inverted. 2nd Blue top tube. Mix by inverting 8-10 times. 3rd Red top tube. Does NOT need to be inverted. 4th Green top tube. Mix by inverting 8-10 times. 5th Purple top tube. Mix by inverting 8-10 times.

7. Once blood drawing is complete, remove tourniquet, occlude vein, and insert IV tubing or saline lock onto the catheter hub and refer to the venous access procedure. 9. Assure that the blood samples are labeled with the correct patient information (if the tubes are not properly labeled, they may not be usable at the hospital!) Label with the patient’s name, along with the date and time the sample was collected, and the initials of the EMS provider that collected the blood. 10. Deliver the blood tubes to the RN taking report at the emergency department.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM HEALTHCARE

EMS CODE STROKE BLOOD DRAW PROTOCOL

DRAW IN THIS ORDER

Start blood draw with this tube WHITE TUBE This is a “Waste” tube THIS TUBE MUST BE DRAWN FIRST ST 1

Primary Use – Coagulation Tests (PT & PTT) LIGHT BLUE MIX BY INVERTING 8-10 TIMES nd MUST be filled to the fill mark on the tubes label 2 (indicated by a ◄ or ▀ on the tube)

Serum – Non-additive RED TUBE Primary Use – Blood Chemistries DO NOT INVERT 3rd

Lithium Heparin DO NOT USE SODIUM HEPARIN TUBE GREEN TUBE Primary Use – Troponin MIX BY INVERTING 8-10 TIMES

4th

EDTA liquid Primary Use - CBC PURPLE TUBE MIX BY INVERTING 8-10 TIMES FULL DRAW REQUIRED 5th

Blood tubes must be labeled!

Patient first and last name:______

Date of Birth:______

Date/time of collection:______

Paramedic Initials:______

SSM Medical Direction Standard Procedure (Skill) Arterial Access: Line Maintenance

P EMT- P P Clinical Indications:

 Transport of a patient with an existing arterial line.

Procedure:

1. Make certain arterial line is secured prior to transport, including intersection of arterial catheter and IV / monitoring lines. 2. Use available equipment for monitoring of arterial pressures via arterial line. 3. Do not use the arterial line for administration of any fluids or medications. 4. If there is any question regarding dislodgement of the arterial line and bleeding results, remove the line and apply direct pressure over the site for at least five minutes before checking to ensure hemostasis.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Venous Access: Central Line Maintenance

P EMT- P P Clinical Indications:

 Transport of a patient with a central venous line already in place.

Procedure:

1. Prior to transportation, ensure the line is secure. 2. Medications and IV fluids may be administered through a central venous pressure line if that line has already been accessed and the patient is currently receiving medications or fluids through the line. 3. Do not manipulate the central venous catheter. 4. If the central venous catheter becomes dysfunctional, does not allow drug administration, or becomes dislodged, contact medical control and do not use the line. 5. Document the time of any pressure measurements, the pressure obtained, and any medication administration in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) CNS Catheter: Epidural Catheter Maintenance

P EMT- P P Clinical Indications:

 Presence of an epidural catheter in a patient requiring transport.

Procedure:

1. Prior to transport, ensure catheter is secure and that transport personnel are familiar with medication(s) being delivered and devices used to control medication administration. 2. No adjustments in catheter position are to be attempted. 3. No adjustments in medication dosage or administration are to be attempted without direct approval from on-line medical control. 4. Report any complications immediately to on-line medical control. 5. Document the time and dose of any medication administration or rate adjustment in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Assessing a Central Venous Catheter (CVC)

P EMT- P P Clinical Indications:

 To provide direction to pre-hospital personnel for accessing implanted (Port-A-Cath) or external Central Venous Catheter (CVC) of an acutely ill or injured patient that has such a device.

Procedure:

These procedures are for patients with life threatening conditions that are in need of immediate venous access. Accessing a Port-A-Cath 1. Prime needle and extension tubing with normal saline. 2. Attempt to provide a sterile setting in which to attempt accessing the CVC. 3. Lay patient in supine position, wear mask, sterile gloves, and have patient turn head away from site of needle insertion. 4. Locate port septum. Put on sterilized gloves. 5. Cleanse skin with alcohol, use a ChloraPrep, wipe 3 times for sterilization 6. Stabilize the port with non-dominate hand. Insert the needle perpendicular to the skin, through the skin and septum, until needle touches port backing (needle stop.) 7. Aspirate blood to verify placement, and flush with 5-10 cc normal saline to verify patency and cleanse the port. Some CVCs may not draw but will flush and run. 8. If the port will not flush, look for peripheral IV site, if unsuccessful go to IO insertion. 9. Cover site with clear adhesive dressing. Place tape over tubing close to the insertion site to hold securely to avoid movement and dislodging of the needle. 10. Cleanse luer-lock of extension tubing with a ChloraPrep prior to attaching IV tubing for continuous bolus. Accessing External CVCs 1. Most external ports will have 2 lines, one with a red cap (arterial), and another with a blue cap (venous). DO NOT ACCESS THE RED CAP. 2. Take the blue cap line, clean with ChloraPrep wipe, flush the line with normal saline, attach IV tubing and allow Normal Saline to flow.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) CNS Catheter: Ventricular Catheter Maintenance

P EMT- P P Clinical Indications:

 Transport of a patient with an intra-ventricular catheter in place.

Procedure:

1. Prior to transport, ensure the catheter is secure. 2. Prior to transport, determine from the referring hospital/physician the desired patient position (e.g., supine, head of bed elevated 30 degrees, etc.). 3. Prior to transport, determine the height at which the drain is to be maintained, given the patient position desired from #2 above (if applicable). 4. Do not manipulate or move the drain. 5. If the patient or height of the drain is altered, immediately correct based on the pre-determined configuration in step 2 and 3 above. 6. Report any problems immediately to the receiving facility or on-line medical control. 7. Document the time and any adjustments or problems in the patient care report (PCR).

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Wound Care- General

B EMT B Clinical Indications: P EMT- P P

 Protection and care for open wounds prior to and during transport.

General Wound Care Procedures:

1. Use personal protective equipment, including gloves, gown, and mask as indicated. 2. If active bleeding, elevate the affected area if possible and hold direct pressure. Do not rely on “compression” bandage to control bleeding. Direct manual pressure is much more effective. 3. Consider tourniquet early for extremity bleeding unable to be controlled with direct pressure. 4. Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate (this may have to be avoided due to extreme pain or if bleeding was difficult to control). Consider analgesia per protocol prior to irrigation. See Irrigation Procedure. 5. Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to ensure the bandage is not too tight. 6. Monitor wounds and/or dressings throughout transport for bleeding. 7. Document the wound and assessment and care in the patient care report (PCR).

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Wound Care- Irrigation

B EMT B Clinical Indications: P EMT- P P

 Initial decontamination and irrigation for wounds, burns, and eye injuries prior to and during transport.

Irrigation Guidelines and Procedures:

1. Wound irrigation and decontamination are key to stopping ongoing tissue injury, preventing infection, and promoting wound healing. Irrigation should be started in the field if possible. 2. Refer to the Decontamination Procedure for any patient(s) who may have significant hazardous materials exposure. Follow these irrigation guidelines for isolated injury or exposure (e.g. small burn to the extremity, chemical splash to an eye). 3. Control bleeding and evaluate and treat life threats first. Refer to the Wound Care- General Procedure, and appropriate trauma protocols. 4. Irrigate thermal burns, chemical burns, or contaminated wounds with normal saline, Ringer’s Lactate or sterile water as appropriate. Consider analgesia per protocol prior to irrigation. 5. Sterile solutions are preferred for irrigation, however if not available, do not delay- use tap water. Flush the area as soon as possible with the cleanest readily available water or sterile solution using copious amounts of fluids. 6. For chemical splashes to the eye, emergent irrigation is critical to preventing further tissue damage. If there is no concern for physical trauma to the eye, utilize a Morgan Lens to immediately provide copious irrigation directly to the globe. Have patient remove contact lenses. Follow the “Eye Complaint” Protocol. 7. To utilize the Morgan Lens, follow these steps: a. Instill topical ocular anesthetic (e.g. 2 drops tetracaine) b. Attach Morgan Lens set to IV tubing to sterile solution (e.g. saline bag); START FLOW. c. Have patient look down, retract upper lid, insert Morgan lens under upper lid. d. Have patient look up, retract lower lid, then gently drop lens in place. e. Release lower lid over lens and ensure steady, copious flow. Secure tubing to prevent accidental lens removal. Absorb outflow with towels. DO NOT RUN DRY. f. Irrigate with at least one liter of sterile solution. For lens removal, ENSURE FLOW OF SOLUTION IS CONTINUING, have patient look up, retract lower lid (and upper lid slightly if necessary), slide Morgan Lens out. Stop flow only after removing lens. 8. Document the procedure, including solution and volume used to irrigate, in the PCR.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Wound Care-Taser® Probe Removal

B EMT B Clinical Indications: P EMT- P P

 Patient with uncomplicated conducted electrical weapon (Taser®) probes embedded subcutaneously in non-sensitive areas of skin.  Taser probes are barbed metal projectiles that may embed themselves up to 13 mm into the skin.

Contraindications:

 Patients with conducted electrical weapon (Taser®) probe penetration in vulnerable areas of body as mentioned below should be transported for further evaluation and probe removal - Probes embedded in skin above level of clavicles, genitalia, or female breasts.  Suspicion that probe might be embedded in bone, blood vessel, or other sensitive structure.

Procedure:

1. Ensure wires are disconnected from weapon. 2. Stabilize skin around probe using non-dominant hand. 3. Grasp probe by metal body with pliers or hemostats to prevent puncture wounds to EMS personnel. 4. Remove probe in single quick motion. 5. Wipe wound with antiseptic wipe and apply dressing.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Wound Care-Hemostatic Dressing

B EMT B Clinical Indications: P EMT- P P

 Serious hemorrhage that can not be controlled by other means.

Contraindications:

 Wounds involving open thoracic or abdominal cavities.

Procedure:

1. Apply approved non-heat-generating hemostatic dressing per manufacturer’s instructions. 2. Supplement with direct pressure and standard hemorrhage control techniques, including tourniquet as able. 3. Apply further hemostatic or standard dressings as necessary.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Wound Care-Tourniquet

B EMT B Clinical Indications: P EMT- P P  Life threatening extremity hemorrhage that can not be controlled by other means.  Serious or life threatening extremity hemorrhage and tactical considerations prevent the use of standard hemorrhage control techniques.

Contraindications:  Non-extremity hemorrhage  Proximal extremity location where tourniquet application is not practical

Procedure: 1. Place tourniquet proximal to wound. 2. Tighten per manufacturer instructions until hemorrhage stops and/or distal pulses in affected extremity disappear. 3. Secure tourniquet per manufacturer instructions. 4. Note time of tourniquet application and communicate this to receiving care providers. 5. Dress wounds per standard wound care protocol. 6. If delayed or prolonged transport and tourniquet application time > 45 minutes: consider reattempting standard hemorrhage control techniques and removing tourniquet. 7. If one tourniquet is not sufficient or not functional to control hemorrhage, consider the application of a second tourniquet more proximal to the first.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Warming measures: hypothermia

B EMT B P EMT- P P Clinical Indications:  To provide warming measures for patients that have hypothermic signs/symptoms.

Procedure:

Passive warming measures: 1. Remove patient from cold, place in a warm environment (heated ambulance).

2. Remove wet clothing, maintain patient’s dignity and privacy. Ensure the patient is dry.

3. Cover the patient with blankets, PO fluids as tolerated.

4. For frostbite: Do not rewarm until you can keep patient warm. Re-exposure can cause greater damage.

 DO NOT rub or massage the skin, break blisters, immerse frostbitten extremity in water, or use direct heat to rewarm.

 Bandage the frostbitten area and cover with blankets, if possible have patient hold next to their body.

Active warming measures:

All of the passive measures, and include;

1. Layer several blankets on the patient.

2. Warm Normal Saline boluses. Adults- titrate to effect a systolic blood pressure > 90, max 2 liters. Pediatric- titrate to effect age appropriate blood pressure: (SBP ≥ 70 + 2 x Age), max 60 mL/kg.

3. Hot packs to the axillae and groin. Do not place directly against the skin.

4. Handle the patient gently.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Cooling measures: hyperthermia

B EMT B Clinical Indications: P EMT- P P  To provide cooling measures for patients that have hyperthermic signs/symptoms;  Heat Cramps consists of benign muscle cramping to dehydration and is not associated with an elevated temperature.  Heat Exhaustion consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature.  Heat Stroke consists of dehydration, tachycardia, hypotension, temperature >104° F (40° C), and an altered mental status. Tissue damage ensues when core temperature reaches 109° F (43° C).

Contraindications:

 Care must be taken to avoid causing vasoconstriction or shivering. Vasoconstriction will impede heat loss and shivering will create heat.

Procedure:

Passive cooling measures:

1. Remove patient from heat, place in a cool environment (air conditioned ambulance).

2. Remove excessive / constrictive clothing, remember to maintain patient’s dignity and privacy.

3. Use a fan to cool the patient, mist the skin with tepid water. Consider forearm immersion.

4. PO fluids as tolerated.

Active cooling measures:

All of the passive measures, and include;

1. Applying a single layer wet sheet to bare skin.

2. Cool Normal Saline boluses. Adults- titrate to effect a systolic blood pressure > 90, max 2 liters. Pediatric- titrate to effect age appropriate blood pressure: (SBP ≥ 70 + 2 x Age), max 60 mL/kg.

3. Ice packs to the neck, axillae and groin. Do not place directly against the skin.

Certification Requirements:

 Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Decontamination

B EMT B Clinical Indications: P EMT- P P  Any patient who may have been exposed to hazardous materials, including chemical, biological, or radiological weapons.

Procedure: 1. In coordination with HAZ-MAT and other Emergency Management personnel, establish hot, warm and cold zones of operation. 2. Ensure that personnel assigned to operate within each zone have proper personal protective equipment. 3. In coordination with other public safety personnel, assure each patient from the hot zone undergoes appropriate initial decontamination. This is specific to each incident; such decontamination may include: • Removal of patients from hot zone • Simple removal of clothing • Irrigation of eyes • Passage through high-volume water bath (e.g., between two fire apparatus) for patients contaminated with liquids or certain solids. Patients exposed to gases, vapors, and powders often will not require this step as it may unnecessarily delay treatment and/or increase dermal absorption of the agent(s). 4. Initial triage of patients should occur after step #3. Immediate life threats should be addressed prior to technical decontamination. 5. Assist patients with technical decontamination (unless contraindicated based on #3 above). This may include removal of all clothing and gentle cleansing with soap and water. All body areas should be thoroughly cleansed, although overly harsh scrubbing which could break the skin should be avoided. 6. Place triage identification on each patient. Match triage information with each patient’s personal belongings which were removed during technical decontamination. Preserve these personnel affects for law enforcement (may become evidence). 7. Monitor all patients for environmental illness. 8. Transport patients per local protocol.

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 SSM Medical Direction Standard Procedure (Skill) Annual Intra- Departmental Influenza Administration Procedure

P EMT- P P Clinical Indications:  CDC Recommendations: Annual influenza vaccination is recommended for all health-care personnel and persons in training for health-care professions. Personnel in health-care settings who should be vaccinated include physicians, nurses, and other workers in inpatient and outpatient-care settings, medical emergency-response workers (e.g., paramedics and emergency medical technicians).

Contraindications:

 Egg Allergy Persons with a history of egg allergy who have experienced only hives after exposure to egg should receive influenza vaccine.  Allergy to Vaccine Component / Allergic Reaction after Previous Dose A history of a severe allergic reaction (e.g., anaphylaxis) after a previous dose of influenza vaccine, or to any component of the vaccine being given is a contraindication for that vaccine.  Guillain Barré Syndrome (GBS) “As a precaution, persons who are not at high risk for severe influenza complications and who are known to have experienced GBS within 6 weeks of an influenza vaccine generally should not be vaccinated.  The patient should wait until they are well to be vaccinated if they are currently running a fever, or have signs of a acute respiratory illness.

Procedure:

1. VIS (Vaccine Information Sheet) produced by the CDC must be given to each employee before being administered the vaccine. 2. In this instance, the employee is being treated as a patient, not an employee. All HIPAA rules apply and a copy of Privacy Policies should be made available. 3. Each employee must completely fill out eligibility and authorization form that will be supplied with flu shots annually. This patient information needs to be stored in a separate file, away from the patient’s employee file. 4. All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available. 5. Follow Medication Administration and Injections Procedures.

Certification Requirements:  Maintain knowledge of the indications, contraindications, technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations, or other mechanisms as deemed appropriate by SSM Medical Direction.

SSM EMS Procedure 2016 Formulary Section

Acetaminophen (Tylenol™) Adenosine (Adenocard™) Albuterol (Proventil™) (Ventolin™) Ipratropium Bromide (Atrovent™) Amiodarone (Cordarone™) Aspirin Atropine Atropine and Pralidoxime auto-injector (Nerve Agent Kit) Calcium Chloride Calcium Gluconate Dextrose 10% (D10) Dextrose 5% in water (D5W) Diazepam (Valium®) Diltiazem (Cardizem®) Diphenhydramine (Benadryl®) Dopamine (Intropin®) Epinephrine 1:1000 Epinephrine 1:10,000 Etomidate (Amidate®) Famotidine (Pepcid®) Formulary Section Fentanyl (Sublimaze®) Furosemide (Lasix®) Glucagon (GlucaGen®) Haloperidol (Haldol®) Hydroxocobalamin (Cyanokit®) Influenza Vaccine (annual flu shot) Ketamine Hydrochloride (Ketalar™) Lactated Ringers Lidocaine (Xylocaine®) Levalbuterol Hydrochloride (Xopenex®) Lorazepam (Ativan®) Magnesium Sulfate Methylprednisolone (Solu-Medrol®) Metoclopramide (Reglan®) Midazolam (Versed®) Morphine Sulfate Naloxone (Narcan®) Nitroglycerin (Nitrolingual®)(Nitrobid®) Ondansetron (Zofran®) Oral Glucose Oxygen Oxymetazoline (Afrin®) Sodium Bicarbonate Sodium Chloride 0.9% (Normal Saline) Tetracaine (TetraVisc®) Thiamine (Biamine®)

SSM EMS Formulary 2016 Medications Section

Acetaminophen (Tylenol®)

Class Antipyretics, nonopioid analgesics

Action Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS.

Indications Fever

SSM EMS Protocol Fever/Infection Control, Pediatric Pain Control

Contraindications Severe hepatic impairment/active liver disease; known hypersensitivity

Precautions Hepatic disease/renal disease; Chronic alcohol use/abuse; Malnutrition

Side Effects Rash, urticaria

Interactions Concurrent use of anticonvulsants, barbiturates will decrease the therapeutic effects of acetaminophen.

Pediatric Dosage 15 mg/kg < 12 years old- MAX DOSE 650 mg

Route PO

SSM EMS Medications 2016 Medications Section

Adenosine (Adenocard®)

Class Antidysrhythmic

Action Slows conduction through AV node

Indications Symptomatic narrow-complex tachycardias; Wide-complex tachycardias that are known to be supraventricular in nature

SSM EMS Protocol Adult Tachycardia-Narrow Complex, Adult Tachycardia-Wide Complex, Pediatric Tachycardia

Contraindications Second- or third-degree heart block; Sick sinus syndrome; Dysrhythmias other than SVTs; Known hypersensitivity

Precautions Arrhythmias, including blocks, are common at the time of cardioversion; Can produce bronchospasm in patient’s with asthma

Side Effects Facial flushing; Headache; Shortness of breath; Dizziness; Nausea; Chest pain

Interactions Potential additive effects when used on patients taking other medications that block AV node – digoxin, calcium channel blockers; Methylxanthines (caffeine, theophylline) antagonize effects and response may be minimal or absent

Adult Dosage A 10 ml rapid Normal Saline flush should immediately follow each dose. Initial 6 mg given as a rapid IV bolus over a 1-2 second period; If, after 1-2 minutes, cardioversion does not occur, administer a 12 mg dose over 1-2 seconds

Pediatric Dosage A 5 ml rapid Normal Saline flush should immediately follow each dose. Initial – 0.1 mg/kg (max dose 6 mg) If, after 1-2 minutes, cardioversion does not occur repeat at 0.2 mg/kg (max dose 12 mg) one time.

Route IV / IO

SSM EMS Medications 2016 Medications Section

Albuterol (Proventil®) (Ventolin®)

Class Beta-adrenergic bronchodilator (β2-selective)

Action Bronchodilation by relaxing bronchial smooth muscle resulting in reduced airway resistance, increased vital capacity and relief of bronchospasm

Indications Relief of bronchoconstriction in patients with reversible obstructive airway disease – bronchial asthma and acute exacerbation of COPD

SSM EMS Protocol Adult COPD/Asthma, Pediatric Respiratory Distress

Contraindications Symptomatic tachycardias; Known hypersensitivity

Precautions Use with caution in patients with underlying cardiovascular disease or hypertension; May precipitate angina pectoris or cardiac dysrhythmias; MAOIs and TCAs may increase potential for cardiovascular reactions; Beta-blockers may diminish its effects

Side Effects Tachycardia; Restlessness; Tremor; Nausea; Headache; Dizziness

Adult Dosage 2.5 mg/3 mL nebulized over 5-10 minutes, may repeat as needed three times.

Pediatric Dosage 2.5 mg/3 mL nebulized over 5-10 minutes, may repeat as needed three times.

Route Inhalation via nebulizer

Additional May be administered concurrently with ipratropium bromide (Atrovent)

SSM EMS Medications 2016 Medications Section

Ipratropium Bromide (Atrovent®)

Class Anticholinergic; Bronchodilator

Action Blocks bronchoconstriction secondary to parasympathetic tone

Indications Brochial asthma or COPD refractory to albuterol

SSM EMS Protocol Adult COPD / Asthma, Adult Allergic Reaction / Anaphylaxis, Pediatric Respiratory Distress, Pediatric Allergic Reaction / Anaphylaxis

Contraindications Known hypersensitivity to ipratroprium

Precautions Pregnancy; Benign prostatic hypertrophy; Use with caution in patients with history of urinary retention; Should not be considered as first-line pharmacological intervention for respiratory distress

Side Effects Nausea/vomiting; Coughing; Headache; Tachycardia; Dry mouth; Blurred vision

Adult Dosage 0.5 mg (500mcg) diluted in 3mL sterile saline. May repeat as needed up to 3 times

Pediatric Dosage 0.5 mg (500mcg) diluted in 3mL sterile saline. May repeat as needed up to 3 times

Route Inhalation via nebulizer

Additional May be administered concurrently with albuterol (Proventil)

SSM EMS Medications 2016 Medications Section

Amiodarone (Cordarone®) Class Antidysrhythmic (Class III) Possesses properties of all four Vaughan-Williams classes

Actions Sodium, calcium and potassium channel blocker; Prolongs intranodal conduction; Prolongs refractoriness of the AV node

Indications VF/Pulseless VT; Hemodynamically stable VT when cardioversion unsuccessful; Wide-complex tachycardia of unknown origin; As an adjunct to electrical cardioversion of SVT

SSM EMS Protocol Adult V-Fib / Pulseless V-Tach, Adult Tachycardia-Wide Complex, Pediatric V-Fib / Pulseless V-Tach, Pediatric Tachycardia

Contraindications Known hypersensitivity; Cardiogenic shock; Pulmonary congestion; Sinus bradycardia; Hypotension; Second- or third-degree heart block without an artificial pacemaker

Precautions Proarrhythmic with concurrent antidysrhythmic medications; May potentiate bradycardia and hypotension with beta blockers and calcium channel blockers; Increases risk of AV block and hypotension with calcium channel blockers; Consider slower administration for patients with hepatic or renal dysfunction; May prolong QT interval

Side Effects Hypotension; Bradycardia (slow down the rate of infusion); Headache; AV conduction abnormalities; Flushing; Dizziness

Interactions Do not use with other drugs that prolong QT interval

Adult Dosage VF/Pulseless VT Initial 300mg IV / IO repeat once after 5 minutes at 150 mg IV / IO Maintenance infusion: 1 mg/min over 6 hours Wide-Complex Tachycardia Initial bolus: 150 mg over 10 minutes (15 mg/min)

Pediatric Dosage VF/Pulseless VT 5 mg/kg IV / IO (max dose of 300 mg) Repeat every 5 min (up to 3 times) max total dose 15 mg/kg Wide-Complex Tachycardia 5 mg/kg IV / IO over 20 minutes (max dose 150 mg)

Route IV / IO

SSM EMS Medications 2016 Medications Section

Aspirin

Class Platelet inhibitor; Anti-inflammatory; Analgesic; Antipyretic

Actions Decreases platelet aggregation

Indications Acute coronary syndrome

SSM EMS Protocol Adult Cardiac: Chest Pain and STEMI

Contraindications Known hypersensitivity

Precautions GI Bleeding; Asthma

Side Effects Stomach irritation; Heartburn; Nausea

Adult Dosage 324 mg chewable

Pediatric Dosage NOT INDICATED

Route PO

SSM EMS Medications 2016 Medications Section

Atropine Sulfate

Class Parasympatholytic (anticholinergic)

Actions Blocks acetylcholine at muscarinic receptors resulting in an increased heart rate; Used in know or suspected organophosphate and carbamate toxicities to control GI or pulmonary distress

Indications Symptomatic bradycardias; PEA with absolute bradycardia (rate <60); Organophosphate or carbonate toxicities; Cholinergic nerve gas toxicity

SSM EMS Protocol Adult Bradycardia, Adult Asystole / PEA, Pediatric Bradycardia, Nerve Agent (includes WMD)

Contraindications Known hypersensitivity; Tachycardia; Third-degree AV block

Precautions Dose of 0.04 mg/kg should not be exceeded except in cases of Organophosphate or carbonate toxicities; Use for symptomatic bradycardia in the presence of myocardial ischemia / infarction

Side Effects Tachycardia; Palpitations; Dry mouth; Myosis; Blurred vision; Urinary retention

Adult Dosage Bradycardia with a pulse 0.5 mg IV / IO every 5 minutes (max dose of 0.04 mg/kg or 3 mg) PEA with absolute bradycardia (rate <60) 1 mg IV / IO every 3-5 minutes (max dose of 0.04 mg/kg or 3 mg) Organophosphate / Carbamate toxicity 2 mg IV / IO / IM every 5 minutes until significant reduction in secretions

Pediatric Dosage Organophosphate / Carbamate toxicity 0.05 mg/kg IV / IO / IM every 5 minutes until significant reduction in secretions

Route IV / IO / IM / ETT (double the IV dose, cardiac arrest only)

SSM EMS Medications 2016 Medications Section

Atropine and Pralidoxime auto-injector (Nerve Agent Kit)

Class Parasympatholytic (anticholinergic)

Actions Competitively blocks the effects of acetylcholine, including excess acetylcholine due to organophosphorous poisoning at muscarinic cholinergic receptors and in peripheral autonomic ganglia and the central nervous system. Reactivation of phosphorylated acetylcholinesterase. Reversal of nicotinic effects of acetylcholinesterase inhibition, particularly on skeletal muscle. Reversal of muscarinic effects of cholinesterase inhibition, usually additive with atropine.

Indications Poisoning by nerve agents having anticholinesterase activity.

SSM EMS Protocol Nerve Agent (includes WMD)

Contraindications In the presence of life-threatening poisoning by organophosphorous nerve agents or insecticides, there are no absolute contraindications. When symptoms of poisoning are not severe, DuoDote Auto-Injector should be used with extreme caution in people with heart disease, arrhythmias, recent myocardial infarction, severe narrow angle glaucoma, pyloric stenosis, prostatic hypertrophy, significant renal insufficiency, chronic pulmonary disease, or hypersensitivity to any component of the product.

Precautions Dose of 0.04 mg/kg should not be exceeded except in cases of Organophosphate or carbonate toxicities; Use for symptomatic bradycardia in the presence of myocardial ischemia / infarction

Side Effects Blurred vision, dry mouth, flushing of skin, pupillary dilatation, urine retention, dizziness, headache, drowsiness, nausea, tachycardia, hypertension, hyperventilation, and muscular weakness.

Adult Dosage 2.1 mg atropine, 600 mg pralidoxime chloride via (per) auto injector. May be repeated to a total of 3 doses.

Pediatric Dosage NOT INDICATED

Route IM

SSM EMS Medications 2016 Medications Section

Calcium Chloride

Class Electrolyte

Actions Increases cardiac contractility

Indications Known or suspected hyperkalemia, known or suspected hypocalcemia, calcium channel blocker overdose, beta blocker overdose, consider prior to administration of calcium channel blockers (Diltiazem) for patients with tenuous BP (SBP < 100). Calcium may mitigate hypotensive effects of peripheral vasculature smooth muscle relaxation while not preventing wanted cardiac rate control effects.

SSM EMS Protocol Adult Asystole / PEA, Adult Tachycardia-Narrow Complex, Adult Dialysis-Renal Failure, Adult Overdose / Toxic Ingestion, Pediatric Overdose / Toxic Ingestion, Crush Syndrome Trauma

Contraindications VF during cardiac resuscitation, patients on digitalis, hypercalcemia

Precautions IV line should be flushed between calcium chloride and sodium bicarbonate administration to prevent precipitation. If available use separate IV lines.

Side Effects Dysrhythmias (bradycardia and asystole); Hypotension; Metallic taste

Adult Dosage 1 g IV / IO given over 3 minutes

Pediatric Dosage 20 mg/kg IV / IO given over 3 minutes (max dose 1 g)

Route IV / IO

SSM EMS Medications 2016 Medications Section

Calcium Gluconate

Class Electrolyte

Actions Increases cardiac contractility

Indications Known or suspected hyperkalemia, known or suspected hypocalcemia, Calcium channel blocker overdose, beta blocker overdose

SSM EMS Protocol Adult Dialysis-Renal Failure, Adult Overdose / Toxic Ingestion, Pediatric Overdose / Toxic Ingestion

Contraindications VF during cardiac resuscitation, patients on digitalis, hypercalcemia

Precautions Should be give slowly, rapid injection of calcium gluconate may cause vasodilation, decreased blood pressure, bradycardia, cardiac arrhythmias, syncope and cardiac arrest. Infiltration (extravasation) can cause tissue necrosis. IV line should be flushed between calcium chloride and sodium bicarbonate administration to prevent precipitation. If available use separate IV lines.

Side Effects Tingling sensations, a sense of oppression or heat waves and a calcium or chalky taste. Infiltration (extravasation) can cause tissue necrosis.

Adult Dosage 3 g IV / IO given over 10 minutes

Pediatric Dosage 60 mg/kg IV / IO (max 3 g) given over 10 minutes

Route IV / IO

Special instructions As an alternative to Calcium Chloride when there is a shortage, not routinely carried on rigs.

SSM EMS Medications 2016 Medications Section

Dextrose 5% in water (D5W)

Class Carbohydrate

Actions Provides a base for IV medication administration

Indications Used as a base to mix either Amiodarone or Magnesium Sulfate for an IV infusions.

SSM EMS Protocol Adult V-fib and pulseless V-tach, Adult Wide Complex Tachycardia, Adult COPD / Asthma, Pediatric V-fib and pulseless V-tach, Pediatric tachycardia, Pediatric Respiratory Distress,

Contraindications None in the emergency setting

Precautions May cause hyperglycemia. Infusions exceeding 20 minutes (not routine) must be administered in glass or polyolefin bottles.

Side Effects Hyperglycemia and possible hyperosmolarity

Adult Dosage Mix 150 mg of Amiodarone (single vial/3 mL) into the 100 mL bag of D5W. Use a 10 drop administration set and run the infusion in over 10 minutes (approximately 1-2 drips/second)

Mix 2 grams of Magnesium Sulfate Injection USP 50% (4 mL of solution from a 5 grams/10mL vial) into the 100 mL bag of D5W. Use a 10 drop administration set and run the infusion in over 10 minutes (approximately 1-2 drips/second)

Pediatric Dosage 5 mg/kg of Amiodarone (Max dose of 150 mg) into the 100 mL bag of D5W. Use a 10 drop administration set and run the infusion in over 20 minutes (approximately 2-4 drips/second)

40 mg/kg of Magnesium Sulfate Injection USP 50% and run the infusion in over 20 minutes (approximately 2-4 drips/second).

It may not be necessary to use a whole 100 mL bag on infants and small children.

Route IV / IO

SSM EMS Medications 2016 Medications Section

Dextrose 10% (D10)

Class Carbohydrate

Actions Elevates blood glucose level rapidly

Indications Hypoglycemia as indicated by blood glucose measurement

SSM EMS Protocol Adult Diabetic, Pediatric Diabetic

Contraindications None in the emergency setting

Precautions Should be preceded by 100mg of thiamine if either alcoholism or malnutrition suspected. Diabetics may have poor wound healing, and IO access may present a greater risk for infection or poor wound healing. If smaller veins are used, local venous irritation may occur.

Side Effects Local venous irritation; Infiltration (extravasation) can cause tissue necrosis.

Adult Dosage Dextrose 10%- 10 grams (100 cc) IV / IO bolus. Continue infusion of D10, titrate blood glucose to >80 mg / dL

Pediatric Dosage <6 years old (<20 kg) Blood Glucose <70 mg/dL, Dextrose 10% 0.5 g/kg IV / IO >6 years old (>20 kg) Dextrose 10%- 10 grams (100 cc) IV / IO bolus. Continue infusion of D10, titrate blood glucose to >80 mg / dL.

Route IV / IO

Dilution Instructions Make Dextrose 10% (D10) by adding 25 grams (a prefilled syringe) of Dextrose 50% (D50) to 200 mL of normal saline.

SSM EMS Medications 2016 Medications Section

Dextrose 10% (D10)

Dextrose 10% comes packaged as 25 grams (0.1 gram/cc) of Dextrose in 250 cc bag

Approximate age WEIGHT DOSE VOLUME

̴< 1 month 3 kg 1.5 grams 15 cc

̴1 months 4 kg 2 grams 20 cc

̴2 months 5 kg 2.5 grams 25 cc

̴3 months 6 kg 3 grams 30 cc

̴6 months 8 kg 4 grams 40 cc

̴12 months 10 kg 5 grams 50 cc

̴18‐24 months 12 kg 6 grams 60 cc

̴3 years 14 kg 7 grams 70 cc

̴4 years 16 kg 8 grams 80 cc

̴5 years 18 kg 9 grams 90 cc

̴6 years 20 kg 10 grams 100 cc

> 6 years >20 kg 10 grams initial IV Bolus 100 cc

Continue infusion of Dextrose 10%, > 6 years titrate blood glucose to >80 mg / dL

SSM EMS Medications 2016 Medications Section

Diazepam (Valium®)

Class Benzodiazepine, DEA Schedule IV Controlled Substance

Actions Anticonvulsant; Skeletal muscle relaxant

Indications Generalized seizures; status epilepticus

SSM EMS Protocol Adult Seizure, Pediatric Seizure

Contraindications Known hypersensitivity; hypotension; acute narrow angle glaucoma

Precautions Midazolam IntraNasal is effective in termination of seizures. DO NOT delay IntraNasal administration to obtain IV or IO access in an actively seizing patient. Diazepam is not effective when administered IM. Do not mix with other drugs because of possible precipitation problems – should administer into IV of normal saline only; Reduce dose in elderly patients; Use extreme caution when administering to patients taking other CNS depressants

Side Effects Drowsiness; Hypotension; Respiratory depression; Apnea

Adult Dosage 5-10 mg IV / IO Repeat every 3-5 min as needed until seizure stops or max total dose of 20 mg

Pediatric Dosage Rectal: 0.5 mg/kg (max initial dose 4 mg) IV / IO: 0.2 mg/kg Repeat every 5 min as needed until seizure stops (max total dose of 1 mg/kg)

Route IV / IO / Rectal

SSM EMS Medications 2016 Medications Section

Diltiazem (Cardizem®)

Class Calcium channel blocker

Actions Slows conduction through the AV node; Increases refractoriness in AV node; Produces coronary and peripheral vasodilation

Indications PSVT; Atrial Fibrillation with rapid ventricular response; Atrial Flutter with rapid ventricular response; MAT

SSM EMS Protocol Adult Tachycardia-Narrow Complex

Contraindications Sick sinus syndrome; Second- or third-degree AV block without a functioning pacemaker; Hypotension (<90 mmHg systolic); Cardiogenic shock; Hypersensitivity; WPW; VT; Wide- complex tachycardia of unknown origin; AMI; Patients receiving IV beta blockers

Precautions Incompatible with IV furosemide; Patients with renal or hepatic dysfunction. If patient is 60 or older give half dose and wait 5 minutes. If SBP > 100 administer the other half of the dose.

Side Effects Nausea and vomiting; Hypotension; First- and second-degree AV block; Bradycardia; CHF; Ventricular dysrhythmias; Diaphoresis; Syncope; Headache

Adult Dosage 20 mg IV / IO over 2 minutes Age ≥ 60 give 10 mg then repeat 10 mg in 5 minutes if SBP ≥ 100

Pediatric Dosage NOT INDICATED

Route IV / IO

SSM EMS Medications 2016 Medications Section

Diphenhydramine (Benadryl®)

Class Antihistamine

Actions Histamine receptor site (H1) blockade

Indications Moderate to severe allergic reaction; Anaphylaxis; Acute extrapyramidal reaction (dystonic reaction)

SSM EMS Protocol Adult Allergic Reaction, Pediatric Allergic Reaction

Contraindications Known hypersensitivity; Patients taking MAOIs; newborns and nursing mothers

Precautions Use caution when administering to patients with asthma and/or CNS depression

Side Effects Drowsiness; Sedation; Hypotension; Dry mouth; Tachycardia; Bradycardia; Paradoxical excitement in children

Adult Dosage 50 mg IV / IO / IM

Pediatric Dosage 1 mg/kg IV / IO / IM (max dose 50 mg)

Route IV / IO / IM

SSM EMS Medications 2016 Medications Section

Dopamine (Intropin®)

Class Sympathomimetic

Action Positive inotropic agent; positive chronotropic agent; vasoconstriction

Indications Hemodynamically significant hypotension in the absence of hypovolemia; Hypovolemic shock (only after complete fluid resuscitation)

SSM EMS Protocol Adult Asystole / PEA, Adult Post Resuscitation, Adult Induced Hypothermia, Adult Bradycardia, Adult CHF / Pulmonary Edema, Adult Hypotension / Shock, Adult Overdose / Toxic Injestion, Pediatric Asystole / PEA, Pediatric Post Resuscitation, Pediatric Induced Hypothermia, Pediatric CHF / Pulmonary Edema, Pediatric Hypotension / Shock, Pediatric Overdose / Toxic Injestion,

Contraindications Hypovolemic shock when complete fluid resuscitation has not occurred

Precautions Should not be administered in the presence of severe tachyarrhythmias; Should not be administered in the presence of ventricular fibrillation; Ventricular irritability

Side Effects Ventricular tachydysrhythmias; Hypertension

Adult Dosage 5-20 mcg/kg/minute IV / IO 5-10 mcg/kg/min = beta effects (increased rate, increased contractility) 10-20 mcg/kg/min = alpha effects (vasoconstriction) titrate to SBP of >90 mmHg

Pediatric Dosage 2-20 mcg/kg/minute IV / IO Titrate to effect age appropriate BP (SBP ≥ 70 + 2 x Age)

Route IV/ IO

SSM EMS Medications 2016 Medications Section

Dopamine (Intropin®) Drip Chart

1. Mix - 400 mg Dopamine in 250 ml Dextrose 5% water ( D5W ). The resulting solution has a concentration of 1600 mcg / ml. This is the same solution in the pre-mixed bags available at the pharmacy.

2. Use a 60 drop IV administration set (60 drops/1 mL).

3. Use the following flow rate chart; the number at the intersection of the desired Dopamine dose and patient weight is the number of drops per minute to achieve that dose.

Dosage = mcg / kg / minute 2 3 4 5 6 7 8 9 10 15 20 77 35 3 4 5 7 8 9 10 11 13 20 26 88 40 3 5 6 8 9 11 12 14 15 23 30 99 45 3 5 7 8 10 12 14 15 17 25 34 110 50 4 6 8 9 11 13 15 17 19 28 38 121 55 4 6 8 10 12 14 17 19 21 31 41 132 60 5 7 9 11 14 16 18 20 23 34 45 143 65 5 7 10 12 15 17 20 22 24 37 49 154 70 5 8 11 13 16 18 21 24 26 39 53 165 75 6 8 11 14 17 20 23 25 28 42 56 176 80 6 9 12 15 18 21 24 27 30 45 60 BODY WEIGHT 187 85 6 10 13 16 19 22 26 29 32 48 64 198 90 7 10 14 17 20 24 27 30 34 51 68 209 95 7 11 14 18 21 25 29 32 36 53 71 220 100 8 11 15 19 23 26 30 34 38 56 75 231 105 8 12 16 20 24 28 32 35 39 59 79 242 110 8 12 17 21 25 29 33 37 41 62 83 253 115 9 13 17 22 26 30 35 39 43 65 86 Pounds Kilograms

SSM EMS Medications 2016 Medications Section

Epinephrine 1:1000

Class Sympathomimetic

Action Increased bronchodilation; Increased heart rate; Increased myocardial contractility; Increased peripheral vasoconstriction

Indications Acute allergic reaction (anaphylaxis); Bronchial asthma

SSM EMS Protocol Adult COPD / Asthma, Adult Allergic Reaction / Anaphylaxis, Pediatric V-Fib / Pulseless V- Tach, Pediatric Asystole / PEA, Pediatric Respiratory Distress, Pediatric Allergic Reaction,

Contraindications Hypovolemic shock (correct hypovolemia prior to use)

Precautions Should be protected from light; Use with extreme caution in patients with coronary insufficiency (continuous cardiac monitoring required); Patients who are ≥ 50 years of age, have a history of cardiac disease, take beta-blockers / digoxin or patient's who have heart rates ≥ 140 give one-half the dose of epinephrine ( = 0.15 mg) Epinephrine may precipitate cardiac ischemia. These patients should receive a 12 lead ECG at some point in their care, but this should NOT delay administration of epinephrine.

Side Effects CNS stimulation (anxiety, tremor); Tachycardia; Headache; Dysrhythmias; Palpitations; Myocardial ischemia; Palpitations and tachycardia

Adult Dosage Anaphylaxis 0.3-0.5 mg IM

Pediatric Dosage Anaphylaxis 0.01 mg/kg (Max dose 0.3 mg) IM In cardiac arrest with NO IV / IO access 0.1 mg/kg ETT Severe Respiratory Distress 1 mg in 2 mL of normal saline, inhalation via nebulizer, may repeat as needed 3 times

Route IM, Inhalation via nebulizer, ETT

SSM EMS Medications 2016 Medications Section

Epinephrine 1:10,000 Class Sympathomimetic

Action Increased bronchodilation; Increased heart rate; Increased myocardial contractility; Increased peripheral vasoconstriction

Indications Severe anaphylaxis; Cardiac arrest (VF/VT, asystole, PEA); Symptomatic bradycardia (after atropine, dopamine and TCP); Severe refractory hypotension

SSM EMS Protocol Adult V-Fib / Pulseless V-Tach, Adult Aystole / PEA, Adult Bradycardia, Adult Allergic Reaction / Anaphylaxis, Pediatric Asystole / PEA, Pediatric Bradycardia, Pediatric Allergic Reaction / Anaphylaxis

Contraindications Hypovolemic shock (correct hypovolemia prior to use) Except in cardiac arrest when correction of hypovolemia and cardiac resuscitation will be concurrent activities

Precautions Should be protected from light; Sodium bicarbonate & Furosemide will inactivate epinephrine, flush line well between administration.

Side Effects CNS stimulation (anxiety, tremor); Tachycardia; Headache; Dysrhythmias; Palpitations; Myocardial ischemia

Adult Dosage Cardiac arrest 1 mg IV repeat every 3-5 min Refractory bradycardia with shock 1-10 mcg/min IV infusion (see next page) Refractory Anaphylaxis 0.5- 1 mg IV / IO or 1-10 mcg/min IV infusion (see next page)

Pediatric Dosage Cardiac arrest 0.01 mg/kg (max 1 mg per dose) repeat every 3-5 minutes Bradycardia 0.01 mg/kg (max 1 mg per dose) repeat every 3-5 minutes

Route IV / IO / ETT (adult cardiac arrest, double the IV dose)

SSM EMS Medications 2016 Medications Section

Epinephrine 1:10,000 continued

Preparing an epinephrine drip

1. Remove 10 mL of fluid from a 250 mL normal saline IV bag.

2. Inject 1 mg of epinephrine 1:10,000 into the normal saline IV bag and shake well.

3. Do not forget to label the bag, it has a concentration of 4 mcg/mL.

4. Use a 60 drop IV administration set (60 drops/1 mL)

5. Use the following table for drip rates;

Dose of Epinephrine Drops per minute (mcg/minute) 2 mcg/min 30 4 mcg/min 60 6 mcg/min 90 8 mcg/min 120 10 mcg/min 150

SSM EMS Medications 2016 Medications Section

Etomidate (Amidate®)

Class Non-barbiturate/non-benzodiazepine sedative-hypnotic

Action Short-acting drug that produces anesthesia

Indications Sedation prior to intubation

SSM EMS Protocol Adult Pharmacologically Assisted Intubation

Contraindications Known hypersensitivity; Not indicated for patients under 10 years of age

Precautions Marked hypotension; Severe asthma,

Side Effects Hypotension; Hypertension; Nausea/vomiting; Breathing difficulties; Dysrhythmias; Involuntary skeletal muscle movement , Respiratory Depression/Arrest

Adult Dosage 0.3 mg/kg (max dose 40 mg)

Pediatric Dosage NOT INDICATED for patients under 10 years of age.

Route IV / IO

SSM EMS Medications 2016 Medications Section

Famotidine (Pepcid®)

Class histamine h2 antagonists

Action Inhibition of gastric acid secretion.

Indications Management of gastric hypersecretory states

SSM EMS Protocol Adult Allergic Reaction / Anaphylaxis, Pediatric Allergic Reaction / Anaphylaxis

Contraindications Hypersensitivity; no other contraindications for short term use

Precautions Give over at least 2 min. Rapid administration may cause hypotension.

Side Effects Confusion, dizziness, drowsiness, hallucinations, headache, arrhythmias

Adult Dosage 20 mg IV / IO over 2 minutes or ODT

Pediatric Dosage 1 mg/kg IV / IO over 2 minutes

Route IV / IO / ODT

SSM EMS Medications 2016 Medications Section

Fentanyl (Sublimaze®)

Class Narcotic analgesic, DEA Schedule II Controlled Substance

Action Analgesia and sedation; Decrease sympathetic response during sedative-facilitated intubation

Indications Moderate to severe pain; Sedative-facilitated intubation

SSM EMS Protocol Adult Post Resuscitation, Adult Induced hypothermia, Adult Chest Pain: Cardiac and STEMI, Adult Pharmacologically Assisted Intubation, Pain Control: Adult, Pediatric Post Resuscitation, Pediatric Induced Hypothermia, Pediatric Bradycardia, Pediatric Pulmonary Edema / CHF, Pediatric Pharmacologically Assisted Intubation, Pediatric Pain Control

Contraindications Known hypersensitivity; Hypotension; Dysrhythmias; Myasthenia gravis; Respiratory depression

Precautions Respiratory depression Give slowly – rapid injection could cause Rigid Chest Syndrome Naloxone should be available

Side Effects Bradycardia; Respiratory depression; Euphoria

IntraNasal (IN) Dosage The first dose can be replaced by an IntraNasal dose, For the Intranasal route only, the initial dose is doubled (Adult/Peds. 2 mcg/kg) The maximum initial dose remains the same for each age group.

Adult Dosage 1 mcg/kg IV / IO / IM, max initial dose 100 mcg After 10 minutes, if indicated, 25 mcg IV / IO / IM Repeat every 10 minutes as needed to the max total dose of 200 mcg Chest Pain 50 -100 mcg IV / IO repeat 25 mcg every 10 minutes as needed. max total dose of 200 mcg

Pediatric Dosage 1 mcg/kg IV / IO / IM, max initial dose 75 mcg After 10 minutes, if indicated, 0.5 mcg/kg IV / IO / IM Repeat every 10 minutes as needed to the max total dose of 150 mcg

Route IV / IO / IM / IN

SSM EMS Medications 2016 Medications Section

Furosemide (Lasix®)

Class Potent loop diuretic

Action Venodilation resulting in reduced venous return; Increases renal excretion of water, sodium, magnesium, calcium and chloride resulting in diuresis

Indications Acute pulmonary edema without signs and symptoms of shock

SSM EMS Protocol Adult CHF / Pulmonary Edema

Contraindications Known hypersensitivity; Pregnancy; Hypovolemia; Dehydration; Hypotension; Hypokalemia

Precautions Should be protected from light; Use with caution in severe liver disease, renal disease and suspected electrolyte abnormalities

Side Effects Few in emergency usage; When administered rapidly, may cause transient deafness

Adult Dosage 40 mg IV / IO for patients not currently taking oral diuretic 80 mg IV / IO for patients currently taking oral diuretic

Pediatric Dosage NOT INDICATED Route IV / IO

SSM EMS Medications 2016 Medications Section

Glucagon (GlucaGen®)

Class Hormone

Action Increases blood glucose by stimulating glycogenolysis

Indications Severe hypoglycemia with a failure to establish venous access Calcium channel blocker overdose; Beta blocker overdose (not listed in protocols, dose prohibitive)

SSM EMS Protocol Adult Diabetic, Adult Pediatric Overdose / Toxic Ingestion, Pediatric Diabetic

Contraindications Known hypersensitivity

Precautions Glucagon only works to correct hypoglycemia if the liver has significant glycogen stores.

Side Effects Hyperglycemia (may be severe); Hypotension; Nausea / Vomiting; Urticaria; Respiratory distress

IntraNasal (IN) Dosage The dose for hypoglycemia can be given via an IntraNasal dose, For the IntraNasal route, the dose is doubled, 2 mg max IN dose for adults. The maximum initial dose remains the same for pediatric group.

Adult Dosage Hypoglycemia 1-2 mg IM repeat in 15 minutes if indicated Calcium channel blocker or beta blocker overdose 1-4 mg IV / IO over 2-5 minutes

Pediatric Dosage Hypoglycemia 0.1 mg/kg IM (max dose 1 mg) repeat in 15 minutes if indicated Beta blocker overdose 0.1 mg/kg IV / IO (max dose 5 mg)

Route IV / IO / IM / IntraNasal

SSM EMS Medications 2016 Medications Section

Haloperidol (Haldol®) Class antipsychotic

Action The mechanism of action of haloperidol is unknown.

Indications Haloperidol is indicated for acute psychosis and combativeness

SSM EMS Protocol Behavioral

Contraindications Hypersensitivity; Haloperidol is contraindicated in the presence of other sedatives (with the exception of benzodiazepines), cardiac disease, and Parkinson’s disease. Haloperidol is also contraindicated for patients with a known allergy to neuroleptic antipsychotic medications such as Thorazine®, Droperidol®, Prolixin®, and Mellaril®.

Precautions Administering haloperidol to a patient who has a history of seizures or who is taking anti- convulsant medications may precipitate convulsion activity; haloperidol reduces the convulsion threshold and anticonvulsant medications decrease the effects of haloperidol. Geriatric patients should receive a decreased dose to reduce the possibility of side effects due to decreased liver function.

Side Effects Adverse reactions may include physical and mental impairment, dystonic reactions, akathisia, dry mouth, blurred vision, and orthostatic hypotension.

Adult Dosage 5 mg IM may repeat dose one time after 15 minutes if indicated

Pediatric Dosage NOT INDICATED

Route IM

SSM EMS Medications 2016 Medications Section

Hydroxocobalamin (Cyanokit®)

Class Cyanide antidote

Action Binds to the cyanide ion to form cyanocobalamin (Vitamin B12) which is then excreted in the urine.

Indications Hydroxocobalamin is indicated for the treatment of known or suspected cyanide poisoning. Significant impairment of the CNS with or without cardiovascular symptoms in the presence of adequate oxygenation and perfusion suggests the diagnosis of cyanide poisoning.

SSM EMS Protocol Cyanide Exposure

Contraindications Do not administer the antidote to an asymptomatic or mildly symptomatic patient, despite a history of exposure, who is awake and alert with normal, stable vital signs.

Precautions Transient episodes of hypertension have been noted. Use caution in patients with known anaphylactic reaction to hydroxocobalamin or cyanocobalamin.

Side Effects Red colored urine, redness at the infusion site and erythema were frequently reported. Other adverse reactions include: hypertension, rash, nausea, headache, dizziness.

Adult Dosage 5 grams IV / IO infusion over 15 minutes. Another 5 gram infusion may be considered 15 minutes after the end of first infusion. 10 gram max dose.

Pediatric Dosage 70 mg/kg IV / IO infusion over 15 minutes. 5 gram max dose.

Instructions Not yet routinely carried on most units due to expense. Do not delay transport to ED waiting for a unit (not already on scene) that carries hydroxocobalamin (Cyanokit®) Cyanokit® is available as 5 grams of lyophilized hydroxocobalamin in a 250 ml glass vial. Reconstitute with 200 ml of normal saline and mix by repeatedly inverting vial for 60 seconds – DO NOT SHAKE. Inspect after mixing – if the solution is not dark red or there are visible particulate matter, do not use.

SSM EMS Medications 2016 Medications Section

Influenza Vaccine (annual flu shot)

Class Annual seasonal flu vaccine

Action Flu vaccines cause antibodies to develop in the body about two weeks after vaccination. These antibodies provide protection against infection with the viruses that are in the vaccine.

Indications CDC Recommendations: Annual influenza vaccination is recommended for all health-care personnel and persons in training for health-care professions. This covers intra-departmental (employee) administration only.

SSM EMS Protocol Annual Intra-Departmental Influenza Administration Procedure

Contraindications Known hypersensitivity; Serious systemic or anaphylactic reaction to eggs; Guillain-Barré Syndrome

Precautions Use of the current year, inactivated injection with a needle “the flu shot”, generally carries less contraindications and warnings. As a precaution with moderate or severe acute illness, all vaccines should be delayed until the illness has improved.

Side Effects Allergic reaction; Soreness, redness, or swelling where the shot was given; hoarseness; sore, red or itchy eyes; cough; fever; aches; headache; itching; fatigue

Adult Dosage Generally administered from a prefilled single dose syringe.

Pediatric Dosage NOT INDICATED for intradepartmental administration

Route IM

SSM EMS Medications 2016 Medications Section

Ketamine Hydrochloride (Ketalar™)

Class: General anesthetic, NMDA receptor antagonist, DEA Schedule III Controlled Substance

Action: Rapid-acting general anesthetic producing an anesthetic state characterized by profound analgesia.

Indications: Psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature, and superhuman strength. Indicated when your patient is in a hyper agitated state and may cause harm to the caregiver or to self.

SSM EMS Protocol: Excited Delirium, Adult COPD / Asthma, Adult Pain Protocol

Contraindications: Hypersensitivity; Ketamine hydrochloride is contraindicated in those in whom a significant elevation of blood pressure would constitute a serious hazard.

Precautions: Caution in overly intoxicated patients, chronic alcoholics, be prepared for decrease respiratory, and elevation of blood pressure, blood pressure return to normal after 3-5 minutes.

Side Effects : Laryngospasm, hypersalivation, nausea/vomiting and possible drug interactions. Example: ETOH, Benzo’s, opiates and psych meds. Emergence phenomena: A hallmark event of Ketamine, more common in patients with psychiatric disorders, have been described as vivid dreams, hallucinations, floating sensations, delirium, recovery agitation, and dysphoria.

Adult Dosage : Excited Delirium: 5 mg/kg IM, 1.5 mg/kg IV Status Asthmaticus: 1-2 mg/kg IV / IO Adult pain control: 0.02 mg/kg IV / IO / IM / IntraNasal

Pediatric Dosage NOT INDICATED for patients < 14 years of age

Route: IM or IV

SSM EMS Medications 2016 Medications Section

Lactated Ringers

Class Isotonic crystalloid solution

Action Lactated Ringer's solution is often used for fluid resuscitation after a blood loss due to trauma, surgery or burn injury

Indications This solution is indicated for use in adults and pediatric patients as a source of electrolytes and water for hydration.

SSM EMS Protocol Thermal Burns, Blast Injury / Incident (Pearls)

Contraindications Lactate administration is contraindicated in severe metabolic acidosis or alkalosis, and in severe liver disease or anoxic states which affect lactate . Avoid Ringers Lactate IV Solution in crush syndrome trauma due to potassium and potential worsening hyperkalemia.

Precautions Solutions containing lactate should be used with great care in patients with metabolic or respiratory alkalosis, and in those conditions in which there is an increased level or an impaired utilization of lactate, such as severe hepatic insufficiency.

Side Effects The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentration.

Adult Dosage Weight based multiplied by % of injury surface area (0.25 mL / kg ( x % TBSA) / hr)

Pediatric Dosage Weight based multiplied by % of injury surface area (0.25 mL / kg ( x % TBSA) / hr)

Route IV / IO

SSM EMS Medications 2016 Medications Section

Lidocaine (Xylocaine®) Class Antidysrhythmic (Class IB);

Action Suppresses ventricular ectopic activity; Increases ventricular fibrillation threshold; Reduces velocity of electrical impulse through conductive system; Local anesthetic

Indications Lidocaine is used to suppress or prevent ventricular premature complexes especially in the setting of myocardial ischemia or infarction and for the treatment of VT and VF. Intraosseous infusion in a conscious patient

SSM EMS Protocol Adult V-Fib / Pulseless V-Tach, Adult Tachycardia-Wide Complex, Adult Pharmacologically Assisted Intubation, Pediatric V-Fib / Pulseless V-Tach, Pediatric Pharmacologically Assisted Intubation, Venous Access: Intraosseous Procedure

Contraindications Known hypersensitivity; High-degree of heart block (second-degree type 2, third-degree, bifascicular block, LBBB) in the absence of an artificial pacemaker; PVCs in conjunction with bradycardia (always treat the bradycardia first with atropine); Adams-Stokes syndrome

Precautions Maximum dosage is 3mg/kg; Dosage should not exceed 300 mg/hr; Monitor for central nervous system toxicity (muscle twitching, slurred speech, altered mental status, decreased hearing, paresthesia, and seizures) ; Dosage should be reduced by 50% in-patients older than 70 years of age or who have liver disease; A 75-100 mg loading dose will only maintain adequate blood levels for 20 min

Side Effects Lightheadedness; Blurred vision; Hypotension; Cardiovascular collapse; Bradycardia; Altered level of consciousness; CNS irritability

Adult Dosage Cardiac Arrest V-Fib/V-Tach 1.5 mg/kg IV / IO repeat dose once in 5 minutes (max total dose 3 mg/kg) Wide Complex Tachycardia 0.5-1.5 mg/kg IV / IO repeat dose 0.5-0.75 mg/kg every 5 minutes (max total dose 3 mg/kg) Pharmacologically Assisted Intubation (suspected intracranial insult) 1.5mg/kg IV / IO (ideally one minute prior/but do not delay intubation) IO site anesthetic 20-40 mg (2-4 cc) 2% solution infused prior to administration of fluids and/or medication

Continued on next page

SSM EMS Medications 2016 Medications Section

Lidocaine (Xylocaine®) continued

Pediatric Dosage Cardiac Arrest V-Fib/V-Tach 1mg/kg IV / IO (max dose 100 mg) repeat 0.5 mg/kg every 5 minutes (max total dose 3 mg/kg) Pharmacologically Assisted Intubation (suspected intracranial insult) 1.5mg/kg IV / IO (ideally one minute prior/but do not delay intubation)

Route IV / IO / ETT (double dose) Lidocaine drip preparation 1. If a premixed bag isn’t available (generally 2 Grams Lidocaine in 500 mL D5W) mix – 2 Grams Lidocaine in 500 mL D5W – 1 Gram Lidocaine in 250 mL D5W The concentration must be = 4 mg/mL 2. Use a 60 drop IV administration set (60 drops/1 mL) 3. Use the following flow rate chart; Lidocaine dose per minute should = the dose that converted the rhythm.

mg of Lidocaine 4 mg 60

Drops per 3 mg 45 minute 15 1 mg

30 2 mg

SSM EMS Medications 2016 Medications Section

Levalbuterol Hydrochloride (Xopenex®)

Class sympathomimetic bronchodilator

Action Beta-adrenergic agonist causing bronchodilation and relaxation of smooth muscles of all airways.

Indications Treatment for bronchospasm

SSM EMS Protocol Pediatric Respiratory Distress

Contraindications Hypersensitivity to Xopenex or racemic albuterol.

Precautions Can have undesirable effects with beta-blockers, diuretics and digoxin. Patients taking Monoamine Oxidase Inhibitors (MAOI’s) and Tricyclic antidepressants (TCA’s) should have been discontinued for 2 weeks prior to administration of Levalbuterol.

Side Effects Adverse reactions may include: tachycardia, arrhythmias, anginal pain, restlessness, anxiety dizziness, headache, and hypokalemia.

Adult Dosage NOT INDICATED

Pediatric Dosage In patients using levalbuterol (Xopenex) you may substitute the patient’s levalbuterol for Albuterol in the protocol.

Route Inhalation via nebulizer

Special Instructions Only for use if patient is prescribed and patient provides or if patient physician provides this medication, as it is not carried on SSM EMS units.

SSM EMS Medications 2016 Medications Section

Lorazepam (Ativan®)

Class Benzodiazepine, DEA Schedule IV Controlled Substance

Action Anticonvulsant; Skeletal muscle relaxant

Indications Generalized seizures; Status epilepticus;

SSM EMS Protocol Adult Seizure, Obstetrical Emergency

Contraindications Known hypersensitivity; Pregnancy; Nursing mothers; Hypotension

Precautions Use extreme caution when administering to patients taking other CNS depressants; Expires in 6 weeks if not refrigerated; Prior to IV administration, must be diluted with equal volume of sterile water or sterile saline (do not dilute for IM administration)

Side Effects Drowsiness; Hypotension; Respiratory depression; Apnea

Adult Dosage Seizure 1-2 mg IM / IV / IO Repeat initial dosing every 3 to 5 minutes for continued seizure activity, Max 10 mg

Pediatric Dosage Seizure 0.1 mg/kg IM / IV / IO Max initial dose 2 mg Dilute dose with equal amount of Normal Saline. Repeat initial dose every ? minutes for continued seizure activity, Max ? mg Route IV / IO / IM

SSM EMS Medications 2016 Medications Section

Magnesium Sulfate Class Magnesium sulfate is an electrolyte, a smooth muscle relaxant and a CNS depressant.

Action Magnesium sulfate reduces acetylcholine release at the neuromuscular junction, reducing muscle contractions and promoting muscle relaxation.

Indications Magnesium sulfate is indicated for seizures associated with eclampsia, as a bronchodilator, for replacement of magnesium in hypomagnesemia, and for the treatment of Torsades de Pointes as well as refractory VT/VF.

SSM EMS Protocol Adult V-Fib / Pulseless V-Tach, Adult Tachycardia-Wide Complex, Adult COPD / Asthma, Adult Seizure, Pediatric V-Fib / Pulseless V-Tach, Pediatric Tachycardia, Pediatric Respiratory Distress,

Contraindications Hypersensitivity; Heart block; and renal failure.

Precautions Hypotension; Calcium chloride should be readily available as an antidote if respiratory depression ensues; CNS depressant effects may be enhanced if patient is on other CNS depressants; Significant changes in cardiac function may occur with cardiac glycosides (digoxin, digitalis); Use with caution in renal failure

Side Effects Facial flushing; Hypotension; Depressed reflexes; Hypothermia; Reduced heart rate; Circulatory collapse; Respiratory depression

Adult Dosage Seizure activity associated with pregnancy 4 g IV / IO over 2-3 minutes. For persistent seizure after 5-10 minutes, May repeat 2 g IV / IO over 2-3 minutes Torsades de pointes 2 g IV / IO over 2-3 minutes Respiratory distress 2 g IV / IO over 10 minutes

Pediatric Dosage Torsades de pointes 40 mg/kg slow IV / IO over 10 minutes (pulse present) cardiac arrest over 2-3 minutes. May repeat every 5 min (max dose 2 g) Respiratory distress 40 mg/kg slow IV / IO over 20 minutes (max dose 2 g)

Route IV / IO Final solution administered to patient should be diluted to < 20% concentration.

SSM EMS Medications 2016 Medications Section

Methylprednisolone (Solu-Medrol®)

Class Glucocorticoid

Action Methylprednisolone suppresses acute and chronic inflammation, potentiates vascular smooth muscle relaxation, and may alter airway hyperactivity.

Indications Severe allergic reactions, asthmatic attacks and bronchospasm associated with COPD that do not respond to other treatments.

SSM EMS Protocol Adult COPD / Asthma, Adult Allergic Reaction / Anaphlaxis, Pediatric Hypotension / Shock (Pearls), Pediatric Allergic Reaction / Anaphlaxis, Pediatric Respiratory Distress

Contraindications Hypersensitivity; Use with caution in patients with GI bleeding, diabetes mellitus or severe infection

Precautions Must be reconstituted and used promptly; Onset of action may be 2-6 hours and thus should not be expected to be of use in the critical first hour following an anaphylactic reaction – the earlier that it is administered, the faster the patient will benefit

Side Effects GI bleeding; Prolonged wound healing; Headache; Hypokalemia; Alkalosis

Adult Dosage 125 mg IV / IO

Pediatric Dosage 2 mg/kg IV / IO (max dose 125 mg)

Route IV / IO

SSM EMS Medications 2016 Medications Section

Metoclopramide (Reglan®)

Class Prokinetic , Antiemetic

Action Stimulates the muscles of the gastrointestinal tract including the muscles of the lower esophageal sphincter, stomach, and small intestine by interacting with receptors for acetylcholine and dopamine on gastrointestinal muscles and nerves

Indications Nausea and vomiting

SSM EMS Protocol Adult Vomiting and Diarrhea

Contraindications Known hypersensitivity; Metoclopramide should not be used whenever stimulation of gastrointestinal motility might be dangerous, e.g., in the presence of gastrointestinal hemorrhage, mechanical obstruction, or perforation.

Precautions May worsen diarrhea and should be avoided in patients with this symptom. Use caution with administration of Metoclopramide in elderly patients; may cause extra sedation.

Side Effects Dizziness, Drowsiness, extrapyramidal reactions, may worsen muscle tremors in Parkinson’s Patients

Adult Dosage 10 mg IV / IO administered slow over 2 minutes 10 mg IM

Pediatric Dosage NOT INDICATED

Route IV / IO / IM

Special instructions To administer Metoclopramide over two (2) minutes, draw up 8 ml of NS and 2ml/10 mg of Metoclopramide. This equals 10cc of fluid. Give 2.5 cc every thirty (30) seconds.

SSM EMS Medications 2016 Medications Section

Midazolam (Versed®)

Class Benzodiazepine, DEA Schedule IV Controlled Substance

Action Sedative; Anxiolytic; Amnesic

Indications Sedation before cardioversion and TCP; Skeletal muscle relaxant; Acute anxiety states; Pharmacologically Assisted Intubation

SSM EMS Protocol Behavioral, Excited Delirium Syndrome, Adult Post Resuscitation, Adult Induced Hypothermia, Adult Tachycardia-Narrow Complex, Adult Tachycardia-Wide Complex, Adult Bradycardia, Adult CHF / Pulmonary Edema (Pearls), Adult Airway, Adult Pharmacologically Assisted Intubation, Adult COPD / Asthma (Pearls), Adult Seizure, Obstetrical Emergency, Pediatric Post Resuscitation, Pediatric Induced Hypothermia, Pediatric Tachycardia, Pediatric Bradycardia, Pediatric Airway, Pediatric Pharmacologically Assisted Intubation, Pediatric Seizure, Crush Syndrome Trauma, Bites and Envenomations

Contraindications Known hypersensitivity; Shock (hypotension)

Precautions More potent than diazepam; Can cause hypoventilation, respiratory depression, or arrest – patients at higher risk include those with COPD, acute alcohol intoxication or concomitant use of narcotics or barbiturates; Use extreme caution when administering to patients taking other CNS depressants. Give half the dose for chemical restraint for age > 65.

Side Effects Respiratory depression or arrest; Hypotension; Laryngospasm; Nausea/vomiting; Fluctuations in vital signs

Route IV / IO / IM / IntraNasal

Crush Syndrome (adult and pediatrics) In addition to opioid pain control consider 0.1-0.2 mg/kg IV / IO / IntraNasal / IM consider giving in divided doses and give slowly over 2–3 minutes; PREPARE TO MANAGE THE AIRWAY FOR THIS DRUG COMBINATION

See additional dosages on the next page

SSM EMS Medications 2016 Medications Section

Midazolam (Versed®) continued Adult Dosage

Chemical Restraint 10 mg IntraNasal or 5 mg IV / IO / IM > 65 years of age, 5 mg IntraNasal or 2.5 mg IV / IO / IM

Post Resuscitation 2.5 mg IV/ IO repeat every 3-5 minutes as needed (max total dose 10 mg)

Sedation 5 mg IntraNasal or 2.5 mg IV / IO, may repeat IV / IO dose if needed (max total dose 5 mg)

Assist with CPAP Compliance 1-2 mg IV / IO Read Pearls before administration

Pharmacologically Assisted Intubation 0.1 mg/kg IV / IO followed by Fentanyl for induction, after intubation 2.5 mg IV / IO every 3-5 minutes, if indicated (max total dose 10 mg)

Active Seizure 5 mg IntraNasal / IM, do not wait to IV access, or 2.5 mg IV / IO Repeat initial dosing every 3 to 5 minutes for continued seizure activity to (max total dose 20 mg)

Muscle Spasm (bites and envenomations) 0.5 – 2 mg IV / IO over 2 to 3 minutes or 5 mg IntraNasal / IM (Max total dose 5 mg)

Pediatric Dosage

Chemical Restraint / Sedation 0.2 mg/ kg IntraNasal or 0.1 mg/kg IV / IO (max dose 2.5 mg) may repeat once in 3 -5 minutes if needed (max total dose 5 mg)

Post Resuscitation 0.1 mg/kg IV / IO (max dose 5 mg) may repeat once in 3 -5 minutes if needed

Pharmacologically Assisted Intubation 0.1 mg/kg IV / IO followed by Fentanyl for induction, after intubation 0.1 mg/kg IV / IO (max dose 5 mg), if indicated

Active Seizure 0.2 mg/kg IntraNasal (max initial dose 5 mg), do not wait to IV access, or 0.1 mg/kg IV / IO Repeat initial dosing in 2 to 3 minutes for continued seizure activity (max total dose 10 mg)

Muscle Spasm (bites and envenomations) 0.1 mg/kg IV / IO over 2 to 3 minutes or 0.2 mg IntraNasal / IM (Max total dose 5 mg)

SSM EMS Medications 2016 Medications Section

Morphine Sulfate Class Narcotic analgesic, DEA Schedule II Controlled Substance

Action Morphine sulfate is a natural opioid and increases vasodilation while decreasing venous return and systemic vascular resistance, thus decreasing myocardial oxygen demand. It also produces analgesia and euphoria, thus effectively treating moderate to severe pain.

Indications Morphine sulfate is indicated for acute myocardial infarction, acute pulmonary edema, and pain management.

SSM EMS Protocol Adult Chest Pain: Cardiac and STEMI, Pediatric Pulmonary Edema / CHF,

Contraindications Morphine sulfate is contraindicated in known hypersensitivity, hypovolemia, hypotension, and head injury.

Precautions Morphine sulfate may result in respiratory depression and hypotension (especially in patients who are volume depleted or those with increased systemic vascular resistance). Consider the patient’s age, weight, clinical condition, other recent drugs or alcohol, and prior exposure to opiates when determining initial opioid dosing. Weight-based dosing may provide a standard means for dose calculation, but does NOT predict patient response. For example, minimal doses of opioids may cause respiratory depression in the elderly, opiate naïve, and possibly intoxicated patients.

Side Effects Altered level of consciousness; Nausea/vomiting; Respiratory depression; Bronchospasm; Hypotension

Adult Dosage Pain 0.1 mg/kg IV / IO / IM give over 2-3 minutes (max initial dose 10 mg) If indicated, after 10 minutes, 2 mg IV / IO / IM. May repeat every 5 minutes until improvement (maximum total dose of 20 mg) Chest Pain 4 mg (0.1 mg/kg) IV / IO repeat every 5 minutes as needed (max total dose 12 mg)

Pediatric Dosage 0.1 mg/kg IV / IO (max total dose 10 mg)

Route IV / IO / IM

SSM EMS Medications 2016 Medications Section

Naloxone (Narcan®)

Class Narcotic antagonist

Action Reverses effects of narcotics

Indications Naloxone is indicated to reverse respiratory and central nervous system depression induced by opioids.

SSM EMS Protocol Adult Cardiac Arrest (Pearls), Adult Asystole / PEA, Adult Seizure, Adult Overdose / Toxic Ingestion, Pediatric Asystole / PEA,

Contraindications Known hypersensitivity

Precautions Administer with caution to patients dependent on narcotics as it may cause withdrawal effects; Reassess patient often since some narcotic effects have longer duration than naloxone; Certain drugs such as proproxyphene (darvon) may require much higher doses of naloxone for reversal; May not reverse hypotension

Side Effects Nausea/vomiting; Withdrawal syndrome

Adult Dosage 1-2 mg Intranasal is preferred 1st dose. Additional doses (every 3-5 min) may given 0.4-2 mg IV / IO / IM titrate to effect adequate ventilation and oxygenation, not given to restore consciousness.

Pediatric Dosage 0.1 mg/kg IV / IO / IM (max 2 mg) May repeat dose every 3-5 min. MAX TOTAL DOSE 6 mg.

Route IV / IO / IM / ETT / IntraNasal

SSM EMS Medications 2016 Medications Section

Nitroglycerin (Nitrolingual®)(Nitrobid®)

Class Vasodilator, Nitrate

Action Nitroglycerin is a direct vasodilator, which acts principally on the venous system although it also produces direct coronary artery vasodilation as a result. There is a decrease in venous return, which decreases the workload on the heart and thus, decreases myocardial oxygen demand.

Indications Chest pain or discomfort associated with suspected AMI or Angina Pectoris. Pulmonary edema with hypertension.

SSM EMS Protocol Chest pain: Cardiac and STEMI, Adult CHF / Pulmonary Edema

Contraindications Known hypersensitivity; Hypotension; Head injury; Cerebral hemorrhage; Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 36 hours due to potential severe hypotension.

Precautions Must have IV established prior to administration; Systolic blood pressure must be >100 mmHg; Frequently monitor blood pressure; Protected from light and heat; Use extreme caution when administering to patient with inferior AMI

Side Effects Headache; Dizziness; Flushing; Nausea and Vomiting; Hypotension; Reflex tachycardia

Adult Dosage Nitroglycerin Paste SBP > 100 = 1 inch SBP > 150 = 1.5 inches SBP > 200 = 2 inches

Spray or tablet Nitroglycerin 0.3 / 0.4 mg (1 tablet or 1 spray) SL Repeat every 3- 5 minutes (no max if SBP > 100)

Pediatric Dosage NOT INDICATED

Route Transdermal absorption / SL

SSM EMS Medications 2016 Medications Section

Ondansetron (Zofran®)

Class Antiemetic

Action Prevents and alleviates nausea/vomiting

Indications Treatment or prevention of nausea/vomiting

SSM EMS Protocol Adult Vomiting and Diarrhea, Pediatric Vomiting and Diarrhea, Eye Injury / Complaint

Contraindications Known hypersensitivity

Precautions Administer via IV slow, over 2 minutes

Side Effects Extra-pyramidal reaction (rare)

Adult Dosage 8 mg ODT (orally disintegrating tablet) given once or 4 mg IV / IO administered slow over 2 minutes, may repeat dose once in 15 minutes if indicated 4 mg IM may repeat dose once in 15 minutes if indicated

Pediatric Dosage 0.2 mg/kg ODT / IV / IO / IM (max dose 4 mg)

Route IV / IO / IM / ODT Special instructions To administer Zofran over two (2) minutes, draw up 8ml of NS and 2ml/4mg of Zofran. This equals 10cc of fluid. Give 2.5 cc every thirty (30) seconds.

SSM EMS Medications 2016 Medications Section

Oral Glucose

Class Carbohydrate

Action Elevates blood glucose level rapidly

Indications Hypoglycemia as indicated by blood glucose measurement

SSM EMS Protocol Adult Diabetic, Pediatric Diabetic

Contraindications Patients that cannot protect airway

Precautions Should be preceded by 100mg of thiamine if either alcoholism or malnutrition suspected Consider patient’s age, ability to swallow and follow directions

Side Effects None

Adult Dosage One tube (pre-packaged 15-25g) May repeat based on blood glucose results

Pediatric Dosage One tube (pre-packaged 15-25g) May repeat based on blood glucose results

Route PO

SSM EMS Medications 2016 Medications Section

Oxygen

Class Atmospheric gas

Action Necessary for cellular metabolism; Reverses hypoxemia

Indications Hypoxia; Ischemic-type chest pain; Respiratory insufficiency; Useful in any condition with cardiac work load, respiratory distress, or illness or injury resulting in altered ventilation and/or perfusion.

SSM EMS Protocol Multiple

Contraindications There are no known contraindications in providing oxygen.

Precautions Use with caution in patients with COPD; Humidify, if possible, when providing high-flow rates Do not hyperoxygenate, titrate to pulse ox reading 94% - 99%

Side Effects Drying of mucous membranes; Respiratory depression in patients with chronic carbon dioxide retention

Adult Dosage 2-15 L/min 1-4 liters/min via nasal cannula 10-15 liters/min via NRB mask 10-15 liters via BVM (sufficient to allow reservoir bag to completely refill between ventilations)

Pediatric Dosage 2-15 L/min 1-4 liters/min via nasal cannula 10-15 liters/min via NRB mask 10-15 liters via BVM (sufficient to allow reservoir bag to completely refill between ventilations)

Route Inhalation

SSM EMS Medications 2016 Medications Section

Oxymetazoline (Afrin®)

Class Sympathomimetic

Action Nasal Vasoconstriction

Indications Epistaxis

SSM EMS Protocol Epitaxis

Contraindications Severe Hypertension

Precautions Not to be used for >3 days

Side Effects Temporary burning, stinging, dryness in the nose, or sneezing.

Adult Dosage 2 sprays in the affected nostril followed by direct pressure

Pediatric Dosage NOT INDICATED

Route Nasal spray

SSM EMS Medications 2016 Medications Section

Sodium Bicarbonate 8.4%

Class Alkalinizing agent; Electrolyte

Action Buffers metabolic acidosis by reacting with hydrogen ions to form water and carbon dioxide

Indications Known or suspected preexisting bicarbonate responsive acidosis; Management of metabolic acidosis (DKA); Intubated patient with continued long arrest interval; Upon return of spontaneous circulation after long arrest interval; Tricyclic antidepressant overdose; Role in certain toxicities (refer to medical control and/or poison control for guidance); Consider early in suspected excited delirium cardiac arrest.

SSM EMS Protocol Behavioral (Pearls), Excited Delirium, Adult V-Fib / Pulseless V-Tach, Adult Asystole / PEA, Dialysis / Renal Failure, Crush Syndrome

Contraindications Respiratory acidosis; Metabolic and respiratory alkalosis; Severe pulmonary edema; Hypocalcemia; Hypokalemia; Hypernatremia

Precautions Correct dosage is essential to avoid overcompensation of pH; May deactivate catecholamines if IV line not flushed sufficiently; May precipitate calcium solutions; Delivers large sodium load; Potentially worsens intracellular acidosis by producing carbon dioxide which crosses the cellular membrane more easily than bicarbonate (adequate patient ventilation essential); May worsen CHF; May increase edematous or sodium-retaining states. Sodium Bicarbonate and Calcium Chloride / Gluconate should not be mixed. Ideally give in separate lines.

Side Effects Metabolic alkalosis; Hypoxia; Pise in cellular Pco2 and increased tissue acidosis; hypernatremia; Seizures; Tissue necrosis at injection site

Adult Dosage Asystole / PEA (overdose, hyperkalemia), Crush Syndrome 50 mEq IV / IO Tricyclic Antidepressant OD with QRS of > 0.12 seconds 50-150 mEq IV / IO Repeat every 5 minutes until QRS narrows to < 0.12 seconds

Pediatric Dosage <10 kg patients use Sodium Bicarbonate 4.2% (Discard 25 mEq of 8.4%, replace with 25 mL of NS) Asystole / PEA (overdose, hyperkalemia), Crush Syndrome 1 mEq/kg IV / IO Tricyclic Antidepressant OD with QRS of > 0.09 seconds 1 mEq/kg IV / IO (max dose 50 mEq) Repeat 1 mEq/kg every 5 min if QRS remains ≥0.09 seconds.

Route IV / IO

SSM EMS Medications 2016 Medications Section

Sodium Chloride 0.9% (Normal Saline)

Class isotonic crystalloid solution

Action Provides fluid and sodium replacement

Indications Normal saline can be used as the vehicle for many parenteral drugs and as an electrolyte replenisher for maintenance or replacement of deficits of extracellular fluid. It can also be used as a sterile irrigation medium.

SSM EMS Protocol Multiple

Contraindications Severe renal impairment; (relative) Congestive Heart Failure

Precautions Sodium chloride should be administered with care to patients with congestive heart failure, hypertension, peripheral or pulmonary edema, impaired renal function, urinary tract obstruction, pre-eclampsia and very young or elderly patients.

Side Effects Volume Overload; Congestive Heart Failure; Diuresis; Thirst

Adult Dosage Shock / Hypotension 500 mL bolus IV / IO, repeat to effect systolic blood pressure of > 90 (max total dose 2 L)

Pediatric Dosage Shock / Hypotension 20 mL/kg IV / IO, repeat to effect age appropriate BP (SBP ≥ 70 + 2 x Age) (max total dose 60 mL/kg)

Route IV / IO

SSM EMS Medications 2016 Medications Section

Tetracaine (TetraVisc®)

Class Anesthetic, local (ophthalmic)

Action Stabilizes membranes of conjunctival and corneal pain fibers to inhibit depolarization and perception of pain.

Indications Before using a Morgan Lens; Tetracaine is intended for use in the patient who is unable to cooperate with you in adequately flushing the eye(s) due to discomfort or pain.

SSM EMS Protocol Eye Injury / Complaint, Morgan Lens Procedure

Contraindications Known hypersensitivity to the drug. Tetracaine may cross- react in patients with allergy to procaine (Novocain) or chloroprocaine (Nesacaine) and is relatively contraindicated in these patients as well.

Precautions Do not use the solution if it contains crystals. Discolored solutions should not be used. Containers must be kept tightly closed. Warn patient not to touch or rub eye while cornea is anesthetized. This may cause corneal abrasion, further injury, and greater discomfort once tetracaine wears off.

Side Effects Transient (< 60 seconds) burning, stinging, tearing

Adult Dosage 2 drops of 0.5% solution

Pediatric Dosage Safety and effectiveness in children have not been established.

Route Medication should be instilled into eye in lower conjunctival sac. Patient should be instructed to look up towards the top of the head while the paramedic pulls down the lower lid and instills the medication within the pouch formed by the inner surface of the lower lid and the conjunctiva.

SSM EMS Medications 2016 Medications Section

Thiamine (Biamine®)

Class Vitamin

Action Necessary for normal carbohydrate metabolism

Indications Alcoholism; Vitamin B1 deficiency; Delirium Tremens

SSM EMS Protocol Excited Delirium Syndrome, Adult Diabetic, Adult Seizure

Contraindications Hypersensitivity

Precautions Rare anaphylactic reactions have been reported. However the possibility of Wernicke's Syndrome following glucose administration presents substantially greater risk than the possibility of significant hypersensitive reaction.

Side Effects Hypotension (from rapid injection or large dose); Nausea and vomiting

Adult Dosage 100 mg IV / IO / IM

Pediatric Dosage rarely used, contact medical control

Route IV / IO / IM

SSM EMS Medications 2016 SSM EMS Policies Section

Section Table of Contents

Atypical Protocol Utilization

Patient Without a Protocol Transport and Care Plans Safe Transport of Pediatric Patients Air Transport Infant Abandonment Child Abuse Recognition and Reporting

Elderly Abuse / Neglect Recognition and Reporting Domestic Violence Recognition and Reporting

Patients with Special Healthcare Needs SSM EMS Policies Section Deceased Persons Discontinuation of Prehospital Resuscitation Do Not Resuscitate Order Disposition of Patients and Patient Instructions Documentation of the PCR Documentation with Multiple Providers EMS Documentation Quality-NCCEP Documentation of Vital Signs EMS Back in Service Time EMS Dispatch Center Time EMS Wheels Rolling (Turn Out) Time Emergency Medical Dispatch Equipment Failure Hospital Diversion

Interfacility Transfers Non-Paramedic Transport of Patients

Physician on Scene Poison Center Practitioner Disciplinary Policy Certification Policy

SSM EMS Policy 2016 SSM EMS Policy Atypical Protocol Utilization and Online Medical Direction

Purpose:

The purpose of this policy is to:  Provide world-class patient care and give direction for providers who encounter complicated, unusual, and atypical patient encounters.  Establish an orderly method by which clinical issues can be rapidly addressed.  This policy does not affect administrative issues related to employee/employer relationships (sick outs, injuries, narcotic replacements, etc.).

Policy:

1. Clinical encounters requiring use of this protocol may be divided into two types: a. Those whose clinical situation is covered by existing protocol but who are presenting an operational/administrative challenge (e.g., patient refusals, non-intubated post-ROSC patients) and require non-medical control guidance, Atypical Protocol Utilization (APU), or b. those whose clinical situation is not covered by existing protocol (e.g., modification of drug dosage, termination of resuscitation not covered in current policy) and thus require medical control orders via on-line medical direction (OLM).

2. Patients (b) requiring OLM shall contact medical control via as described in steps 4 and 5 below. The provider requesting OLM must be at the scene with the patient.

3. The first call for (a) operational / administrative issues related to an individual patient or patients should be placed to the Supervisor on duty for the service. If possible, the call should be placed directly to their cell phone. If this is not practical, the on scene crew should contact OLM.

4. If the request is for OLM or if there are no supervisors immediately available for administrative / operational issues, the next call will be to a Chief Officer or the Department’s Medical Officer.

5. If neither are available, request OLM from a physician at the most appropriate receiving hospital via radio. Only physicians may provide medical direction. Other staff, including PAs and nurses, may not provide online medical direction. The name of the physician providing direction must be reported in the Patient Care Report (PCR).

6. In the electronic patient care report, the name of the individual providing OLM will be documented in the narrative section. The Paramedic will add a note confirming the advice provided as stated in the PCR Documentation Policy.

SSM EMS Policy 2016 SSM EMS Policy Patient Without a Protocol

Policy:

Anyone requesting EMS services will receive a professional evaluation, treatment, and transportation (if needed) in a systematic, orderly fashion regardless of the patient’s problem or condition.

Purpose:

To ensure the provision of appropriate medical care for every patient regardless of the patient’s problem or condition.

Procedure:

1. Treatment and medical direction for all patient encounters, which can be triaged into a SSM EMS System patient care protocol, is to be initiated by protocol.

2. When confronted with an emergency or situation that does not fit into an existing SSM EMS System patient care protocol, the patient should be treated by the Universal Patient Care Protocol and a Medical Control Physician should be contacted for further instructions.

SSM EMS Policy 2016 SSM EMS Policy Transport and Care Plans

Policy:

All sick or injured persons requesting transport shall be transported without delay to an appropriate local emergency department of the patient’s preference. The only exceptions to this rule are found below.

Purpose:

To establish a uniform protocol for the transportation of the sick and injured.

1. An “appropriate local emergency department” includes ALL Saint Louis CITY and COUNTY EMERGENCY DEPARTMENTS (ED), or hospitals in contiguous counties. The ability to pay or insurance status if known SHALL NOT BE A FACTOR. If the unit availability status of the System is a concern, contact your supervisor prior to patient-requested out-of-county transport.

2. All sick or injured persons requesting transport who do not express a preference will be transported without delay to the closest most appropriate facility.

3. Transport decisions should take into strong consideration a patient’s pre-existing health care relationships. In general, patients should be taken to the hospital at which they have a pre- existing patient-provider relationship unless the patient expressly requests otherwise. For example, a patient who has had recent surgery who now has a possible surgical complication should return to the hospital at which the surgery was performed. If a patient has an SSM cardiologist, for example, the patient should generally be taken to a SSM facility for possible cardiac problems. These situations are not necessarily inconsistent with time-sensitive conditions and the Triage and Destination Plans. Patients may choose their preferred destination specialty receiving hospital; providers should document discussion of possible risks and benefits associated with possible longer transport times.

SSM EMS Policy 2016 SSM EMS Policy Safe Transport of Pediatric Patients

Policy:

Without special considerations, children are at risk of injury when transported by EMS. EMS must provide appropriate stabilization and protection to pediatric patients during EMS transport.

Purpose:  To Provide a safe method of transporting pediatric patients within an ambulance.  Protect the EMS system and personnel from potential harm and liability associated with the transportation of pediatric patients.

Procedure: 1. Drive cautiously at safe speeds observing traffic laws. 2. Tightly secure all monitoring devices and other equipment. 3. Ensure that all pediatric patients less than 40 lbs are restrained with an approved child restraint device secured appropriately to the stretcher or captain’s chair. 4. Ensure that all EMS personnel use the available restraint systems during the transport. 5. Transport adults and children who are not patients, properly restrained, in an alternate passenger vehicle, whenever possible. 6. Do not allow parents, caregivers, or other passengers to be unrestrained during transport. 7. NEVER attempt to hold or allow the parents or caregivers to hold the patient during transport. 8. For patients with medical conditions that may be aggravated by stress, make every attempt to optimize safety when comforting the child. 9. Do not transport the pediatric patient who is assessed as meeting trauma center criteria in a child seat that was involved in the collision that produced the child’s injury.

SSM EMS Policy 2016 SSM EMS Policy Air Transport

Indications:

A helicopter may be utilized when ALL of the following criteria are present:  Patient meets criteria for trauma center evaluation.  The patient is entrapped and extrication is expected to last greater than 20 minutes.  The ground transport time is greater than 15 minutes.  The patient is not in traumatic cardiac arrest.  A helicopter may also be utilized when any of the following is present:  A situation approved by the medical director or medical control physician – or –  Mass Casualty Incident (MCI).  The patient meets burn center criteria.

Procedure:

The highest certified technician on the crew (usually the EMT-P) will determine that a helicopter may be needed for the patient. An on-scene Fire Department Officer may request a helicopter to expedite its arrival.

That technician will request that the 911 dispatch center contact all helicopter services for a estimated time of arrival (ETA) to the scene. The 911 dispatch center will determine which air ambulance is nearest and utilize this resource.

A safe landing zone should be established.

If the helicopter does not arrive prior to the extrication of the patient, the patient should be immediately placed in the ambulance and transport begun to the nearest trauma center.

Under NO circumstances will transport of a patient be delayed to use a helicopter.

SSM EMS Policy 2016 SSM EMS Policy Child Abandonment

Policy:

Safe Place for Newborn Act 2000 Ann. Statute 210.950

Purpose: You can leave your baby, up to 1 year old, with an on duty employee at any hospital, fire department, emergency medical professional or law enforcement agency in Missouri.

To provide:  Protection to infants that are placed into the custody of EMS under this law  Protection to EMS systems and personnel when confronted with this issue

Procedure:

1. Initiate the Pediatric Assessment Procedure. 2. Initiate Newly Born Protocol as appropriate. 3. Initiate other treatment protocols as appropriate. 4. Keep infant warm. 5. Call local Department of Social Services or the county equivalent as soon as infant is stabilized. 6. Transport infant to medical facility as per protocol. 7. Assure infant is secured in appropriate child restraint device for transport. 8. Document protocols, procedures, and agency notifications in the PCR.

SSM EMS Policy 2016 SSM EMS Policy Child Abuse Recognition and Reporting

Policy:

Child abuse is the physical and mental injury, sexual abuse, negligent treatment, and/or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare. The recognition of abuse and the proper reporting is a critical step to improving the safety of children and preventing child abuse.

Purpose:

Assessment of a child abuse case is based upon the following principles:  Protect the life of the child from harm, as well as that of the EMS team from liability.  Suspect that the child may be a victim of abuse, especially if the injury/illness is not consistent with the reported history.  Respect the privacy of the child and family.  Collect as much evidence as possible, especially information.

Procedure:

With all children, assess for and document psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, fussy behavior, hyperactivity, or other behavioral disorders.

With all children, assess for and document physical signs of abuse, including and especially any injuries that are inconsistent with the reported mechanism of injury.

With all children, assess for and document signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition.

Immediately report any suspicious findings to both the receiving hospital (if transported) and to the Department of Social Services Social Worker On Call by contacting the 911 dispatch center. While law enforcement may also be notified, Missouri law requires the EMS provider to report the suspicion of abuse to DSS. EMS should not accuse or challenge the suspected abuser. This is a legal requirement to report, not an accusation. In the event of a child fatality, law enforcement must also be notified.

* To report suspected child abuse or neglect, call the Saint Louis County Child Protective Services 314-615-2903, if you get a recording call your 911 dispatch center.

SSM EMS Policy 2016 SSM EMS Policy Elderly Abuse / Neglect Recognition and Reporting

Policy:

Elderly abuse is physical and mental injury, sexual abuse, negligent treatment, and/or maltreatment of an adult by a person who is responsible for the welfare of that adult. The recognition of abuse and the proper reporting is a critical step to improving the safety of the elderly and preventing abuse or neglect.

Purpose:

Assessment of a Elder abuse case is based upon the following principles:  Protect the life of the elderly from harm, as well as that of the EMS team from liability.  Suspect that the Elder adult may be a victim of abuse, especially if the injury/illness is not consistent with the reported history.  Respect the privacy of the Elder adult and family.  Collect as much evidence as possible, especially information.

Procedure:

With all suspected elderly abuse, assess for and document psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive anger towards family or caregivers or other behavioral disorders.

With all suspected elderly abuse, assess for and document physical signs of abuse, including and especially any injuries that are inconsistent with the reported mechanism of injury.

With all suspected elderly abuse, assess for and document signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition. Example; soiled clothes,soiled bed linens, no access to food or water.

Immediately report any suspicious findings to both the receiving hospital (if transported) and to the Department of Social Services Social Worker On Call by contacting the 911 dispatch center. While law enforcement may also be notified, Missouri law requires the EMS provider to report the suspicion of abuse to DSS. EMS should not accuse or challenge the suspected abuser. This is a legal requirement to report, not an accusation. In the event of a fatality, law enforcement must also be notified.

For suspected elder abuse or neglect, contact Department of Social Services at 800-392-0210 After office hours, the adult social services worker on call can be contacted by the 911 communications center.

SSM EMS Policy 2016 SSM EMS Policy Domestic Violence Recognition and Reporting

Policy:

Domestic violence is physical, sexual, or psychological abuse and/or intimidation, which attempts to control another person in a current or former family, dating, or household relationship. The recognition, appropriate reporting, and referral of abuse is a critical step to improving patient safety, providing quality health care, and preventing further abuse.

Purpose:

Assessment of an abuse case is based upon the following principles:  Protect the patient from harm, as well as protecting the EMS team from harm and liability.  Suspect that the patient may be a victim of abuse, especially if the injury/illness is not consistent with the reported history.  Respect the privacy of the patient and family.  Collect as much information and evidence as possible and preserve physical evidence.

Procedure:

*Immediately report any suspicious findings of abuse or neglect to the receiving hospital. 1. Assess the/all patient(s) for any psychological characteristics of abuse, including excessive passivity, compliant or fearful behavior, excessive aggression, violent tendencies, excessive crying, behavioral disorders, substance abuse, medical non-compliance, or repeated EMS requests. This is typically best done in private with the patient.

2. Assess the patient for any physical signs of abuse, especially any injuries that are inconsistent with the reported mechanism of injury. Defensive injuries (e.g. to ), and injuries during pregnancy are also suggestive of abuse. Injuries in different stages of healing may indicate repeated episodes of violence.

3. Assess all patients for signs and symptoms of neglect, including inappropriate level of clothing for weather, inadequate hygiene, absence of attentive caregiver(s), or physical signs of malnutrition.

4. For suspected domestic violence, where the patient is refusing further care and transport; Ensure law enforcement is informed of suspicions EMS personnel should attempt in private to provide the patient with Domestic Violence & Rape Crisis Line (314)531-7273, or the National Hotline, 1-800-799-SAFE

SSM EMS Policy 2016 SSM EMS Policy Patients with Special Health Care Needs

Policy:

Medical technology, changes in the healthcare industry, and increased home health have created a special population of patients that interface with the EMS system. It is important for EMS to understand and provide quality care to patients with special health care needs.

Purpose:

Provide quality patient care and EMS services to patients with special health care needs. Understand the need to communicate with the caregivers regarding healthcare needs and devices that EMS may not have experience with.

Procedure:

Caregivers who call 911 to report an emergency involving a patient with special health care needs may not report that the emergency involves a special health care need. EMS personnel may choose to contact the patient’s primary care physician for assistance with specific conditions or devices for advice regarding appropriate treatment and/or transport of the child in the specific situation.

Do not overlook family members who tend to be primary caregivers as a resource. They are often very well informed about the specific health condition and may be able to help with medical devices crews are unfamiliar with.

Transportation of the patient, if necessary, will be made to the hospital appropriate for the specific condition of the patient. In some cases this may involve bypassing the closest facility for a more appropriate destination.

SSM EMS Policy 2016 SSM EMS Policy Deceased Persons

Purpose:

 Organize and provide for a timely disposition of any deceased person.  Maintain respect for the deceased and family.  Obvious death in the field shall be limited to: Non-traumatic: non-hypothermic patient with rigor mortis and / or dependent lividity, patient that is pulseless / apneic. If traumatic in origin, injuries obviously incompatible with life include; massively deforming head or chest injuries, blood and/or cerebral spinal fluid from the ears, or other features of a particular patient encounter that would make resuscitation futile.

Procedure:

Any scene where a death has taken place should be considered a potential crime scene and must be treated accordingly.  Minimize personnel traffic of the scene, minimize movement of the body, noting position, location orientation when determining if patient meets sudden death criteria.  Carefully account your surroundings, localizing weapons, or persons at the scene prior to EMS arrival and document thoroughly.  EMS must wear gloves and avoid contact with potential evidence.  Attach monitor, verify in two leads and run a EKG strip.  Contact Local Law enforcement and appropriate county medical examiner/coroner  Document as much of the patients medical history, medications, position of the patient, whom was on scene, and document your decision of why you declared the patient unresuscitatable.  No ambulance may transport a deceased patient to a hospital or other location, unless it is deemed to be in the interest of public health, Medical Control must be contacted before transport occurs.

In the occurrence EMS is first arrival to scene, SAFETY of crewmembers is of main concern.

SSM EMS Policy 2016 SSM EMS Policy Discontinuation of Prehospital Resuscitation

Policy:

Unsuccessful cardiopulmonary resuscitation (CPR) and other advanced life support (ALS) interventions may be discontinued prior to transport or arrival at the hospital when this procedure is followed.

Purpose:

The purpose of this policy is to allow for discontinuation of pre-hospital resuscitation after the delivery of adequate and appropriate ALS therapy.

Procedure:

Discontinuation of CPR and ALS intervention may be implemented prior to contact with Medical Control if ALL of the following criteria have been met:

 Adequate CPR has been administered.  Airway has been successfully managed with verification of device placement. (end tidal waveform capnography is preferred) Acceptable management techniques include orotracheal intubation, nasotracheal intubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy.  IV or IO access has been achieved.  Persistent asystole or Pulseless Electrical Activity (PEA) is present and no reversible causes are identified.  Minimum of 3 separate doses of 1:10,000 Epinephrine. Given every 3-5 minutes apart.  EMS transport personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate.

If all of the above criteria are met and discontinuation of pre-hospital resuscitation is possibly indicated or desired, contact Medical Control.

The Deceased Subjects Policy should be followed.

Document all patient care and interactions with the patient’s family, personal physician, medical examiner, law enforcement, and medical control in the EMS patient care report (PCR).

SSM EMS Policy 20162010 SSM EMS Policy Do Not Resuscitate (DNR) Order

Policy:

Any patient presenting to any component of the EMS system with a completed Missouri Do Not Resuscitate (DNR) form (purple form) shall have the form honored and treatment withheld in the event of cardiac arrest.

Purpose:

To honor the terminal wishes of the patient and to prevent the initiation of unwanted resuscitation.

Procedure:

When confronted with a cardiac arrest patient, the Original Missouri DNR form (purple form - not a copy) must be present in order to honor the DNR request and withhold treatment.

DNR requests may also be overridden by the patient, the patient’s agent, or if the patient’s primary physician is on-scene.

If other situations are encountered, begin resuscitation based on appropriate protocol(s) and contact Medical Control immediately. Examples:  Living wills or other documents (signed by physician and the patient) indicating the patients desire to withhold treatment.  If patient’s agent (family members, Power of Attorney, or legal guardian) are present and ask that resuscitative efforts be withheld in the absence of a DNR.

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SSM EMS Policy 2016 SSM EMS Policy Disposition of Patients and Patient Instructions

This policy applies to all credential levels.

Mentally capable patients maintain the right to refuse care and/or transport. If unsure, contact Medical Control. Medical Control may not order a patient who is capable to be transported but may be able to talk with the patient directly and convince him or her to seek appropriate treatment or transport. Patients who are not capable at the time of the EMS encounter and/or present a danger to themselves or others shall be transported to a local emergency department for mental health evaluation, or to an approved alternative destination. Providers should make every effort to transport patients with their consent, regardless of capacity, however transport of incapacitated individuals may occur without their consent as necessary. Contact Law Enforcement for assistance with transporting patients without their consent. Disagreement with the provider does not itself constitute lack of capacity.

All patients refusing service shall be informed of the availability of service and:

Offered treatment and transport in a non-confrontational, polite manner, Advise to call 911 for emergency service if condition changes/worsens, Advise that the patient(s) accept full responsibility for their actions. Patients are considered to be capable of refusing care if they do not endorse suicidal or homicidal ideation, are oriented to person, place and time (or to their baseline mental status in a nursing home), and can express understanding of the risks of refusal.

The use of alcohol or other drugs should not be used solely as a criterion for rendering a person incapable of making a medical decision. Rather, the circumstances of the event should be taken into account. For example, the patient who has used alcohol or other drugs with a potential for head trauma and altered mental status will require transport based on implied consent whereas the substance-using patient in their home with no evidence of trauma who meets the capacity criteria listed above may be capable of making a medical decision.

Documentation:

In the PCR narrative, describe the patient encounter, VITAL SIGNS, and advice given. Use the "Refusal of Care” procedure in the call reporting system to document that the patient is alert and oriented to person, place, and time, and that the patient understands given instructions. Have the patient sign the AMA form, have a third party witness the signature, and give a copy to the patient. If not possible, document the reason why this was not accomplished (patient refused to wait on paramedic resource, patient refused to sign, etc.) Complete the “Refusal of Care” Procedure in the electronic call report Patients should receive the appropriate pre-printed “Patient Instructions” form (see appendix) EMS personnel shall not discuss cost, system status/unit availability, or any other non-clinical subject in regards to a patient’s decision to accept or decline treatment and/or transport.

SSM EMS Policy 2016 SSM EMS Policy Documentation of the Patient Care Report (PCR)

POLICY:

All entities under SSM Medical Direction must comply with 19 CSR 30-40.375 Uniform Data Collection System and Ambulance Reporting Requirements for Ambulance Services.

PURPOSE:

This rule provides the requirements for an ambulance service to report certain information on each ambulance report and to submit the data to the MO Bureau of EMS.

PROCEDURE:

For every patient contact, the following describes the minimum required documentation. Each ambulance report shall include, but not be limited to, the following information: run report number; date of run; ambulance state of pickup, pickup service number, vehicle identification. Run to scene: type of run from scene, times dispatched, en route, arrive scene depart scene and arrive destination; place of incident; patient destination, place of incident; patient destination; personnel license numbers; systolic blood pressure; respiratory rate: scene, and arrive destination; place of incident; patient destination; personnel license numbers; systolic blood pressure; respiratory rate; Glasgow coma score; protective equipment used factors affecting emergency medical services treatment authorization; trauma assessments; cause of injury; illness assessment and destination determination, patient name, address, date of birth, race and sex; and treatment administrated.

The ambulance service shall keep a copy of this information for at least 5 years.

AUTHORITY: sections 190.175 and 190.185

SSM EMS Policy 2016 SSM EMS Policy Documentation with Multiple Providers

Purpose:

Provide world class patient care to the citizens of the Fire/EMS agencies that serve under SSM Medical Control.

Provide a consistent method for documenting patient care encounters that include multiple providers, particularly when a private transport unit is involved.

Policy:

All providers involved in the patient care activity are responsible for ensuring accurate and complete patient care documentation. The lead provider (listed as “primary attendant”) on the PCR is ultimately responsible for the report, however ALL providers should read the entire report once all documentation is complete to ensure accuracy.

In the situation where all providers are present during the completion of the documentation, the care team may coordinate the recording of their participation and care, and a single provider may document the patient care encounter with review by all care providers.

In the situation where all providers are not present during the completion of the documentation (for example, a paramedic provided some patient care on-scene but did not accompany the crew to the hospital the following shall be accomplished:

The paramedic will complete a PCR to include patient name and demographics.

The primary transport unit will complete a full PCR to include patient name, demographics, narrative, all procedures and care provided by all providers on the call.

In the case of a patient in whom follow-up is performed by a paramedic after the call, or specific assessment is performed, this care shall be documented by the paramedic. An addendum will be added to the PCR. If there is any dispute over documentation, the first attempt to reconcile will be accomplished via conversation between the Medical Officer and the primary provider.

Corrections will be placed in an addendum. If the dispute cannot be resolved in this manner, the SSM Medical Director shall be contacted for mediation.

SSM EMS Policy 2016 SSM EMS Policy EMS Documentation and Data Quality

Policy:

The complete EMS documentation associated with an EMS event’s service delivery and patient care shall be electronically recorded into a Patient Care Report (PCR) within 24 hours of the completion of the EMS event with an average EMS Validation Score of 95%.

Purpose:

The purpose of this policy is to:  Promote timely and complete EMS documentation.  Promote quality documentation that can be used to evaluate and improve EMS service delivery, personnel performance, and patient care to the county’s citizens.  Promote quality documentation that will decrease EMS legal and risk management liability. Provide a means for continuous evaluation to assure policy compliance.

Definition: The EMS documentation of a Patient Care Report (PCR) is based on the appropriate and complete documentation of the EMS data elements as required and defined within the Missouri EMS Standards (www.NEMSIS.org). Since each EMS event and/or patient scenario is unique, ALL of the data elements relevant to that EMS event and/or patient scenario should be completed.

The EMS Validation Score is calculated on each EMS PCR as it is electronically processed into the Missouri Ambulance Reporting System (MARS). Data Validatoni Scores are provided within MARS and EMS Toolkit Reports. The best possible score is a 100 (one hundred) and with each data quality error a point is taken away to the data validation score.

A complete Patient Care Report (PCR) must contain the following information (as it relates to each EMS event and/or patient):  Service delivery and Crew information regarding the EMS Agency’s response  Dispatch information regarding the dispatch complaint, and EMD card number (if available)  Patient care provided prior to EMS arrival  Patient Assessment as required by each specific complaint based protocol  Past medical history, medications, allergies, and DNR/MOST status  Trauma and Cardiac Arrest information if relevant to the EMS event or patient  All times related to the event  All procedures and their associated time  All medications administered with their associated time  Disposition and/or transport information  Communication with medical control  Appropriate Signatures (written and/or electronic)

SSM EMS Policy 2016 SSM EMS Policy Documentation of Vital Signs

Policy:

Every patient encounter by EMS shall be documented. Vital signs are a key component in the evaluation of any patient and a complete set of vital signs is to be documented in the patient care report (PCR) for any patient who receives any assessment component.

Purpose:

To ensure:  Objective evaluation of every patient’s general clinical status  Documentation of a complete set of vital signs

Procedure:

An initial complete set of vital signs includes:  Pulse rate  Systolic AND diastolic blood pressure (cap refill may be substituted in children < 3)  Respiratory rate  Pain / severity (when appropriate to patient complaint)  GCS for Injured Patients

When no ALS treatment is provided, palpated blood pressures are acceptable for REPEAT vital signs. Based on patient condition, complaint, and protocol used, vital signs may also include: Pulse Oximetry, Temperature, End Tidal CO2, Breath Sounds, Level of Response.

If the patient refuses evaluation, an assessment of capacity and a patient disposition form must also be completed. In addition, providers should record any vital signs that the patient or situation allows (e.g. a respiratory rate may be obtained by observation alone), and include an explanation of the clinical situation and refusal in the PCR narrative.

When any components of vital signs were obtained using the cardiac monitor, the data should be exported electronically to the PCR. Where values are inconsistent with manually obtained values, values may be appropriately edited to reflect the manually obtained values.

Document situations that preclude the evaluation of a complete set of vital signs. Generally, children > 3 years of age should have a BP measured, and cap refill measured for < 3 years of age. For young children, the need for BP measurement should be determined on a case by-case basis considering the provider’s rapport with the child and the child’s clinical condition. Blood pressure measurement is not required for all patients, but should be measured if possible, especially in critically ill patients in whom blood pressure measurement may guide treatment decisions. Record the time vital signs were obtained; any abnormal vital sign should be repeated and monitored closely.

SSM EMS Policy 2016 SSM EMS Policy EMS Back in Service Time

Policy:

All EMS Units transporting a patient to a medical facility shall transfer the care of the patient and complete all required operational tasks to be back in service for the next potential EMS event within 30 minutes of arrival to the medical facility, 90% of the time.

Definition:

The EMS Back in Service Time is defined as the time interval beginning with the time the transporting EMS Unit arrives at the medical facility destination and ending with the time the EMS Unit checks back in service and available for the next EMS event.

Purpose:

The purpose of this policy is to:  Assure that the care of each EMS patient transported to a medical facility is transferred to the medical facility staff in a timely manner.  Assure that the EMS unit is cleaned, disinfected, restocked, and available for the next EMS event in a timely manner.  Assure that the EMS patient care report (PCR) is completed and left with the receiving medical facility (This requirement may be waived under emergency or low system resource conditions when approved by the facility at the request of a chief medical officer. Where this occurs it should be documented in the subsequent patient care report).  Provide quality EMS service and patient care to the county’s citizens.  Provide a means for continuous evaluation to assure policy compliance.

Procedure:

The following procedures shall be implemented to assure policy compliance:

1. The EMS Unit’s priority upon arrival at the medical facility will be to transfer the care of the patient to medical facility staff as soon as possible. 2. EMS personnel will provide a verbal patient report on to the receiving medical facility staff. 3. The EMS Unit will be cleaned, disinfected, and restocked (if necessary) during the EMS Back in Service Time interval. 4. Any EMS Back in Service Time delay resulting in a prolonged EMS Back in Service Time will be documented in Patient Care Report (PCR) as an “EMS Turn-Around Delay”. defined in NEMSIS Standards Document. 5. All EMS Turn-Around Delays will be reviewed regularly within the SSM Medical Direction QI/QA process.

SSM EMS Policy 2016 SSM EMS Policy EMS Dispatch Center Time

Policy:

The EMS Dispatch Center Time will be less than 90 seconds, 90% of the time, for all events identified and classified as an emergent or hot (with lights and siren) response.

Definition:

The EMS Dispatch Center Time is defined as the time interval beginning with the time the initial 911 phone call rings at the 911 Communications Center requesting emergency medical services and ending with the dispatch time of the EMS Unit responding to the event.

Purpose:

The purpose of this policy is to:

 Provide the safest and most appropriate level of response to all EMS events within the EMS System.  Provide a timely and reliable response for all EMS events within the EMS System.  Provide quality EMS service and patient care to the EMS services under SSM Medical Direction.

Procedure:

Any EMS Dispatch Center Time delays resulting in a prolonged EMS Dispatch Center Time for emergent hot (with lights and sirens) events will be documented in Patient Care Report (PCR) as an “EMS Dispatch Delay” as required and defined in NEMSIS.org

EMS Dispatch Delays will be reviewed regularly within the SSM Medical Direction QA/QI.

SSM EMS Policy 2016 SSM EMS Policy EMS Wheels Rolling (Turn-Out) Time

Policy:

The EMS Wheels Rolling (Turn-out) Time will be less than 90 seconds, 90% of the time, for all events identified and classified as an emergent or hot (with lights and siren) response.

Definition:

The EMS Wheels Rolling (Turn-out) Time is defined as the time interval beginning with the time the EMS Dispatch Center notifies an EMS Unit to respond to a specific EMS event and ending with the time the EMS Unit is moving en route to the scene of the event.

Purpose:

The purpose of this policy is to:  Provide a timely and reliable response for all EMS events within the EMS System.  Provide quality EMS service and patient care to all citizens.  Provide a means for continuous evaluation to assure policy compliance.

Procedure:

The following procedures shall be implemented to assure policy compliance:

 The EMS Unit Wheels Rolling (Turn-out) time will be less than 90 seconds from time of dispatch, 90% of the time. If a unit fails to check en route within :59 (mm:ss), the next available EMS unit will be dispatched.

 Any EMS Wheels Rolling (Turn-out) Time delay resulting in a prolonged EMS Response Time for emergent hot (with lights and sirens) events will be documented in Patient Care Report (PCR) as an “EMS Response Delay". All EMS Response Delays will be reviewed regularly within the SSM Medical Direction.

SSM EMS Policy 2016 SSM EMS Policy Emergency Medical Dispatch

Policy:

 Persons calling for emergency assistance will never be required to speak with more than two persons to request emergency medical assistance.

 Each EMS unit shall remain in the response zone assigned by CAD. To avoid dispatch errors, movement outside of this area must be directed by or reported to the communications center.

 Emergency Medical Units will be dispatched by EMD’s in accordance to the standards developed by the Medical Director and the Emergency Medical Dispatch Protocols.

 Emergency Medical Units will initially respond emergency (“hot”) to all requests. As more information becomes available, from the telecommunications center or on scene medical responders, the mode of response may downgraded to non-emergency (“cold”). A non-emergency response is appropriate for alpha and omega level responses as soon as this can be established.

Purpose:

The purpose of this policy is to:  Provide quality patient care and EMS service to the citizens of the districts under SSM Medical Control.  Develop a uniform level of response for the EMS System.  Provide a means for continuous quality improvement feedback.  Provide for the safest and most appropriate level of response to the patient(s).

Procedure:

Emergency Medical Units dispatched for cold response will not upgrade to a hot response unless:

1. Public Safety personnel on-scene request a code 3 response. 2. Telecommunicators determine that the patient’s condition has changed, and requests you to upgrade to a code 3 response.

An ambulance may divert from a cold/non-emergency call to a higher priority call and then:

1. The diverting ambulance must notify the telecommunicator of their diversion to the higher priority call. 2. The diverting ambulance ensures that an ambulance is dispatched to the original call.

An ambulance may divert from one emergency call to another emergency call if:

1. The other call is clearly of higher priority (e.g., Echo vs. Code 3) – or -- 2. The EMS unit comes upon what appears to be a higher priority call (e.g., en route to a Code 3 call and comes upon an MVC with high potential for trauma alert/one patients)

An ambulance may by-pass what appears to be a lower priority situation and continue to the originally assigned call. The communications center should be notified so that another EMS resource may be assigned to the lower priority situation.

SSM EMS Policy 2016 SSM EMS Policy Equipment Failure

Policy:

Purpose:

To address and minimize the failure of equipment integral to patient care or mechanical failure of a transport vehicle. Each agency shall provide a daily check sheet in order to test biomedical equipment and vehicles to minimize the risk of such failures.

Procedure:

1. As soon as the failure is recognized, contact the appropriate emergency communications center, advise them of the failure, and have the nearest appropriate EMS resource dispatched. This may be a supervisor, an ambulance, or some other resource, depending upon patient need.

2. Based on the condition of the patient, advise the communications center to send the resource either emergency traffic or non-emergency traffic.

3. Closely monitor and treat the patient to the best of your ability with the remaining functional equipment.

4. Except in unusual circumstances, the original attending provider should continue to provide for the patient until arrival at the hospital, regardless of which unit is actually transporting the patient.

5. While it is appropriate to notify supervisory personnel of the failure at the conclusion of patient care activities, care and transport should not be delayed while awaiting the arrival of a supervisor (unless the supervisor is responding as the nearest unit based on #1 above).

6. An incident report should be completed as soon as practical after the failure. In all cases, this form shall be completed prior to the end of the tour of duty of the personnel involved. A copy of the incident report should accompany the equipment for inspection.

7. All equipment associated with the failure shall be gathered and secured for inspection. This includes all cables, electrodes, tubing, masks, or any other equipment associated with the failure. This medical equipment shall not be utilized in patient care activity until written clearance to do so is provided by the appropriate authority. Accessories such as those mentioned above should be left attached to the failed equipment in the manner that they were attached at the time failure was noted.

SSM EMS Policy 2016 SSM EMS Policy Hospital Diversion

Policy:

St. Louis area hospitals have agreed that diversion status will only be used if the facility is experiencing a “unique situation” which is inhibiting their ability to provide any patient care. This could include total power failures, violent acts, acts of nature, no physical access to the facility, etc. An alternate facility should be found for the patient.

Purpose:

To establish a protocol to be utilized in instances when capacity has been exceeded and there is assurance that all reasonable options to safely accommodate patients have been explored.

Procedure:

Patient transport request: We will honor all patient requests to be transported to the hospital of their choice. If a hospital has expressed a “diversion status”, the Paramedic shall thoroughly* explain the details to the patient. *Thoroughly: means to explain that the facility is experiencing a “unique situation” and they are unable to accept any patients at this time. Time Critical Patients: Unstable patients will be transported to the closest facility capable of stabilizing the patient following state guidelines for time critical diagnosis. Trauma Patients: Transport these patients to the appropriate trauma center. If you encounter a problem at a facility contact your EMS Chief Medical Officer or SSM Medical Control. Patient Condition Change: When transporting a patient, and patient has requested a specific facility. We will honor that request. If that patient’s condition becomes critical and the Paramedic feels that the condition is critical, you may make the decision to transport to the nearest facility. Contact the receiving hospital and inform of the critical change of destination.

SSM EMS Policy 2016 SSM EMS Policy Interfacility Transfers

Policy:

To provide guidance regarding transporting a patient from a medical facility to another medical facility that requires Advanced Life Support care during transport and the facility does not send a registered nurse to attend the patient.

Purpose:

In general, SSM EMS providers should only perform interfacility transfers for time-critical conditions, including those patients who meet specialty destination center criteria who are not already at an appropriate specialty receiving center: Trauma, Stroke, STEMI, Post-Cardiac Arrest, and Pediatrics.

Should a SSM EMS crew be contacted regarding an interfacility transfer for a non-time- critical patient, the crew should contact their Chief Medical Officer for guidance regarding how to proceed.

Procedure:

1. The transporting paramedic may maintain any infusion approved by the SSM Medical Director for interfacility transport by an EMT-Paramedic provided: a. The technician is familiar with the medication being infused. b. The medication is being regulated by an IV pump while en route to the new medical facility. c. The patient has stable vital signs prior to departure from the facility.

2. The transporting paramedic should ensure that all appropriate documentation accompanies the patient.

3. While in transit to the new facility, all appropriate standing orders shall remain in place.

4. If the patient deteriorates, the transferring facility should be notified via radio or cellular phone.

5. If additional ALS orders are needed, the receiving facility should be contacted to issue those orders if the receiving hospital is inside of Saint Louis County. If the receiving facility is outside of Saint Louis County, the transferring facility should be contacted for ALS orders.

SSM EMS Policy 2016 SSM EMS Policy Non- Paramedic Transport of Patients

Policy:

 A Paramedic resource will be dispatched to every request for EMS service.  For the purposes of this policy, “Paramedic” refers to a Missouri Licensed Paramedic with no current restrictions on their clinical practice.  At least one Paramedic will be on-board the ambulance during transport of all patients unless natural disaster or other exceptions as approved by policy or the Medical Director.  The provider with the highest level of SSM EMS System Credential on scene shall conduct a detailed physical assessment and subjective interview with the patient to determine his or her chief complaint and level of distress. If this provider determines that the patient is stable and ALL patient care needs can be managed by a provider with a lower level credential, patient care may be transferred to a technician of lower certification for care while in en-route to the hospital. All personnel are encouraged to participate in patient care while on-scene, regardless of who “attends” with the patient while en-route to the hospital.  The determination of who attends should be based upon the patient’s immediate treatment needs and any reasonably anticipated treatment needs while en-route to the hospital. The highest-credentialed provider on scene retains the right to make the decision to personally attend to any patient transported based on his or her impression of the patient’s clinical condition or needs.  The paramedic performing the paramedic assessment must document the findings of that assessment. Other documentation may be completed by the transporting provider. As with all documentation, both all providers are responsible for the content of the report.

The care of the following patients cannot be transferred to a lower level credential (i.e. to an EMT- B from an EMT-P) :

1. Any patient who requires or might reasonably require additional or ongoing medications, procedures and/or monitoring beyond the scope of practice of the lower credentialed provider. This includes any critically ill or unstable patient as advanced airway management may be required in any decompensating patient. EMT-Basic and providers may be credentialed to perform some but not all airway management, and medications associated with airway management are limited to Paramedic scope of practice by the SSM Medical Direction.

2. Any patient for whom ALL EMS providers on scene do not agree can be safely transported without a Paramedic in attendance in the patient care compartment. As a general rule, if providers are questioning who should attend the patient, the paramedic should attend the patient.

3. Any patient suffering from chest pain of suspected cardiac origin, cardiac arrhythmia, moderate- to-severe respiratory distress, multiple trauma, or imminent childbirth.

4. Post-ictal seizure patients due to the possibility of a re-occurrence of a seizure.

SSM EMS Policy 2016 SSM EMS Policy Physician on Scene

Policy:

The medical direction of pre-hospital care at the scene of an emergency is the responsibility of those most appropriately trained in providing such care. All care should be provided within the rules and regulations of the state of Missouri.

Purpose:

 To identify a chain of command to allow field personnel to adequately care for the patient  To assure the patient receives the maximum benefit from pre-hospital care  To minimize the liability of the EMS system as well as any on-scene physician

Procedure:

1. When a non medical-control physician offers assistance to EMS or a patient is being attended to by a physician with whom they do not have an ongoing patient relationship, EMS personnel must provide the On-Scene Physician Form to the physician. All requisite documentation must be verified and should the physician wish to continue providing medical assistance to EMS and the patient, the physician must be approved by on-line medical control as soon as possible with consideration of the clinical situation.

2. When a patient is being attended to by a physician with whom they have an ongoing patient- provider relationship, EMS personnel may follow orders given by the physician if the orders conform to current SSM EMS protocols, the physician agrees to the requirements presented on the “On-Scene Physician” form, and if the physician signs the Patient Care Report. Notify medical control at the earliest opportunity.

3. EMS personnel may accept orders from a patient’s physician over the phone with the approval of medical control. The paramedic should obtain the specific order and the physician’s name and phone number for relay to medical control so that medical control can discuss any concerns with the physician directly. For the purposes of this policy, a physician may be considered “on scene” and therefore able to take medico-legal responsibility for the patient (and therefore issue orders) if contact is made with the physician by telephone or other “live” but remote two-way communication method. For the purposes of this policy a physician does not have to be physically present to be considered “on scene.”

4. Orders received from an authorized (as determined by this policy) physician may be followed, even if they conflict with existing local protocols, provided the orders encompass skills and/or medications approved by both the SSM EMS Medical Director and for a provider’s credential level. Under no circumstances shall EMS personnel perform procedures or give medications that are outside their scope of practice and/or credential as per the SSM EMS Medical Director.

SSM EMS Policy 2016 SSM EMS Policy Poison Center

Policy:

The Missouri State Poison Center may be utilized by the 911 centers and the responding EMS services to obtain assistance with the pre-hospital triage and treatment of patients who have a potential or actual poisoning.

Purpose: The purpose of this policy is to:  Improve the care of patients with poisonings, envenomations, and environmental/biochemical terrorism exposures in the pre-hospital setting.  Provide for the most timely and appropriate level of care to the patient, including the decision to transport or treat on the scene.  Integrate the State Poison Center into the pre-hospital response for hazardous materials and biochemical terrorism responses

Procedure: 1. The 911 call center will identify and if EMD capable, complete key questions for the Overdose / Poisoning, Animal Bites/Attacks, or Carbon Monoxide/Inhalation/HazMat emergency medical dispatch complaints and dispatch the appropriate EMS services and/or directly contact the State Poison Center for consultation. 2. If no immediate life threat or need for transport is identified, EMS personnel may conference the patient/caller with the Poison Center Specialist at 314-268-4195. If possible, dispatch personnel should remain on the line during conference evaluation. 3. The Poison Center Specialist will evaluate the exposure and make recommendations regarding the need for on-site treatment and/or hospital transport in a timely manner. If dispatch personnel are not on-line, the Specialist will re-contact the 911 center and communicate these recommendations. 4. If the patient is determined to need EMS transport, the poison center Specialist will contact the receiving hospital and provide information regarding the poisoning, including treatment recommendations. EMS may contact medical control for further instructions or to discuss transport options. 5. If the patient is determined not to require EMS transport, personnel will give the phone number of the patient/caller to the Poison Center Specialist. The Specialist will initiate a minimum of one follow-up call to the patient/caller to determine the status of patient. 6. Minimal information that should be obtained from the patient for the poison center includes: ● Name and age of patient ● Substance(s) involved ● Time of exposure ● Any treatment given ● Signs and symptoms 7. Minimal information which should be provided to the Poison Center for mass poisonings, including biochemical terrorism and HazMat, includes: ● Substance(s) involved ● Time of exposure ● Signs and symptoms ● Any treatment given

SSM EMS Policy 2016 SSM EMS Policy Practitioner Disciplinary Policy

Policy: The SSM EMS Medical Direction, a practitioner’s right to practice medicine is based on extension of the Medical Director’s license to practice medicine. For the purposes of this procedure, a “practitioner” is any individual practicing under the SSM EMS Medical Director at the level of EMT-B or higher level of certification. If, in the opinion of the Medical Director, an action (or failure to act) on the part of a practitioner is of such a nature that the action or failure to act is inconsistent with, or a violation of, these procedures, or the practice standard generally accepted in the medical community, the actions described below shall occur, pursuant to the provisions of 19 CSR 30-40.303

1. The practitioner will be notified in writing of the issues/concerns that merit attention by the Medical Director. Notwithstanding this written-notice provision, the provisions of 2 and 3, below, and based on the severity and nature of the act (or failure to act), the Medical Director or his designee may suspend a practitioner’s right to practice upon receipt of information sufficient in the judgment of the Medical or his designee Director to support immediate suspension in the interests of patient safety. If the Medical Director or his designee invokes an immediate suspension, this shall be followed by written notice within three (3) working days of such immediate suspension.

2. A written explanation by the individual explaining the incident shall be presented to the Medical Director within three (3) working days of receipt of the Medical Director’s issues/concerns. If no written explanation of the incident is sent to the Medical Director by that deadline, the Medical Director may base his decision upon such information that is available to him/her as of that deadline.

3. The Medical Director or the individual may request a second meeting to further discuss the issues/concerns. If this option is exercised, the meeting shall occur within five (5) working days of receipt of the request.

4. After reviewing all materials, the Medical Director will issue a disposition of the matter. The Medical Director may exercise one or more of the following options: a. No action taken / matter resolved b. Remediation training c. Warning d. Require to precept at the approved level again e. Temporary suspension of all practice privileges or suspension of specific practice privileges f. Permanent Suspension of practice privileges

Any suspension of practice privileges will extend to all jurisdictions where the practitioner’s right to practice relies on the extension of the SSM EMS System Medical Director’s license to practice medicine.

SSM EMS Policy 2016 SSM EMS Policy Certification / Licensure Requirements

Policy:

All personnel operating under SSM Medical Direction must maintain the following certification / licensure requirements.

Purpose:

To outline the minimum certification / licensure requirements to treat and transport sick and injured patients under SSM Medical Direction.

Procedure:

All EMT-Basic (EMT) and EMT-Paramedic (EMT-P) personnel must maintain a valid Missouri License within their scope of practice.

All EMT and EMT-P personnel must maintain a current Professional Healthcare Basic Life Support (BLS) Provider Card and a current Pre-Hospital Trauma Life Support (PHTLS) or International Trauma Life Support (ITLS) card.

In addition to the above, Paramedics must also maintain current certifications in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

The entity that provides the classes listed above must be approved by SSM Medical Direction and your Departmental Policy.

All personnel must participate in an annual skills evaluation. An annual skills evaluation sheet must be signed by the Medical Director and maintained on file with the EMS Education Manager.

EMT-B’s will be skill tested yearly and will include BLS, immobilization, BIAD insertion, and other skills deemed necessary by SSM Medical Direction.

EMT-P’s, will be skill tested yearly and will include Airway, IV/IO/IM/IN, Cardiac Monitoring and other skills deemed necessary by SSM Medical Direction.

SSM EMS Policy 2016 Appendix Section

Section Table of Contents

Approved Medical Abbreviations Sample DNR Form On-Scene Physician Form Patient Discharge Instructions Burns Resources SSM EMS Appendix Section

SSM EMS Appendix 2016 Approved Medical Abbreviations

The following is a list of approved medical abbreviations. In general, the use of abbreviations should be limited to this list.

A&O x 3 - alert and oriented to person, place and time A&O x 4 - alert and oriented to person, place, time and event A-FIB - atrial fibrillation AAA - abdominal aortic aneurysm ABC - airway, breathing, circulation ABD - abdomen (abdominal) ACLS - advanced cardiac life support AKA - above the knee amputation ALS - advanced life support AMA - against medical advice AMS - altered mental status AMT - amount APPROX - approximately ASA - aspirin ASSOC - associated

BG - blood glucose BILAT - bilateral BKA - below the knee amputation BLS - basic life support BM - bowel movement BP - blood pressure BS - breath sounds BVM - bag-valve-mask

C-SECTION - caesarean section C-SPINE - cervical spine C/O - complaint of (complains of) CA - cancer CABG - coronary artery bypass graft CAD - coronary artery disease CATH - catheter CC - chief complaint CEPH - cephalic CHF - congestive heart failure CNS - central nervous system COPD - chronic obstructive pulmonary disease CP - chest pain

CPR - cardiopulmonary resuscitation CSF - cerebrospinal fluid CT - cat scan CVA - cerebrovascular accident (stroke)

Appendix 2016 Approved Medical Abbreviations

D5W - 5% dextrose in water DKA - diabetic ketoacidosis DNR - do not resuscitate DOA - dead on arrival DT - delirium tremens Dx - diagnosis

ECG - electrocardiogram EEG - electroencephelogram ET - endotracheal ETOH - ethanol (alcohol) ETT - endotracheal tube EXT - external (extension)

FB - foreign body FLEX - flexion Fx - fracture g - gram(s) GI - gastrointestinal GSW - gunshot wound gtts - drops GU - gastrourinary GYN - gynecology (gynecological)

H/A - headache HEENT - head, eyes, ears, nose, throat HR - heart rate (hour) HTN - hypertension Hx - history

ICP - intracranial pressure ICU - intensive care unit IM - intramuscular IV - intravenous

JVD - jugular vein distension kg - kilogram KVO - keep vein open

Appendix 2016 Approved Medical Abbreviations

L-SPINE - lumbar spine L/S-SPINE - lumbarsacral spine L&D - labor and delivery LAT - lateral lb - pound LLQ - left lower quadrant LMP - last mestrual period LOC - level of consciousness (loss of consciousness) LR - lactated ringers LUQ - left upper quadrant

MAST - military anti-shock trousers mcg - microgram(s) MED - medicine mg - milligram(s) MI - myocardial infarction (heart attack) min - minimum / minute MS - mental status MS - mental status change MSO4 - morphine MVC - motor vehicle crash

N/V - nausea/vomiting N/V/D - nausea/vomiting/diarrhea NAD - no apparant distress NC - nasal cannula NEB - nebulizer NKDA - no known drug allergies NRB - non-rebreather NS - normal saline NSR - normal sinus rhythm

OB/GYN - obstetrics/gynecology

PALP - palpation PAC - premature atrial contraction PE - pulmonary embolus PEARL - pupils equal and reactive to light PMHx - past medical history PO - orally PRB - partial rebreather PRN - as needed PT - patient PVC - premature ventricular contraction

Appendix 2016 Approved Medical Abbreviations

RLQ - right lower quadrant RUQ - right upper quadrant Rx - medicine RXN - reaction

S/P - status post SOB - shortness of breath SQ - subcutaneous ST - sinus tachycardia SVT - supraventricular tachycardia Sx - symptom SZ - seizure

T-SPINE - thoracic spine T - temperature TIA - transient ischemic attack TKO - to keep open (UHIHUVWR,9¶V- same as KVO) Tx - treatment

UOA - upon our arrival URI - upper respiratory infection UTI - urinary tract infection

VF - ventricular fibrillation VS - vital signs VT - ventricular tachycardia

WAP - wandering atrial pacemaker WNL - within normal limits

YO (YOA) - years old (years of age)

0RUƃ -male )RUƂ - female + - positive - - negative ? - questionable

Ȍ - psychiatric ~ - approximately > - greater than < - less than = - equal

Appendix 2016 Approved Medical Abbreviations

Ĺ - upper (increased) a - before p - after c-with s - without

¨ - change L-left R - right Ļ - lower (decreased) 1° - primary 2° - secondary

Appendix 2016 OUTSIDE THE HOSPITAL DO-NOT-RESUSCITATE (OHDNR) ORDER

I, ______, authorize emergency medical services personnel to (name) withhold or withdraw cardiopulmonary resuscitation from me in the event I suffer cardiac or respiratory arrest. Cardiac arrest means my heart stops beating and respiratory arrest means I stop breathing.

I understand that in the event that I suffer cardiac or respiratory arrest, this OHDNR order will take effect and no medical procedure to restart breathing or heart functioning will be instituted.

I understand this decision will not prevent me from obtaining other emergency medical care and medical interventions, such as intravenous fluids, oxygen or therapies other than cardiopulmonary resuscitation such as those deemed necessary to provide comfort care or to alleviate pain by any health care provider (e.g. paramedics) and/or medical care directed by a physician prior to my death.

I understand I may revoke this order at any time.

I give permission for this OHDNR order to be given to outside the hospital care providers (e.g. paramedics), doctors, nurses, or other health care personnel as necessary to implement this order.

I hereby agree to the “Outside The Hospital Do-Not-Resuscitate” (OHDNR) Order. Patient – Printed or Typed Name Date

Patient’s Signature or Patient Representative’s Signature Date

REVOCATION PROVISION

I hereby revoke the above declaration. Patient’s Signature or Patient Representative’s Signature Date

I AUTHORIZE EMERGENCY MEDICAL SERVICES PERSONNEL TO WITHHOLD OR WITHDRAW CARDIOPULMONARY RESUSCITATION FROM THE PATIENT IN THE EVENT OF CARDIAC OR RESPIRATORY ARREST. I affirm this order is the expressed wish of the patient/patient’s representative, medically appropriate and documented in the patient’s permanent medical record. Attending Physician’s Signature (Mandatory) Date

Attending Physician – Printed or Typed Name Attending Physician’s Attending Physician’s License No. Telephone No.

Address – Printed or Typed Facility or Agency Name

THIS OHDNR ORDER SHALL REMAIN WITH THE PATIENT WHEN TRANSFERRED OUTSIDE THE HEALTH CARE FACILITY. Emergency Medical Services personnel shall not comply with an outside the hospital do-not-resuscitate order when the patient or the patient’s representative expresses to such personnel in any manner, before or after the onset of a cardiac or respiratory arrest, the desire to be resuscitated or if the patient is or is believed to be pregnant.

Statutory citation 190.600-190.621 RSMo 9/07

Appendix 2016 On-Scene Physician Form

This EMS service would like to thank you for your effort and assistance. Please be advised that the EMS Professionals are operating under strict protocols and guidelines established by their medical director and the State of Missouri. As a licensed physician, you may assume medical care of the patient. In order to do so, you will need to:

1. 5HFHLYHDSSURYDOWRDVVXPHWKHSDWLHQW¶VPHGLFDOFDUHIURPWKH(06$JHQFLHV2QOLQH Medical Control physician. 2. Show proper identification including current Medical Board Registration/Licensure. 3. Accompany the patient to the hospital. 4. Carry out any interventions that do not conform to the EMS Agencies Protocols. EMS personnel cannot perform any interventions or administer medications that are not included in their protocols. 5. Sign all orders on the EMS Patient Care Report. 6. Assume all medico-OHJDOUHVSRQVLELOLW\IRUDOOSDWLHQWFDUHDFWLYLWLHVXQWLOWKHSDWLHQW¶VFDUHLV transferred to another physician at the destination hospital. 7. &RPSOHWHWKH³$VVXPSWLRQRI0HGLFDO&DUH´VHFWLRQRIWKLVIRUPEHORZ.

Assumption of Medical Care

I, ______, MD; License #: ______, (Please Print your Name Here) have assumed authority and responsibility for the medical care and patient management for

______. (,QVHUW3DWLHQW¶V1DPH+HUH)

I understand that I must accompany the patient to the Emergency Department. I further understand that all EMS personnel must follow Missouri EMS Rules and Regulations as well as SSM Medical Direction EMS Protocols.

______, MD Date: _____/_____/_____Time: ______AM/PM (Physician Signature Here)

______, EMS ______Witness (EMS Lead Crew Member Signature Here) (Witness Signature Here)

Appendix 2016 Patient Instructions UNIVERSAL INSTRUCTIONS: • YOU HAVE NOT RECEIVED A COMPLETE MEDICAL EVALUATION. SEE A PHYSICIAN AS SOON AS POSSIBLE.

• IF AT ANY TIME AFTER YOU HAVE TAKEN ANY MEDICATION, YOU HAVE TROUBLE BREATHING, START WHEEZING, GET HIVES OR A RASH, OR HAVE ANY UNEXPECTED REACTION, CALL 911 IMMEDIATELY.

• IF YOUR SYMPTOMS WORSEN AT ANY TIME, YOU SHOULD SEE YOUR DOCTOR, GO TO THE EMERGENCY DEPARTMENT OR CALL 911. ABDOMINAL PAIN: BACK PAIN: FEVER: • Abdominal pain is also called belly pain. Many • Apply heat to the painful area to help relieve pain. • Always take medications as directed. Tylenol and illnesses can cause abdominal pain and it is You may use a warm heating pad, whirlpool Ibuprofen can be taken at the same time. very difficult for EMS to identify the cause. bath, or warm, moist towels for 10 to 20 • If you are taking antibiotics, take them until they • Take your temperature every 4 hours. minutes every hour. are gone, not until you are feeling better. • Stay in bed as much as possible the first 24 • Drink extra liquids (1 glass of water, soft drink or hours. gatorade per hour of fever for an adult) Call or see a physician, go to the emergency • Begin normal activities when you can do them • If the temperature is above 103° F, it can be department, or call 911 immediately if: without causing pain. brought down by a sponge bath with room • Your pain gets worse or is now only in 1 area • When picking things up, bend at the hips and temperature water. Do not use cold water, a • You vomit (throw up) blood or find blood in knees. Never bend from the waist only. fan, or an alcohol bath. your bowel movement Call or see a physician, go to the emergency • Temperature should be taken every 4 hours . • You become dizzy or faint department, or call 911 immediately if: Call or see a physician, go to the emergency • Your abdomen becomes distended or • You have shooting pains into your buttocks, groin, department, or call 911 immediately if: swollen legs, or arms or the pain increases. • Temperature is greater than 101° F for 24 hours • You have a temperature over 100° F • You have trouble urinating or lose control of your • A child becomes less active or alert. • You have trouble passing urine stools or urine. • The Temperature does not come down with • You have trouble breathing • You have numbness or weakness in your legs, Acetaminophen (Tylenol) or Ibuprofen with the feet, arms, or hands. appropriate dose. HEAD INJURY: INSECT BITE/STING: RESPIRATORY DISTRESS: • Immediately after a blow to the head, nausea, • A bite or sting typically is a red lump which • Respiratory Distress is also known as shortness and vomiting may occur. may have a hole in the center. You may of breath or difficulty breathing. • Individuals who have sustained a head injury have pain, swelling and a rash. Severe stings • Causes of Respiratory Distress include reactions must be checked, and if necessary awakened, may cause a headache and an upset to pollen, dust, animals, molds, foods, drugs, every 2 hours for the first 24 hours. stomach (vomiting). infections, smoke, and respiratory conditions • Ice may be placed on the injured area to • Some individuals will have an allergic reaction to such as Asthma and COPD. If possible avoid decrease pain and swelling. a bite or sting. Difficulty breathing or chest any causes which produce respiratory distress. • Only drink clear liquids such as juices, soft drinks, pain is an emergency requiring medical care. • If you have seen a physician for this problem, take or water the first 12 hours after injury.. • Elevation of the injured area and ice (applied to all medication's as directed. • Acetaminophen (Tylenol) or Ibuprofen only may the area 10 to 20 minutes each hour) will Call or see a physician, go to the emergency be used for pain. decrease pain and swelling. department, or call 911 immediately if: Call or see a physician, go to the emergency • Diphenhydramine (Benadryl) may be used as • Temperature is greater than 101° F. department, or call 911 immediately if: directed to control itching and hives. • The cough, wheezing, or breathing difficulty • The injured person has persistent vomiting, is not Call or see a physician, go to the emergency becomes worse or does not improve even able to be awakened, has trouble walking or using department, or call 911 immediately if: when taking medications. an arm or leg, has a seizure, develops unequal • You develop any chest pain or difficulty breathing. • You have Chest Pain. pupils, has a clear or bloody fluid coming from the • The area becomes red, warm, tender, and • Sputum (spit) changes from clear to yellow, green, ears or nose, or has strange behavior. swollen beyond the area of the bite or sting. grey, or becomes bloody. • You develop a temperature above 101° F. • You are not able to perform normal activities. EXTREMITY INJURY: VOMITING/DIARRHEA: WOUND CARE: • Extremity Injuries may consist of cuts, scrapes, • Vomiting (throwing up) can be caused by many • Wounds include cuts, scrapes, bites, abrasions, bruises, sprains, or broken bones (fractures). things. It is common in children, but should or puncture wounds. • Apply ice on the injury for 15 to 20 minutes each be watched closely. • If the wound begins to bleed, apply pressure over hour for the first 1 to 2 days. • Diarrhea is most often caused by either a food the wound with a clean bandage and elevate • Elevate the extremity above the heart as possible reaction or infection. the wound above the heart for 5 to 10 minutes. for the first 48 hours to decrease pain and • Dehydration is the most serious problem • Unless instructed otherwise, clean the wound swelling. associated with vomiting or diarrhea. twice daily with soapy water, and keep the • Use the extremity as pain allows. • Drink clear liquids such as water, apple juice, soft wound dry. It is safe to take a shower but do Call or see a physician, go to the emergency drinks, or gatorade for the first 12 hours or not place the wound in bath or dish water. department, or call 911 immediately if: until things improve. Adults should drink 8 to • See a physician for a tetanus shot if it has been • Temperature is greater than 101° F. 12 glasses of fluids per day with diarrhea. 10 years or more since your last one. • The bruising, swelling, or pain gets worse despite Children should drink 1 cup of fluid for each Call or see a physician, go to the emergency the treatment listed above. loose bowel movement. department, or call 911 immediately if: • Any problems listed on the Wound Care Call or see a physician, go to the emergency • See the Extremity Injury instructions. instructions are noted. department, or call 911 immediately if: • Temperature is greater than 101° F. • You are unable to move the extremity or if • Temperature is greater than 101° F. • Bruising, swelling, or pain gets worse or bleeding numbness or tingling is noted. • Vomiting or Diarrhea lasts longer than 24 hours, is not controlled as directed above. • You are not improved in 24 to 48 hours or you are gets worse, or blood is noted. • Any signs of infection, such as redness, drainage not normal in 7 to 10 days. • You cannot keep fluids down or no urination is of yellow fluid or pus, red streaks extending noted in 8 hours. from the wound, or a bad smell is noted. Burns Resources Fluid Formula

Formula for Fluid Resuscitation of the Burn Patient (Also known as the Parkland Formula)

Pts Wt kg x %TBSA x 4.0cc LR infused over 24 hours with half given in the first 8 hours.

(For the equation, the abbreviations are: PW x TBSA x 4.0 cc )

EMS focuses on the care given during the 1st hour or several hours following the event. Thus the formula as adapted for EMS and the first 8 hours is:

PW x TBSA x 4.0 cc, divide by 2 to take this to the hourly rate, divide that solution by 8 and the equation becomes:

PW x TBSA x 4.0cc / 2 / 8 = total to be infused for each of the first 8 hours.

Another way to state the equation is to use: PW x TBSA x 0.25cc = total to be infused for each hour of the first 8 hours.

Example, 80 kg patient with 50 %TBSA x 0.25 cc = 1000 cc/hr.

Remember: Patient’s Weight in kg (2.2 lbs = 1.0 kg) example: 220 lbs adult = 100 kg

% TSBA = Rule of Nine Total Body Surface Area

Factor for the 1st hr. and each hr. for the 1st 8 hrs. = 0.25

(Reminder, if two IV’s are running, divide total amount to be infused each hr. by 2)

Critical Serious Minor (Red) (Yellow) (Green)

5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or requiring intubation < 5% TBSA 2nd/3rd Degree Burn Burns with Multiple Trauma for airway stabilization No inhalation injury, Not Intubated, Burns with definitive airway compromise Hypotension Normotensive (When reasonable accessible, transport to a GCS < 14 GCS>14 Burn Center) (When reasonable accessible, transport to either a (Transport to the Local Hospital) Level I Burn Center or a Trauma Center)

Appendix 2016