Bites and Envenomations

Home , Animal bite, Spider bite

Trauma Protocols 2009 M MS Allergic if there is and a complete Neck, Lung, Heart, Animal bite Human bite Snake bite (poisonous) Spider bite (poisonous) Insect sting / bite (bee,tick) wasp, ant, Infection risk Rabies risk Tetanus risk - kill a fellow, red on black - venom lack." and early in spring. Yes Differential es, chemotherapy, transplant patients. eurella multicoda). sk of Rabies exposure. roximal to wound. EMS transport ? tlesnake, copperhead, and water moccasin. Pain Control Protocol iddle shape on back). uidance (1-800-84-TOXIN). Notify Destination or ormal mouth bacteria. e reaction is noted initially but tissue necrosis at the few hours, muscular pain and severe abdominal pain Contact Medical Control Position patient supine Immobilize area or limb Universal Patient Care Protocol significant pain If there is allergic reactionReaction refer Protocol to Refer to M Protocol 49 No Rash, skin break, wound Pain, soft tissue swelling, redness Blood oozing from the biteEvidence wound of infection Shortness of breath, wheezing Allergic reaction, hives, itching Hypotension or shock Signs and Symptoms I P B M Bites and Envenomations Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OE transported Animal bites: MR EMT Document contact Pain Control Protocol EMT- I EMT- P Legend Coral snake bites are rare:Amount of Very envenomation little is pain variable,If but generally no very worse pain toxic. with or larger swelling, "Red snakes envenomation on is yellow unlikely. Medical Control Consider contacting the North Carolina Poison Control Center for g Abdomen, Back, and Neuro exam if systemic effects are noted may develop (spider is black with red hourglass onsite belly). of the bite developsEvidence over of the infection: next few swelling,Immunocompromised days redness, patients (brown drainage, are spider fever, at with red an f streaks increased p risk for infection: diabet Black Widow spider bites tend to be minimally painful,Brown but Recluse over spider a bites are minimally painful to painless. Littl Carnivore bites are much moreCat likely bites to may become progress infected toPoisonous and infection snakes all rapidly in have due this ri to area a are specific generally bacteria of (Past the pit viper family: rat Recommended Exam: Mental Status, Skin, Extremities (Location ofHuman injury), bites have higher infection rates than animal bites due to n Domestic vs. Wild Tetanus and Rabies risk Immunocompromised patient Time, location, size of bitePrevious / reaction sting to bite / sting Type of bite / sting Description or bring creature / photo with patient for identification with Animal Control Officer if not I P B M Pearls History Burns: Thermal

Critical Serious Minor (Red) (Yellow) (Green)

5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or < 5% TBSA 2nd/3rd Degree Burn Burns with Multiple Trauma requiring intubation for airway No inhalation injury, Not Intubated, Burns with definitive airway stabilization Normotensive compromise Hypotension or GCS < 14 GCS>14 (When reasonable accessible, (When reasonable accessible, (Transport to the Local Hospital)

transport to a Burn Center) transport to either a Level I Burn Protocols Trauma Center or a Trauma Center)

Remove Rings, Bracelets, and Cool Down the Wound with Normal other Constricting Items Saline

Airway Protocol Cover Burn with Dry sterile sheet or dressings Cover Burn with Dry sterile sheet or dressings

IV Normal Saline, IV Normal Saline, 2 large bore IVs, infuse total of 0.25 x kg infuse total of 0.25 x kg body wt. x % TBSA per body wt. x % TBSA per I I I hour for up to the first 8 I hour for Legend hours. up to the first 8 hrs. (More info below) MR (More info below) B EMT B I EMT- I I Pain Control Protocol P EMT- P P M Notify Destination or M M Medical Control M Contact Medical Control 1. The IV solution should be changed to Lactated Ringers if it is available. It is preferred over Normal Saline. Pearls 2. Formula example and a rule of thumb is; an 80 kg patient with 50% Burn patients are Trauma Patients, evaluate for multisystem trauma. TBSA will need 1000 cc of fluid per hour. Assure whatever has caused the burn, is no longer contacting the injury. (Stop the burning process!) Critical or Serious Burns Recommended Exam: Mental Status, HEENT, Neck, Heart, Lungs, > 5-15% total body surface area (TBSA); 2nd or 3rd degree burns, or rd Abdomen, Extremities, Back, and Neuro 3 degree burns > 5% TBSA for any age group, or Early intubation is required when the patient experiences significant circumferential burns of extremities, or inhalation injuries. electrical or lightning injuries, or Potential CO exposure should be treated with 100% oxygen. (For suspicion of abuse or neglect, or patients with the primary event is CO inhalation, transport to a inhalation injury, or hospital equipped with a hyperbaric chamber is indicated [when chemical burns, or reasonably accessible].) burns of face, hands, perineum, or feet, or Circumferential burns to extremities are dangerous due to potential any burn requiring hospitalization. vascular compromise secondary to soft tissue swelling. (These burns will require direct transport to a burn center, or transfer once Burn patients are prone to hypothermia - never apply ice or cool seen at a local facility where the patient can be stabilized with interventions burns, must maintain normal body temperature. such as airway management or pain relief if this is not available in the field or Evaluate the possibility of child abuse with children and burn injuries. the distance to a Burn Center is significant.) Protocol 50 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 Burns: Chemical and Electrical

History Signs and Symptoms Differential Type of exposure (heat, gas, chemical) Burns, pain, swelling Superficial (1st Degree) red and painful Inhalation injury Dizziness Partial Thickness (2nd Degree) blistering Time of Injury Loss of consciousness Full Thickness (3rd Degree) painless/charred or Past medical history and Medications Hypotension/shock leathery skin Other trauma Airway compromise/distress Thermal Loss of Consciousness singed facial or nasal hair Chemical Tetanus/Immunization status Hoarseness / wheezing Electrical Radiation Legend Universal Patient Care Protocol MR B EMT B P Cardiac Monitor P I EMT- I I P EMT- P P Eye Involvement? Continuous saline M Medical Control M flush in affected eye. Flush are with water or Normal Saline for 10-15 minutes Remove Rings, Bracelets, and other Constricting Items. Remove clothing or expose area Trauma Protocols Trauma Identify entry and exit sites, apply sterile dressings

Pain Control Protocol (IV only for Burn Patients) I I IV Protocol Normal Saline Bolus

Chemical and Electrical Burn Patients Must be Triaged using the Guidelines below and their care must conclude in the Thermal Burn Protocol

Critical Serious Minor (Red) (Yellow) (Green)

5-15% TBSA 2nd/3rd Degree Burn >15% TBSA 2nd/3rd Degree Burn < 5% TBSA 2nd/3rd Degree Burn Suspected Inhalation injury or requiring intubation Burns with Multiple Trauma No inhalation injury, Not Intubated, for airway stabilization Burns with definitive airway compromise Normotensive Hypotension or GCS < 14 (When reasonable accessible, transport to a GCS>14 (When reasonable accessible, transport to either a Burn Center) (Transport to the Local Hospital) Level I Burn Center or a Trauma Center) Pearls Chemical Pearls Electrical Refer to Decontamination Standard Procedure (Skill) WMD Do not contact the patient until you are certain the source of the electric Page shock has been disconnected. Certainly 0.9% NaCl Soln or Sterile Water is preferred, Attempt to locate contact points, (entry wound where the AC source however if it is not readily available, do not delay, use tap contacted the patient, an exit at the ground point) both sites will generally water for flushing the affected area or other immediate water be full thickness. sources. Flush the area as soon as possible with the Cardiac monitor, anticipate ventricular or atrial irregularity, to include V- cleanest readily available water or saline solution using tach, V-fib, heart blocks, etc. copious amounts of fluids. Attempt to identify the nature of the electrical source (AC vs DC), the amount of voltage and the amperage the patient may have been exposed to during the electrical shock. Protocol 51 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 Trauma Protocols 2009 MS I I P B B B B M Barotrauma Decompression sickness ilability of a hyperbaric chamber. Trauma Pre-existing medical problem Pressure injury (diving) Post-immersion syndrome Differential Pelvis, Back, Extremities, Skin, Neuro orsening over the next several hours. an increased chance of survival. ctims from areas of danger. if available for respiratory if Available CPAP Albuterol or other Beta- for respiratory distress based on symptoms Monitor and reassess Appropriate Protocol Protocol 52 Universal Patient Care Protocol distress 12-Lead ECG Consider IV Protocol Consider Agonist Spinal Immobilization Protocol Cardiac Monitor Pulse Oximetry Capnography Drowning Notify Destination or Contact Medical Control Unresponsive Mental status changes Decreased or absent vital signs Vomiting Coughing Apnea Stridor Wheezing Rhales I I Signs and Symptoms P B B B B M I P B M Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OE MR EMT EMT- I EMT- P Legend Medical Control With pressure injuries (decompression / barotrauma), consider transport to or ava All victims should be transportedDrowning for is evaluation a due leading to causeAllow potential of appropriately for death trained w among and would-be certified rescuers. rescuers to remove vi Have a high index ofWith suspicion cold for water possible no spinal timeSome injuries limit patients -- may resuscitate develop all. delayed respiratory These distress. patients have Recommended Exam: Trauma Survey, Head, Neck, Chest, Abdomen, Duration of immersion Temperature of water or possibility of hypothermia Possible trauma to C-spine Possible history of trauma ie: diving board Submersion in water regardless of depth I P B Pearls History M Trauma Protocols 2009 MS Abrasion Contusion Laceration Sprain Dislocation Fracture Amputation I Differential B M f injury. gh incidence of vascular compromise. immediately, so that the appropriate destination if available if life or limb threatening event ourniquet procedure and/or Protocol 53 Pain, swelling Deformity Altered sensation / motor function Diminished pulse / capillary refill Decreased extremity temperature Universal Patient Care Protocol Hemostatic Agent IV Protocol or if pain medication needed If amputation Clean amputated partpart Wrap in sterile dressing soakedsaline in and normal place in airPlace tight container container. on ice if available Wound care Control Hemorrhage with Pressure Splinting as required If hemorrhage can not bedirect controlled pressure by and is lifeconsider threatening T then Pain Control Protocol Signs and Symptoms Notify Destination or Contact Medical Control Extremity Trauma I B M I P B M Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OE MR EMT EMT- I EMT- P Legend Medical Control Lacerations must be evaluated for repair within 6 hours from the time o Hip dislocations and knee andUrgently elbow transport fracture any / injury dislocations withBlood have vascular loss a compromise. may hi be concealed or not apparent with extremity injuries. Peripheral neurovascular status is important In amputations, time is critical. Transport and notify medical control Recommended Exam: Mental Status, Extremity, Neuro can be determined. Wound contamination Medical history Medications Time of injury Open vs. closed wound / fracture Type of injury Mechanism: crush / penetrating / amputation I P B Pearls History M Trauma Protocols I P B M 2009 5 minutes MR Repeat every EMT EMT- I EMT- EMT- P EMT- Legend . Medical Control I P B M GCS > 8 Skull fractureSkull (Concussion, Brain injury Hemorrhage or Contusion, Laceration) hematoma Epidural hematoma Subdural hemorrhage Subarachnoid injury Spinal Abuse I M Differential No Yes Yes > 60 GCS < 8 Seizure? IV Protocol Blood Glucose Blood Monitor reassess and Isolated head trauma ? Protocol 54 Maintain Pulse > Ox 90% Universal Care Protocol Obtain and Record GCS and Record Obtain Can patientCan cough or speak? RUSHUVRQQHO¶VSURWHFWLRQSHUWKH5HVWUDLQW3URFHGXUH / Spinal Immobilization Protocol Immobilization Spinal BasicAirway ManeuversBVM with Notify Destination or Contact MCContact Notify Destination or Maintain EtCO235 between and 45 Alteredmental status Unconscious Respiratory/ failure distress Vomiting Majortraumatic mechanisminjury of Seizure Pain, swelling,Pain, bleeding I M Signs and Symptoms and Signs Head Trauma Head No No Yes < 60 I P B ) (if no IV (if Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS D50 consider Lidocaine if Available Adult Multiple Adult Maintain EtCO2 Airway Protocol Seizure Protocol Trauma Protocol Concussions are periods of confusion or LOC associated with trauma which mayhaveEMS arrives.Any resolvedby the time prolongedconfusionstatus abnormality mental or which does not returnto normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP. Intubation RSI/Drug-AssistedIn areas with shorttransporttimes, is not recommended for patients who are spontaneously breathing and who have oxygenthan90%withsupplemental saturations of greater oxygen. Hypotension usually indicatesunrelatedor shock injuryto the head and injury shouldbe aggressively treated. andThe most important item to monitor documentis achange level in the of consciousness. &RQVLGHU5HVWUDLQWVLIQHFHVVDU\IRUSDWLHQW¶VDQG LimitIV fluids unless is hypotensive. patient In the absence Capnography, of hyperventilatethepatient (adult: 20 breaths/min, child: 30, infant:35) only if ongoing evidence of brain herniation(blown decerebrate pupil, decorticateposturing, or or bradycardia) Increased intracranialpressure(ICP) may cause hypertension and bradycardia Response).(Cushing's Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro Abdomen, Extremities, Heart,Back, HEENT, Lungs, Status, RecommendedMental Exam: / rapidGCS < 12 consider transport air If Evidence for multi-trauma Loss of consciousness Bleeding Past medical history Medications Time of injury Mechanism vs. penetrating) (blunt Glucagon Glucagon Between 35Between and 45 Consider Naloxone If IntubationIf required, I Pearls History P B Trauma Protocols 2009 I P B M Fever(Infection) Dehydration Medications Hyperthyroidism(Storm) Delirium tremems (DT's) Heat cramps Heat exhaustion Heat stroke or tumors CNS lesions Differential Bolus (may repeat X 3) (may repeat X Bolus Protocol 55 Monitor and reassess Notify Destination or Appropriate Protocol Contact Medical Control Contact Medical Basedsymptoms on patient Altered or mental status unconsciousness skin sweatyHot, dry or Hypotension or shock Seizures Nausea IV Protocol - IV Protocol Cardiac monitor ECG 12-Lead Documenttemperature patient Remove from heat source Remove clothing Apply room temperatureand water to skin increase airflow around patient Universal Patient CarePatient Universal Protocol Signs and Symptoms and Signs Hyperthermia I P B M I P B M consists of dehydration, salt depletion, changes,dizzyness, fever, mental headache, status consists of benign consistsmuscle of cramping 2° to dehydration and is not associatedan with elevated consists of dehydration,consists of tachycardia, hypotension, (40° C), and>104° temperature an alteredF mental Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS MR EMT EMT- I EMT- EMT- P EMT- Legend Medical Control Time and exposureof length Poor PO intake Fatigueor muscle and cramping / Past medical history / medicationsPast medical history / Extreme exertion Age Exposure to increased humidityortemperatures and / Heat Exhaustion nauseacramping, and vomiting. Vital signs usually consisthypotension, of tachycardia, andan elevated temperature. Heat Stroke status. Sweating generally disappears as body temperatureC). rises above (40° 104° F shiveringIntense may occur as patient is cooled. Heat Cramps temperature. Extremes of age areExtremes of age more prone to heat emergencies and (i.e. young old). Predisposed antidepressants,tricyclic by use of: phenothiazines, anticholinergicmedications, and alcohol. Cocaine, Amphetamines,and Salicylatesmay body elevate temperatures. Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Exam:RecommendedNeuro Status, Mental HEENT, Heart, Lungs, Skin, I P B History M Pearls Hypothermia

History Signs and Symptoms Differential Past medical history Cold, clammy Sepsis Medications Shivering Environmental exposure Exposure to environment even in Mental status changes Hypoglycemia normal temperatures Extremity pain or sensory CNS dysfunction Exposure to extreme cold abnormality Stroke Extremes of age Bradycardia Head injury Drug use: Alcohol, barbituates Hypotension or shock Spinal cord injury Infections / Sepsis Length of exposure / Wetness Universal Patient Care Protocol Legend MR P Cardiac Monitor P B EMT B Temperature < 95° F (35° C) I EMT- I I

Yes P EMT- P P M Medical Control M Protocols Trauma Handle very gently Remove wet clothing Hot Packs and Blankets Blood Glucose No I IV Protocol I If Glucose < 60 D50 if Adult I D10 if Pediatric I Glucagon if No IV B Consider Naloxone B

Appropriate Protocol Based on patient symptoms

M Contact Medical Control M

Pearls Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro NO PATIENT IS DEAD UNTIL WARM AND DEAD. Defined as core temperature < 35° C (95° F). Extremes of age are more susceptable (i.e. young and old). With temperature less than 30° C (86° F) ventricular fibrillation is common cause of death. Handling patients gently may prevent this. If the temperature is unable to be measured, treat the patient based on the suspected temperature. 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. Consider withholding CPR if patient has organized rhythm or has other signs of life. Discuss with medical control. Intubation can cause ventricular fibrillation so it should be done gently by most experienced person. Do not hyperventilate the patient as this can cause ventricular fibrillation. If the patient is below 30 degrees C or 86 F then only defibrillate 1 time if defibrillation is required. Normal defibrillation procedure may resume once patient reaches 30 degrees C or 86 F. Below 30 degrees C (86 F) antiarrythmics may not work and if given should be given at reduced intervals contact medical control before they are administered. Below 30 C or (86 F) pacing should not be done Protocol 56 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2009 Trauma Protocols I P B M 2009 M MR EMT EMT- I EMT- EMT- P EMT- Legend Flail chest Flail tamponade Pericardial chest wound Open Hemothorax Medical Control I P B M Chest pneumothorax Tension bleeding Intra-abdominal Pelvis / Femur fracture fracture injurySpine / Cord injury (seeHead Head Trauma) Extremity fracture / Dislocation obstruction) (AirwayHEENT Hypothermia to appropriate destination Differential (Life threatening) (Life Differential Notify Destination or EMS System Trauma Plan Contact Medical Control Contact Medical using Splint Suspected Fractures Splint Pelvic Binding Consider External Hemorrhage Control ContinuallyReassess Transport focusing on Normal M Complete Assessment if appropriate Protocol 57 Pain, swelling lesions,Deformity, bleeding Altered or mental status unconscious Hypotension or shock Arrest I Signs and Symptoms and Signs P Airway Protocol initial ABC and responsiveness levelof Adult AssessmentAdult Procedure Protocol Immobilization Spinal Universal Patient CarePatient Universal Protocol Multiple Trauma Multiple Abnormal Vital Signs including GCS including Vital Signs

to appropriate Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS destination using Tension Pneumothorax? May repeat for hypotensionforMay repeat Rapid Transport Restraints/ protective equipment Past medical history Medications Locationor in structure vehicle Others injured or dead Speed and details of MVC Time and mechanism of injury Damage to structure or vehicle Provide Early Notification EMS SystemTrauma Plan Bag valveacceptable mask is an managing methodof airwaypulse the oximetry if can be maintained above 90% Do not overlookDo notpossibilitythe of associated domestic violence or abuse. Scene times should not be delayedfor procedures. shouldThese be performed en routewhen possible. Rapid the unstabletransportof trauma goal. patient is the Geriatricpatients should evaluated bewith a high suspicion. indexof occult injuriesOften are moredifficult to recognize andcan patients decompensate unexpectedly with little warning. Mechanismmostreliable is the indicator of serious injury. In prolongedseriousor extrications considertrauma, air transportation and for transport times the ability give to blood. Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Exam:Recommended Abdomen, Status, Mental Back, NeuroHEENT, Heart, Lung, Skin, keyItems in Red Text are performance Care the EMS Acute Trauma measures Toolkit used in EMSpre-arrivalwith the EMS System Trauma notification. based Plan on chosen is Transport Destination Chest Decompression Splint Suspected Fractures Splint Pelvic Binding Consider External Hemorrhage Control IV Protocol IV Normal Saline Bolus I Limit Scene Time to 10 Time to Scene Limit minutes History P Pearls Consider Injury Protocol Head Trauma Protocols I P P B I P B M 2009 MR EMT EMT- I EMT- EMT- P EMT- Legend Medical Control I P B M Major Symptoms: Nerve exposure agent VX, (e.g., etc.) Sarin, Soman, exposure Organophosphate (pesticide) exposure(e.g., Vesicant Gas, etc.) Mustard Respiratory Irritant Exposure Hydrogen Sulfide, (e.g., etc.) Chlorine, Ammonia, Nerve Agent Kit IM X 3 rapidly (See Pediatric Doses Below) IV Protocol If Seizures: Midazolam (IV/IM) (IV/IM) Lorazepam Atropine 25 mg IV/IM q min mg/kg) (0.02-0.05 symptoms resolve until Differential Altered Mental Status, Seizures, Respiratory Distress, Respiratory Arrest Respiratory Distress, I P P B M or Notify Destination Destination Contact MC Protocol 58 M Visual Disturbances Headache Nausea/Vomiting Salivation Lacrimation Respiratory Distress Diaphoresis Seizure Activity Respiratory Arrest I P M as indicated. Signs and Symptoms and Signs before treatment. Obtain historyexposure of Universal Patient Protocol Care Observe for specific toxidromes Initiate triage and/or decontaminationInitiate triage and/or symptoms. There mustbe symptoms Assess for presence of major or minor Ensure Scene Safety and Proper PPE WMD-Nerve Agent Protocol Agent WMD-Nerve Any local EMS System changes to this must follow document the NC OEMS Protocol Policy and Change be approved by OEMS Minor Symptoms: Visual Disturbances Salivation, Lacrimation, Pralidoxime 2 grams (15-25 mg/kg for Peds) minutes 30IV over IV Protocol Atropine 2q 5 mg IV/IM min mg/kg) (0.02-0.05 symptomsuntil resolve Carefully evaluate patientsexposurefrom to ensure theynotto another (e.g., narcotics, agent vesicants, etc.) Atropine of Pralidoxime 2 mg of Each Nerve 600 mg (2-PAM) and contains Kit Agent The main symptom that the atropine addresses is excessive secretions so atropine should be given until salivation improves. Follow protocols local for decontamination HAZMAT personal and use of protective equipment For patientswithsymptoms, majorlimit there is no for atropine dosing. In the face of a bona fide attack, beginIn the face of a bonafide attack, with 1 Nerve7 years of age, Agent Kit for patients less 2 Nerve than Agent andyearsage, Kits from 8 to 14for patientsKits 3 Nerve Agent of years 15 of age and over. Triage/MCIIf issuessupply exhaustAgent of Nerve use Kits, pediatric atropens(if available). Use the 0.5 mg doseif patient is less thanpatient1 mg dose(18 40 pounds if weighskg), between 40to 90 pounds (18 to 40 kg), and2mg dosepatients for greater 90 pounds than kg). (>40 Potential exposure to unknown substance/hazard Exposure to chemical, biologic, radiologic, nuclearor hazard Monitor appearance for of major symptoms I Pearls History P M Induced Hypothermia

History Signs and Symptoms Differential Non ± Traumatic cardiac Return of pulse Continue to address specific arrest. (post V-Tach, V-Fib differentials associated with the and Asystole arrests are original dysrhymia permissible in this protocol)

ROSC Legend (Return Of Spontaneous Circulation) For post V-Tach, V-Fib and Asystole cardiac P EMT- P P arrests, all others contact Medical Control.

Post resuscitation Criteria for Induced Hypothermia and initial NO protocol temp >34C or 93F At Any Time Unsuccessful Yes loss of Spontaneous Circulation: Intubation ET Tube Placed and No Discontinue cooling and go Protocol ETCO2 reading >20 mmHg to appropriate protocol Yes

Perform Neuro Exam and Record in Successful PCR Induced Hypothermia Procedure Monitor ETCO2 target Expose patient 40 mmHg DO Not Apply cold packs to Axilla and Groin Hyperventilate P P Infuse Cold (4 deg. Celsius) Saline 30 ml/kg to max of 2 liters (if available) Medication, As Needed: Versed 0.15 mg /kg to max of 6 mg Consider Norcurron Morphine 4mg IV/IO bolus then 2 mg P Only if required to P P increments to max of 10 mg P maintain airway Dopamine 10-20 mcg/kg/min for MAP 90-100

Pearls Criteria for Induced Hypothermia: ROSC after V-Tach, V-Fib and Asystole cardiac arrest not related to trauma or hemorrhage. Age greater than 12 Comatose Glasgow Coma Score < 5 Initial temperature > 34C Patient is intubated and remains comatose ( no purposeful response to pain) Utilize Versed for sedation and Morphine as needed for shivering and pain control. If patient meets other criteria for induced hypothermia and is not intubated, then intubate according to protocol before inducing cooling. If unable to intubate DO NOT initiate induced hypothermia. When exposing patient for purpose of cooling, undergarments may remain in place preserve patients modesty Do not delay transport for the purpose of cooling. Reassess airway frequently and with every patient move. Patients develop metabolic alkalosis with cooling. Do not hyperventilate. Pregnancy is a contraindication for Induced Hypothermia.

Buncombe/Madison/Yancey EMS Protocol 59 2009