Clinical Operating Guidelines
Version 02012020
Katherine Remick MD Effective February 1st 2020 thru January 31st 2022 or revised Table of Contents
Clinical Standards ...... Page Attended Patients at Clinic or Alternative Medical Site…………………………………………………………………….CS-1 Atypical Protocol Utilization and Online Medical Direction ...... CS-2 Cancellation or Alteration of Response ...... CS-3 Child Abuse Recognition and Reporting ...... CS-4 Clinical Event Review ...... CS-5 Crime Scene ...... CS-6 Criteria for Death or Withholding Resuscitation ...... CS-7 Definition of a Patient ...... CS-8 Discontinuation of Prehospital Resuscitation ...... CS-9 DNR Advanced Directives ...... CS-10 Documentation of Patient Care Report ...... CS-11 Documentation of Vital Signs ...... CS-12 Domestic Violence Recognition and Reporting ...... CS-13 Emergency Medical Dispatch ...... CS-14 Equipment Failure ...... CS-15 Hospital Diversion ...... CS-16 Human Trafficking…………………………………………………………………………………………………………………………..CS-17 Identification Badges ...... CS-18 Infant Abandonment ...... CS-19 Interfacility Transfers ...... CS-20 Minimal Equipment to Patient Side ...... 1CS-2 On-scene Authority ...... CS-22 Patients with Special Healthcare Needs ...... CS-23 Physician on Scene ...... CS-24 Provider Clinical Performance Review ...... CS-25 Provider Credentialing ...... CS-26 Provider Qualifications ...... CS-27 Refusal of Treatment and/or Transport ...... CS-28 Safe Transport of Pediatric Patients ...... CS-29 Suspension or Revocation of Credential to Practice ...... CS-30 System Design ...... CS-31 Transport Destination Decision ...... CS-32 Transfer of Care to Provider of Lesser Credentials ...... CS-33
Transport COGs
Universal Protocols: All Patients...... Page Universal Patient Care...... U-01 IV Access...... U-02 Patient Safety...... U-03 Deceased Person...... U-04 Spinal Motion Restriction...... U-05
Adult Protocols: Patients ≥ 37 Kg...... Page Airway, Adult...... R-01 Airway, Adult - Obstruction...... R-02 CHF & Pulmonary Edema...... R-03 Respiratory Distress...... R-04 RSI/Medication Assisted Intubation (>37kg)...... R-05 Asystole/PEA...... CA-01 Ventricular Fibrillation & Pulseless Ventricular Tachycardia...... CA-02 Induced Hypothermia ≥ 18yrs...... CA-03 Suspected Acute Coronary Syndrome...... C-01 Bradycardia ...... C-02 Atrial Fibrillation with RVR...... C-03 Supraventricular Tachycardia...... C-04 Wide Complex Tachycardia (VT) With a Pulse...... C-05 Allergic Reaction ...... M-01 Altered Mental Status...... M-02 Bites and Envenomations...... M-03 Fever/Infection Control...... M-04 Hyperkalemia………………………………………………………………………………………………………..…………………………...M-05 Hypertensive Crisis……………………………………………………………………………………………….…………………………….M-06 Hyperthermia...... M-07 Hypothermia ...... M-08 Nausea/Vomiting ...... M-09 Non Traumatic Bleeding...... …...M-10 Overdose/Toxic Ingestion...... M-11 Pain Management...... M-12 Sedation ...... M-13 Seizure ...... M-14 Shock (Non Trauma) ...... M-15 Suspected Stroke...... M-16 Violent/Agitated Patient...... M-17 Burns – Adult and Pedi...... T-01 Drowning / Near Drowning...... T-02 Head Trauma...... T-03 Multiple Trauma...... T-04 Regional Trauma Criterion...... T-05 SMART Triage Algorithm...... T-06
Obstetrical Emergency Protocols...... Page Childbirth / Labor...... OB-01 Obstetrical Emergency...... OB-02 Newly Born...... OB-03
Pediatric Protocols: Patients < 37 Kg...... Page Pediatric Extremity Trauma...... PT-01 Pediatric Head Trauma...... PT-02 Pediatric Multiple Trauma...... PT-03 Airway, Pediatric...... PR-01 Pediatric RSI/Medication Assisted Intubation (<37kg)………………………………………………….……………....… PR-02 Pediatric Respiratory Distress...... PR-03 Pediatric Asystole/PEA...... PCA-01 Pediatric V-Fib/Pulseless V-Tach...... PCA-02 Post Resuscitation...... PCA-03 Pediatric Bradycardia...... PC-01 Pediatric Supraventricular Tachycardia...... PC-02 Pediatric Allergic Reaction...... PM-01 Pediatric Altered Mental Status...... PM-02 Pediatric Fever/Infection...... PM-03 Pediatric Hypotension (Non-Trauma)...... PM-04 Pediatric Sedation...... PM-05 Pediatric Nausea, Vomiting, and Diarrhea ...... PM-06 Pediatric Overdose / Toxic Ingestion...... PM-07 Pediatric Pain Control...... PM-08 Pediatric Seizure...... PM-09
Special Response Protocols (Adult/Pedi)...... Page Toxic Exposure Ammonia (Gas & Liquid)...... TX-01 Carbon Monoxide Exposure...... TX-02 Toxic Exposure Chlorine and Related Compounds...... TX-03 Toxic Exposure Cyanide...... TX-04 Toxic Exposure - Fumigants: Methyl Bromide, Sulfuryl Fluoride, Chloropicrin, & Phosphides ….……… TX-05 Toxic Exposure - Hydrazines...... TX-06 Toxic Exposure - Hydrofluoric Acid...... TX-07 Toxic Exposure - Hydrogen Sulfide, Sulfides, & Mercaptans...... TX-08 Toxic Exposure - Organophosphates/Nerve Agents...... TX-09 Toxic Exposure Sodium Hydroxide...... TX-10 Scene Rehabilitation Protocol Adult ≥ 37 Kg...... REHAB CPR Procedure...... CPR Pediatric CPR Procedure...... Pedi CPR Defibrillation Procedure...... …DEFIB Restraint Procedure...... RESTRAINT
Special Populations Protocols (Adult/Pedi)...... Page Adrenal Insufficency...... SP-1 MCADD 1...... SP-2 MCADD 2...... …SP-3 VAD...... SP-4
Canine Response Protocols……………………………………………………………………………………………….……….……..K9
Clinical Reference ...... … Page Adult Drug Infusion Rates………...... CR-1 Adult Epinephrine Infustion ……………………………………………………………………………………………………………..CR-2 Adult Levophed Infusion Rates ...... CR-3 APGAR Scoring ...... CR-4 GCS ...... CR-5 Mass Casualty Incident Levels ...... CR-6 Oxygen Duration Chart………………………………..…………………………………………………………………………………..CR-7 Pediatric Amiodarone Infusion ...... CR-8 Pediatric Calcium Gluconate Infusion ...... CR-9 Pediatric Epinephrine Infusion ...... CR-10 Pediatric IV Maintenance Fluids ...... CR-11 Pediatric Levophed Infusion Rates ...... CR-12 Pediatric Magnesium Sulfate Infusion ...... CR-13 Regional Trauma System Adult / Pediatric Trauma Criteria ...... CR-14 Rule of Nines ...... CR-15 SMHC EMS Fibrinolytic Checklist………………………………..…………………………………………………………….…...CR-16
Clinical Procedures ...... Pages 12 Lead ECG ...... CP-1 AED ...... CP-2 Airway Obstruction ...... CP-3 Alternative Venous Access...... CP-4 Assessment - Adult ...... CP-5 Assessment - Pediatric ...... CP-6 Auto-injector Delivered Medication ...... CP-7 Blood Glucose Assessment ...... CP-8 Cardiac Pacing ...... CP-9 Cardioversion ...... CP-10 Childbirth ...... CP-11 Clinical Event Reporting ...... CP-12 Contact Precautions ...... CP-13 CPAP ...... CP-14 CPR – Pit Crew ...... CP-15 CPR (BLS) ...... CP-16 Cricoid Pressure ...... CP-17 Decontamination ...... CP-18 Determination of Capacity ...... CP-19 Endotracheal Medication Administration ...... CP-20 End – Tidal CO2 Monitoring Wave Form ...... CP-21 External Jugular Access ...... CP-22 Extremity IV Intravenous Fluid Therapy ...... CP-23 Eye Irrigation BLS Only ...... CP-24 Flex Guide ETT Introducer (Bougie) ...... CP-25 Gastric Tube Insertion ...... CP-26 Hemostatic Agent ...... CP-27 i-gel O2 Airway Device (BIAD) ...... CP-28 Intramuscular Injections ...... CP-29 Insulin Pump ...... CP-30 Intraosseous Infusion EZ - IO ...... CP-31 Kendrick Traction Device ...... CP-32 LUCAS ...... CP-33 Manual Defibrillation ...... CP-34 Nasal Drug Delivery Device ...... CP-35 Nebulized Medication ...... CP-36 Needle Cricothyrotomy ...... CP-37 Orotracheal Intubation ...... CP-38 Orthostatic Blood Pressure Measurement ...... CP-39 Pediatric Immobilization Board (Pedi-Board)…………………………………….…..……………………………………….CP-40 Pelvic Binder (SAM Sling®) ...... CP-41 Physical Restraints ...... CP-42 Pleural Decompression ...... CP-43 Pain Assessment and Documentation ...... CP-44 Pressure Infusion Bag ...... CP-45 Pulse Oximetry ...... CP-46 Respiratory Precautions...... CP-47 Safe Injection Practices ...... CP-48 Spinal Motion Restriction ...... CP-49 Splinting ...... CP-50 Standard Precautions ...... CP-51 Stroke Screens ...... CP-52 Surgical Cricothyrotomy ...... CP-53 Suctioning-Advanced ...... CP-54 Taser® Probe Removal ...... CP-55 Tourniquet ...... CP-56 Transport Ventilator…………………………………………………….………………………………………….…………………….CP-57 Vagus Nerve Stimulator………………………………………………….……………………………………….…………….……....CP-58 Wound Care ...... CP-59
Appendices ...... Page Approved Abbreviations ...... A-1 Hospital Transport Guidelines ...... A-2 Infection Prevention and Exposure Management ...... A-3 Interfacility Medical Staffing Requirements ...... A-4 Provider Clinical Performance Review Process ...... A-5 Patient Transport Condition Classification System...... A-6 Suspected Child Abuse and Reporting ...... A-7 Vital Signs Parameters ...... A-8
Drug Formulary ...... Page Acetaminophen ...... DF-1 Adenosine ...... DF-2 Albuterol ...... DF-3 Amiodarone ...... DF-4 Amyl Nitrite ...... DF-5 Aspirin ...... DF-6 Atropine Sulfate……………………………………………………………………………………………………………………………....DF-7 Brilinta……………………………………………………………………………………………………………………………………………..DF-8 Calcium Gluconate ...... DF-9 Dextrose ...... DF-10 Diltiazem ...... DF-11 Diphenhydramine ...... DF-12 Enalapril………………………………………………………………………………………………………………………………………….DF-13 Epinephrine ...... DF-14 Etomidate…………………………………………………………………………………………………………………………………….. DF-15 Fentanyl Citrate……………………………………………………………………………………………………………………………..DF-16 Glucagon………………………………………………………………………………………………………………………………………..DF-17 Heparin…………………………………………………………………………………………………………………………………………..DF-18 Ipratropium Bromide ...... DF-19 Ketamine………………………………………………………………………………………………………………………………………..DF-20 Labetalol…………………………………………………………………………………………………………………………………………DF-21 Levophed ...... DF-22 Lidocaine ...... DF-23 Magnesium Sulfate ...... DF-24 Methylprednisolone ...... DF-25 Midazolam ...... DF-26 Naloxone ...... DF-27 Nitroglycerin ...... DF-28 Ondansetron ...... DF-29 Oral Glucose ...... DF-30 Pyridoxine ...... DF-31 Rocuronium ...... DF-32 Sodium Bicarbonate ...... DF-33 Sodium Nitrite ...... DF-34 Sodium Thiosulfate ...... DF-35 Terbutaline Sulfate ...... DF-36 Toradol...... DF-37 Tranexamic Acid...... DF-38
Clinical Standards
Table of Contents Clinical Standards ...... Page
Attended Patients at Clinic or Alternative Medical Site…………………………………………………………………….CS-1 Atypical Protocol Utilization and Online Medical Direction ...... CS-2 Cancellation or Alteration of Response ...... CS-3 Child Abuse Recognition and Reporting ...... CS-4 Clinical Event Review ...... CS-5 Crime Scene ...... CS-6 Criteria for Death or Withholding Resuscitation ...... CS-7 Definition of a Patient ...... CS-8 Discontinuation of Prehospital Resuscitation ...... CS-9 DNR Advanced Directives ...... CS-10 Documentation of Patient Care Report ...... CS-11 Documentation of Vital Signs ...... CS-12 Domestic Violence Recognition and Reporting ...... CS-13 Emergency Medical Dispatch ...... CS-14 Equipment Failure ...... CS-15 Hospital Diversion ...... CS-16 Human Trafficking…………………………………………………………………………………………………………………………..CS-17 Identification Badges ...... CS-18 Infant Abandonment ...... CS-19 Interfacility Transfers ...... CS-20 Minimal Equipment to Patient Side ...... CS-21 On-scene Authority ...... CS-22 Patients with Special Healthcare Needs ...... CS-23 Physician on Scene ...... CS-24 Provider Clinical Performance Review ...... CS-25 Provider Credentialing ...... CS-26 Provider Qualifications ...... CS-27 Refusal of Treatment and/or Transport ...... CS-28 Safe Transport of Pediatric Patients ...... CS-29 Suspension or Revocation of Credential to Practice ...... CS-30 System Design ...... CS-31 Transport Destination Decision ...... CS-32 Transfer of Care to Provider of Lesser Credentials ...... CS-33
Attended Patients at Clinic or Alternative Medical Site Standard: Physicians or Advanced Practice Providers already have an established provider/patient relationship prior to calling EMS. That relationship should be supported. Purpose: The purpose of this standard is to allow for and reinforce clear communication between patient, provider, and patient’s physician or advanced practice provider. Background: • A physician or advanced practice provider may request EMS services at a clinic or alternative medical site on behalf of a patient who is currently under his/her care (i.e. a physician-patient relationship has been established). • These calls represent high-risk situations where the physician or advanced practice provider (APP) lacks the resources and/or capabilities to manage the patient’s acute illness or injury. • Emergency Medical Services are requested for any one of the following: o Potential for acute deterioration requiring BLS/ALS intervention o Risk for worsening condition requiring further assessment or intervention o Potential for delays in receiving definitive care • Due to any of the above, self-transport or transport by friend, family, or non-medical transportation service may place the patient and/or the patient’s family at risk. • Failure to evaluate, treat, and transport these patients to an appropriate destination places the patient at risk for deterioration and possibly death or disability. • Any decision to accept or refuse transport should be made by the patient or his/her designated caregiver/power of attorney. • EMS providers may be asked whether ambulance transportation is absolutely necessary, yet EMS providers may lack a full understanding of the medico-social circumstances leading to the physician’s recommendation. • Any changes to the medical treatment plan, should involve the patient’s physician or APP. Solution: • When called to a clinic or alternative site where a patient is under the care of a physician or APP, the expectation is that the patient will be transported to the appropriate destination by EMS. • Any change in the medical treatment plan (i.e. refusal of transport) should involve the patient’s physician or APP. • Failure to involve the physician or APP in the transportation/treatment plan will result in a request for the EMS crew to return to the site to facilitate discussion between the patient and his/her physician or APP. • An EMS provider should not offer any specific diagnosis to a patient. Rather EMS providers are expected to assess, evaluate, and consider potential differential diagnoses or risks. • The medical risks and/or benefits of treatment & transportation should be fully discussed with the patient. • Any concerns regarding patient management and/or diagnostic considerations should involve a discussion between the physician/APP and EMS providers only. If the EMS providers are unable to come to an agreement regarding patient management/treatments, the EMS Medical Director (or Battalion Chief) should be contacted to facilitate discussions.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 1 Atypical Protocol Utilization and Online Medical Direction
Standard: Provide direction on managing patients and circumstances that are outside the protocols. Purpose: Give direction for providers who encounter complicated, unusual, and atypical patient encounters and establish an orderly method by which clinical issues can be rapidly addressed. Application: 1. Clinical encounters requiring use of this protocol may be divided into two types: • Those whose clinical situation is covered by existing protocol but who are presenting a clinical/administrative challenge (e.g., clarification of a COG, patient destination, other healthcare provider issues, etc.) and require non-medical control guidance or • Those whose clinical situation is not covered by existing protocol (e.g., modification of drug dosage, patient medication not addressed in protocol or unfamiliar to a provider, termination of resuscitation not covered in current policy) and thus require medical control orders via on-line medical consultation (OLMC). 2. Patients requiring OLMC shall contact medical control as described in steps 4 and 5 below. The provider requesting OLMC must be at the scene with the patient. 3. The first call for operational/administrative issues related to an individual patient or patients will be placed to an organization’s designated clinical supervisory personnel utilizing the established chain of command. 4. If OLMC consultation is required the request should be initially to the system medical director via a recorded line (dispatch). If unavailable, a physician at the intended receiving hospital should be contacted. Please note that only physicians at receiving hospitals can provide medical direction; other staff, including nurses, may not provide online medical direction. 5. In the PCR, the name of the individual providing OLMC or administrative direction will be documented in the narrative section.
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Standard: Establish direction for cancelling or altering an initial response to a request for service. Purpose: To give the providers in the SMHC EMS System guidance on when they may be able to alter or cancel an initial response based on patient or scene presentation. Application: 1. Resources will be initially dispatched to a 9-1-1 request for service based on the currently approved Medical Priority Dispatch (MPD) standards. 2. After assessing the patient(s) and making a determination of needed resources any on- scene credentialed provider may modify or cancel the response mode of any other system provider not already on-scene. 3. If cancelled, responders may, at their discretion, reduce their response to non lights and sirens (“Code 1”) and continue to the scene in order to provide other assistance deemed appropriate by their organization or department. This does not apply to responses for responsibilities other than patient care (scene safety, fluids, etc).
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Standard: Assessment of a child abused 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. Purpose: Children suffer several types of abuse. All are harmful to their physical and emotional development and all require intervention. Under the Child Abuse Prevention and Treatment Act (CAPTA), child abuse and neglect means, at a minimum, “Any recent act, or failure to act, on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” By Texas State law, all healthcare providers are obligated to report cases of suspected child abuse or neglect to either the local law enforcement agency or the Texas Department of Family and Protective Services (TDFPS). Application: 1. Stabilize and treat all injuries. 2. Immediately request law enforcement assistance. 3. Do not initiate a report to law enforcement or social services in front of the patient, parent, or caregiver. 4. If sexual abuse is suspected, discourage the patient from washing. 5. If patient, parent, or caregivers are hostile, protect your safety and immediately request law enforcement assistance. 6. Do not confront or become hostile to the parent or caregiver. 7. Document: • In their own words (in quotation marks) all statements by the patient, the parent, or caregiver, including statements made about the manner of the injuries • Any abnormal behavior of the patient, parent, or caregiver • The condition of the environment and other residents present • Who received the report of suspected abuse or neglect • If reporting is done after PCR completion, an addendum should be written and attached with reporting date, time, who reported to, etc. This will serve to protect the Provider 8. Transport Providers: • If a notification of abuse or suspected abuse has been made to Law Enforcement or Texas Department of Family and Protective Services (TDFPS), notify the appropriate Battalion Chief to provide support for the completion of reporting regulations and processes. Upon arrival at the destination hospital notify the accepting providers of your concerns. 9. Other System Providers: • If a notification of abuse or suspected abuse has been made to Law Enforcement or Texas Department of Family and Protective Services (TDFPS), contact an SMHC EMS Battalion Chief via EMS Communications to provide support for the completion of reporting regulations and processes
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Standard: When clinically related concerns meeting the indicated criteria are identified, each System Organization’s Performance/Quality Improvement staff will perform a systematic evaluation of the actions and omitted actions associated with the specific event or situation to identify opportunities for improvement. A clinical event review does not require actual harm or a negative patient outcome to have occurred. Purpose: To establish a standardized process to review clinical concerns and/or reports of suboptimal clinical performance with the primary objective focused on the identification of individual and system improvements to clinical care. Application: 1. A clinical event review or performance review may be convened by the SMHC EMS Medical Director or Administrative Battalion Chief. 2. Each System Organization as well as the OMD will foster an environment that encourages reporting of clinical concerns and errors including self reporting 3. At a minimum, a clinical event review will be conducted when suboptimal clinical performance events are identified. 4. Each Organization’s Performance/Quality Improvement staff will conduct an initial review to: a. gather pertinent facts, documentation and data b. analyze the facts, data and related information c. identify the cause(s) of the less than optimal performance d. draft a plan for clinical improvement for review by the Medical Director 5. A report of the above findings will be drafted and submitted to the Office of the Medical Director within the prescribed time frame. 6. Each Organization will maintain copies of the Clinical Event Review report for future review by authorized persons only. 7. The OMD will store electronic and/or paper records of the Clinical Event Review reports submitted to the OMD by each Organization. 8. All aspects of the Clinical Event Review including the proceedings, recordings and documents are considered confidential under the Texas Health and Safety Code Section 773.095. 9. All persons involved in the Review follow all requirements for confidentiality as described in the Clinical Performance Review Process document. 10. Each Organization will ensure its identified performance/quality improvement staff is appropriately trained in the current methods of performance review and analysis. 11. Each System Organization and Individual Provider will fully participate in the Clinical Event Review process as requested by the Office of the Medical Director.
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Standard: To establish guidelines for conducting patient care on a potential crime scene. Purpose: When prehospital care or resuscitation efforts are no longer appropriate it is every Provider’s responsibility to assist law enforcement by preserving evidence at potential crime scene. Any scene involving a patient that is pulseless and apneic is to be considered a crime scene and treated accordingly. In such situations Provider’s should also maintain a heightened awareness for the presence of weapons. Application: General principles of crime scene management: 1. The first arriving Credentialed Provider on-scene must make patient access to determine whether resuscitative efforts are indicated or not. If law enforcement prevents entry, additional responding units should be reduced to “Code 1” response. All law enforcement refusal of access to patients by Providers will be retrospectively reviewed with law enforcement. 2. Weapons should not be handled by a Provider unless necessary to ensure a safe patient care environment. If weapons must be handled, the Provider must wear gloves, clearly document the items original and new location, and inform on-scene Law Enforcement. 3. Never use anything (phones, sink, bathroom, towels, sheets, blankets, pillows, etc.) from an incident scene. 4. Victims of suspected assault should be strongly discouraged against “cleaning up,” washing or showering prior to arrival of Law Enforcement or transport. 5. Providers should not touch anything in the crime scene unless required for patient care activities. Patient demographic information should be obtained from law enforcement when possible. 6. Any ligature(s) involved should be left as intact as possible and should be cut rather than untied. All cuts made should be in an area well away from any knots. 7. Containers of any substance which may have been ingested by the patient/victim should be left in the position found unless needed for ongoing patient care. If the container must be touched, use gloved hands and limit handling to a minimum in order to preserve any fingerprints that may be present. 8. Disposable items used during resuscitation efforts are to be left in place. 9. Intravenous/IO lines, airways and all other disposable equipment used, successfully or unsuccessfully, are to remain in place and/or on-scene. 10. Pronouncement should be made in accordance with the standards outlined in the Criteria for Death or Withholding Resuscitation/Discontinuation of Resuscitation Standards. The existence of a possible crime scene should not influence the decision to initiate resuscitative efforts. 11. Patient information may be given to law enforcement officer pursuant to the Health Information Portability and Protection Act (HIPPA). An EMS Patient Care Report (PCR) may be obtained from the administration offices during regular business hours. 12. Once a pronouncement time is obtained the body becomes the property of the Law Enforcement.
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Crime scene management where no resuscitation is initiated: 1. Any Responder, who is not properly credentialed to seek pronouncements of an obvious Dead on Scene (DOS), should immediately leave the area without touching anything via the path of entry. 2. When confirmation of death is required, only one properly Credentialed Provider should make entry to the area. Crime scene management with unsuccessful resuscitation: 1. Once resuscitation efforts have ceased and a pronouncement has been obtained Providers should immediately vacate the area. 2. The Medical Examiner must be able to differentiate between punctures originating from resuscitation efforts and those present prior to arrival. All unsuccessful IV/IO or pleural decompression attempts should be marked on the body by circling with a marker or pen. Crime scene management with patient transport: 1. Clothing, jewelry or other objects removed from the patient should be left on-scene. Clearly document any items left and inform on-scene Law Enforcement of the items original and current locations. 2. When cutting clothing for the purpose of assessment and/or treatment avoid cutting through existing defects in the clothing (tears, entry or exit points) whenever possible. 3. If the patient has been placed on a sheet, notify the receiving facility that the sheet and all personal effects may be considered evidence. • If law enforcement is not on-scene prior to transport, the first response agency is to remain on scene, out of the crime scene perimeter, until arrival of law enforcement. An effort should be made to keep all individuals out of the area.
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Standard: Define the parameters in which providers in the SMHCEMS System may withhold resuscitative efforts. Purpose: CPR and ALS treatment are to be withheld only if the patient is obviously dead per criteria below or a valid Out-of-Hospital Do Not Resuscitate Form (OOH-DNR) and/or OOH-DNR ID device. The form and device may be from any (US) state. (see separate DNR policy) Application: 1. Resuscitation efforts should not be initiated or continued by a SMHCEMS System provider if one or more of the following is present:
• Rigor mortis and/or dependent lividity; • Decomposition; • Decapitation; • Incineration; • Obviously mortal wounds (severe trauma with obvious signs of organ destruction) • Patient submersion greater than 20 minutes from arrival of first Public Safety entity until the patient is in a position for effective resuscitative efforts to begin. Unless they possibly had an air source. (Diver, etc.) • Fetal death with a fetus < 20 weeks by best age determination available at scene.(Is considered products of conception and does not require time of death) 2. If resuscitation efforts have been initiated or continued by a system provider discontinuation is at the discretion of the paramedic provider. Document in the PCR the specific indications for withholding resuscitation. Fetal death < 20 weeks may be documented on mothers PCR if ≥ 20 weeks create separate PCR Note: • If you are unsure whether the patient meets the above criteria, resuscitate.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 7 Definition of a Patient
Standard: To establish guidelines for who meets the criteria to be considered a patient in the SMHCEMS System. Purpose:
The definition of a patient is any human being that: • Has a complaint suggestive of potential illness or injury • Requests evaluation for potential illness or injury • Has obvious evidence of illness or injury • Has experienced an acute event that could reasonably lead to illness or injury • Is in a circumstance or situation that could reasonably lead to illness or injury All individuals meeting any of the above criteria are considered “patients” in the SMHC EMS System. These criteria are intended to be considered in the broadest sense. The determination of an individual’s status as a patient requires the input of both the individual and the Provider as well as an assessment of the circumstances that led to the 9-1-1 call. If there are any questions or doubts, the individual should be considered a patient. Application: 1. Anyone that fits the definition of a patient must be properly evaluated by a System credentialed provider and appropriate treatment and transportation offered. (If a patient wishes to refuse offered treatment and/or transport Against Medical Advice (AMA) refer to Refusal of Treatment or Transportation Standard and the Determination of Capacity Standard). 2. Anyone that does not fit the definition of a patient as defined above does not require an evaluation or completion of a Patient Care Record. If there is any doubt, an individual should be deemed a patient and appropriate evaluation should be provided and documented in the PCR. 3. If an individual meets the definition of a patient the following apply: • The definition of an adult is a person who is 18 years of age or older • Adults have the right to consent to or refuse medical treatment • The definition of a minor is: • A person under the age of 18 who is not and has not been married or who has not had the disabilities of minority (emancipation) removed for general purposes by a court • Generally, minors can neither consent to, nor refuse, medical treatment. Some minors however, are considered to be emancipated and have the rights of consent/refusal afforded an adult • A minor is considered emancipated if he or she has obtained a court order of emancipation from a Texas court. Minors may petition the court for emancipation if he is: • (i)A resident of Texas;(ii) 17 years of age or at least 16 years of age and living separate from his parents, managing conservator or guardian;(iii) Is self-supporting and managing his own financial affairs
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 2 CS – 8 Definition of a Patient
• In certain situations, a minor may consent to medical treatment without involvement of a parent or legal guardian. A minor may consent to treatment if the minor: • Is on active duty with the US armed services; • Is 16 years or older residing separately from his parents or guardian and is managing his own financial affairs (regardless of the source of income); • Consents to diagnosis and treatment of any infectious/communicable disease with a reporting requirement; • Is unmarried and pregnant and consents to care related to the pregnancy, other than abortion; • Consents to examination and treatment relating to drug or alcohol dependency; • Is unmarried and has custody of their biological child, they may consent to treatment for the child • The protocol definition of a pediatric patient is: • For the purpose of determining transport destination, any patient younger than 18 years of age unless expressly stated in another protocol, standard or procedure. (eg Trauma Transport Guidelines where it is defined as age <15 years) • For the purpose of selecting appropriate treatment protocol, any patient < 37 kg or who can be measured using a Broslow-Luten tape
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 8 Discontinuation of Prehospital Resuscitation Standard: Unsuccessful cardiopulmonary resuscitation (CPR) and other advanced life support (ALS) interventions may be discontinued prior to transport when this standard is followed. Purpose: The purpose of this standard is to allow for discontinuation of prehospital resuscitation after the delivery of adequate and appropriate ALS therapy. Application: 1. Any System Credentialed Provider, in the following circumstances, may discontinue resuscitation efforts without OLMC: • Resuscitation efforts were inappropriately initiated when criteria outlined in the Criteria for Death/Withholding Resuscitation Standard were present • A valid Out of Hospital Do Not Resuscitate Form (OOH-DNR) and/or OOH-DNR ID device was discovered after resuscitative efforts have been initiated. The form and device may be from any (US) State (Original or Copy) as defined in the DNR Standard 2. In addition to the previously stated criteria a Paramedic Credentialed Provider, in the following circumstances, may discontinue resuscitation efforts without OLMC: • If the patient suffers a traumatic injury meeting the following criteria: The patient is pulseless and apneic on arrival of the first provider on scene AND Lacks respiratory effort after basic airway maneuvers AND Asystole on monitor in at least two leads. 3. In the case of suspected medical cause of arrest all of the following criteria must be met: • Patient must be at least 18 years of age or the family of a minor is agreeable after consultation with On-Line Medical Control(OLMC); • Cause of arrest is NOT due to suspected hypothermia; • Adequate CPR has been administered; • Airway has been successfully managed with verification of device placement. Acceptable management techniques include endotracheal intubation, blind insertion airway device (King),Cricothyrotomy, or adequate management with BLS techniques; • IV/IO access has been achieved; • Rhythm-appropriate medications and defibrillations have been administered according to protocol; • Persistent (>20 min) Asystole or agonal rhythm is present and no reversible causes are identified; • Failure to establish spontaneous circulation (palpable pulse) at any point in the arrest; • Failure to establish persistently recurring or refractory ventricular fibrillation/tachycardia or any continued neurological activity (eye opening, or motor response) after appropriate BLS and ALS resuscitation efforts over 20 minutes; • All Paramedic Credentialed providers on scene agree with decision to cease efforts. • If all of the above are not met and the provider feels it is appropriate to discontinue resuscitative efforts contact OLMC. 4. When OLMC is involved in the decision to terminate resuscitative efforts must be continued while: • the family is counseled on the patients unchanging condition and impending discontinuation of efforts; • requesting a pronouncement from OLMC 5. If termination of efforts is anticipated Victim Services, when available, should be contacted as early as possible 6. 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)
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 9 DNR and Advanced Directives
Standard: In the event any provider of the EMS System is presented with a completed Out of Hospital Do Not Resuscitate (OOH-DNR) form and/or OOH-DNR ID device approved by the State of Texas, the provider shall withhold CPR and the listed therapies in the event of cardiac arrest. The form and device may be from any (US) State. Exception: The only exception to this standard is a patient that is known to be pregnant. Purpose: • To honor the terminal wishes of the patient and to prevent the initiation of unwanted resuscitation. Application: 1. When confronted with a cardiac arrest patient, the following conditions must be present in order to honor the DNR request and withhold CPR and ALS therapy: • Out-of-Hospital Do Not Resuscitate (OOH-DNR) – or – OOH-DNR ID device; (Original or Copy) • Valid Out-Of-Hospital Do Not Resuscitate Written Order (Original or Copy) or Device from any (US) State; • A licensed physician on scene or in contact by telephone orders that no resuscitation efforts are to take place 2. A DNR request may be overridden by: • The patient or person who executed the order destroying or directing someone in their presence to destroy the form and/or remove the identification device • The patient or person who executed the order telling the EMS Providers or attending physician that it is his/her intent to revoke the order • The attending physician or physician’s designee, if present at the time of revocation, recording in the patient’s medical record the time, date and place of the revocation and enters “VOID” on each page of the OOH-DNR 3. In the event there is a question regarding whether to honor or not honor an OOH-DNR or Advanced Directive, contact OLMC as needed 4. An advanced directive does not imply that a patient refused supportive or palliative care
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 10 Documentation of Patient Care Report Standard: Establish the minimum documentation requirements for every patient contact. Purpose: To provide consistent and accurate documentation of the events of a patient encounter, the SMHC EMS System Medical Director is responsible for designating the minimum data required for patient care reporting. The following is the minimum requirements for documentation on all patient encounters. Application: • For every patient contact, the following documentation requirements apply and must: 1. Be truthful, accurate, objective, pertinent, legible, and complete with appropriate spelling, abbreviations and grammar. 2. Use only approved medical abbreviations per “Approved Medical Abbreviations”. 3. Reflect the patient’s chief complaint and a complete history or sequence of events that led to their current request or need for care. 4. Contain a detailed assessment of the nature of the patient’s complaints and the rationale for that assessment. 5. Reflect the initial physical findings, a complete set of initial vital signs, all details of abnormal findings considered important to an accurate assessment and significant changes important to patient care. 6. Reflect ongoing monitoring of abnormal findings. 7. Summarize all assessments, interventions and the results of the interventions with appropriate detail so that the reader may fully understand and recreate the events. 8. For drug administrations, include the dosage, route, administration time, and response. 9. List all treatments in chronological order. Response to treatments should also be listed 10. For patients with extremity injury, note neurovascular status before and after immobilization. 11. For patients with spinal immobilization, document motor function before/after spinal immobilization. 12. For IV administration, document the catheter size, site, number of attempts, type of fluid, flow rate, and amount of fluid infused. 13. Upload monitor or if unable then include a lead II strip for all patients placed on the cardiac monitor. Any 12-leads should also be included. Any significant rhythm changes should be documented. For cardiac arrests, the initial strip, ending strip, pre and post defibrillation, pacing attempts, etc. should be attached. 14. Document clearly any requested orders, whether approved or denied. 15. Document any waste of narcotics including the quantity wasted, where wasted, and name of the person who witnessed the waste. 16. Include an explanation for why an indicated and appropriate assessment, intervention, or action prescribed by the Clinical Operating Guidelines did NOT occur. 17. Clearly describe the circumstances and findings associated with any complex call or out- of-the ordinary situations. 18. Be available and completed prior to leaving the destination facility, except in extenuating circumstances. 19. Remain confidential and be shared only with legally acceptable entities. 20. For a birth or stillborn/non-viable fetus document the time of delivery. In cases of a fetus that is without signs of life where no resuscitation attempt is made documentation should include the reasons why resuscitation was withheld. In cases of products of conception (<20 weeks) documentation may be included on the Mother’s PCR. 21. In the case of an interfacility transfer, documentation must include any medications administered or discontinued during transfer.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 11 Documentation Vital Signs
Standard: Every patient encounter by EMS will 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 for any patient who receives an assessment. Patients who are transported will have a minimum of two sets of vital signs documented. Patients who refuse transport will have a minimum of one set of vital signs documented. Purpose: To insure that evaluation of every patient’s volume, cardiovascular and mental status is documented with a complete set of vital signs. Application: 1. It is expected that vital signs will be taken manually initially with possible subsequent vital signs obtained mechanically as long as they correlate with the manual vital signs. If there is a discrepancy, manual vital signs will be continued. Initial vital signs may deferred until transport in severe trauma when other treatments and packaging may take priority and vital signs may interfere with the timely execution of these priorities. 2. An initial complete set of vital signs includes: • Pulse rate • Systolic AND diastolic blood pressure • Respiratory rate • Pain / severity (when appropriate to patient complaint) • GCS on all patients 3. When no ILS or above treatment is provided, palpated blood pressures may be documented if unable to auscultate. 4. Based on patient condition and complaint, vital signs may also include: • Pulse Oximetry • Temperature • End Tidal CO2 • Mental Status (GCS) 5. If the patient refuses this evaluation, document the refusal in the PCR in accordance with the Refusal of Treatment or Transportation Standard. 6. When any components of vital signs were obtained using the cardiac monitor, the data should be exported electronically to the patient care report. Where values are inconsistent with manually obtained values, values may be appropriately edited to reflect the manually obtained values. 7. Document situations that preclude the evaluation of a complete set of vital signs. 8. Record the time vital signs were obtained. 9. Any abnormal vital sign should be repeated and monitored closely.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 12 Domestic Violence (Partner and/or Elder Abuse) Recognition and Reporting
Standard: 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. Elder abuse is the physical and/or mental injury, sexual abuse, negligent treatment, or maltreatment of a senior citizen by another person. Abuse may be at the hand of a caregiver, spouse, neighbor, or adult child of the patient. 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 and the EMS team from harm • 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 Application: 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 forearms), 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. Immediately report any suspicious findings to the receiving hospital (if transported). If an elder or disabled adult is involved, also contact the Local Law Enforcement Agency.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 13 Emergency Medical Dispatch
Standard: • This standard establishes a uniform level of response for the EMS System and provide for the safest and most appropriate level of response to the patient(s) Purpose: • EMS Units and First Responders will be dispatched in accordance to the standards developed by the Medical Director and the Emergency Medical Dispatch (EMD) Protocols • EMS Units and First Responders will respond emergency or non-emergency in accordance to EMD standards. As more information from 911 Communications or on scene medical responders becomes available, the response may be upgraded or downgraded. Application: 1. EMS Units and First Responders dispatched for non-emergency response, will not upgrade to an emergency response unless: • The 911 Communications personnel determine that the patient’s condition has changed and upgrades the incident to an emergency response • Public Safety personnel on-scene requests an emergency response 2. EMS Units and First Responders may be diverted from a lower priority incident to a higher priority incident based on EMD Protocol, if the diversion provides a significant time savings. 3. The EMS unit or First Responder may divert their response if they come upon what appears to be a higher priority incident. 4. If an EMS unit comes upon an MVC with potential for injured patients the unit may divert from their original call and request another unit be dispatched to their original call. 4. EMS Units and First Responders may by-pass an MVC incident if it appears that there are no injuries while they are en route to a higher priority call. 911 Communications should be notified so that another EMS resource may be assigned to the lower priority incident.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 14 Equipment Failure
Standard: Any patient care equipment that fails to function as it was intended while managing a patient will be removed from service and reported to the EMS Battalion Chief and Deputy Chief via incident report. Purpose: Define a process for tracking, reporting and evaluation of patient care equipment that has failed to function as it was intended while managing a patient. Application: 1. To minimize the risk of equipment failure each agency shall maintain a daily equipment check sheet and periodically test biomedical equipment in accordance with manufacturer recommendations. 2. If there is a failure of equipment during patient care which is deemed essential to the ongoing care of the patient immediately contact the EMS communications center or Battalion Chief, advise them of the failure, and have the nearest appropriate resource dispatched. This may be a supervisor, an ambulance, or some other resource, depending upon patient need. 3. Based on the condition of the patient request that the resource respond either emergency (Code 3) or non-emergency (Code 1). The decision to await the arrival of replacement equipment is at the discretion of the on-scene provider in charge and dependent upon how essential the equipment is to the ongoing management and/or monitoring of the patient. 4. Closely monitor and treat the patient to the best of your ability with the remaining functional equipment. 5. While it is appropriate to notify supervisory personnel of the failure care and transport should not be delayed while awaiting the arrival of a supervisor (unless the supervisor is responding as the nearest resource based on #2 above). 6. 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 equipment shall not be utilized in patient care activity until the Battalion Chief and Deputy Chief have received documentation that the equipment was evaluated by the manufacturer or their approved service agent. 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. 7. A incident report shall be completed and forwarded to the Battalion Chief as soon as practical after the failure. In all cases, this report shall be completed prior to the end of the provider’s tour of duty. 8. This standard should be applied in addition to any process established by a system organization and is not considered a substitute for the organizational reporting requirements.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 15 Hospital Diversion
Standard: This standard establishes the conditions under which a System hospital may go on diversion and the process by which this should be implemented and discontinued. Purpose: • The SMHC EMS System, with few exceptions, employs a no diversion policy for the transport destination of EMS patients • This standard was developed in cooperation with the hospital networks, the medical community and the Capital Area Trauma Regional Advisory Council. Application: 1. All hospitals are to remain open to EMS patients at all times except in the conditions described herein or in extraordinary circumstances with approval of the Medical Director. 2. Black-Internal Disaster: • If a hospital experiences an “Internal Disaster” such as Fire, Utility Failure or other significant infrastructure failure they may close to EMS transports(and all other services) • If a hospital with a specialized designation such as a “Stroke Center” experiences failure of critical equipment needed to meet that requirement (i.e., CT Scanner) they may close to EMS transports for that particular patient category 3. Black-Trauma Priority: • This does not include any patients meeting Trauma Activation criteria • This diversion status is limited to two hours and expires automatically unless an extension is requested 4. Any attempt to divert patients due to reasons other than those listed above should result in notification of the Battalion Chief. 5. In each case listed above Transport units, Battalion Chief, and other individuals will be notified of the change in hospital status via radio broadcast, pager, or phone. 6. EMS Transport units should honor the request of the affected hospital by diverting patients to another appropriate open facility. The patient should be informed of the reason the hospital is diverting EMS patients and in the absence of a time critical or unstable patient condition the EMS provider(s) should recommend that a patient be transported to another network hospital where possible. When a time critical or unstable patient condition exists the recommendation should be transport to the closest appropriate facility that is not on diversion. If the patient refuses the recommended destination the EMS unit should transport the patient to a facility (not on diversion) of their choosing.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 2 CS – 16 Hospital Diversion
7. If a patient insists on being transported to a facility on diversion providers should explain the reason for the diversion status and that transport to that facility may result in significant delays in their care, worsening of their condition or even death. Providers may use any means at their disposal to convince the patient of the need to go to an alternate facility. This includes, but is not limited to, contacting a supervisor or on line medical control at the diversion facility. If a patient insists on transport to that facility and the only alternative is refusal of transport the EMS provider(s) should have the patient sign a refusal acknowledging the explained risks of transport to that facility and transport the patient to their destination of choice. If that hospital is unable to care for the patient due to a lack of equipment or expertise (e.g. STEMI to non-PCI facility, Stroke to facility without CT capabilities, etc) the EMS providers should advise their supervisor of the situation and upon arrival at the destination remain immediately available for transfer of the patient. The length of this availability is to be determined in consultation with the EMS Supervisor. The provider should thoroughly document their description of the risks and their efforts to convince the patient to go elsewhere. 8. If a hospital has closed to all patient traffic including walk-ins due to catastrophic loss of capabilities or potential threat to the safety of both providers and patients the hospital is no longer considered an approved receiving hospital until the condition is removed. Patients should be informed that the hospital is closed and that they will be denied access to the facility. The patient should be transported to another appropriate facility in accordance with #6 above. If a patient still wishes to refuse transport they should be informed of the risks and a refusal obtained in accordance with the Refusal of Treatment/Transportation Standard.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 16 Human Trafficking
Standard: Assessment of potential human trafficking victim:
• Suspect patient may be a potential victim • Protect the life of the victim from harm, as well as that of the EMS team from liability and potential violent situations. • Respect the privacy of the patient • Collect as much evidence as possible, especially information. Purpose: The U.S. Department of Homeland Security defines trafficking as “modern-day slavery involving the use of force, fraud, or coercion to obtain some type of labor or commercial sex act.” Human trafficking is a hidden crime and victims rarely come forward to seek help. Recognizing key indicators of human trafficking is the first step in identifying victims. Not all indicators are present in every human trafficking situation and the presence or absence of any indicators is not necessarily proof of human trafficking. NEVER attempt to confront a suspected trafficker directly or alert a victim of suspicions. Get law enforcement involved. To report suspected human trafficking:
• Help from National Human Trafficking Hotline: 1-888-373-7888 • Text HELP or INFO to 233733 (BeFree).
Application: 1. Immediately contact law enforcement for assistance 2. Stabilize and treat all injuries. 3. Attempt to separate patient from other individuals 4. Do not initiate a report to law enforcement or Human Trafficking Hotline in front of handler, or others present. 5. Do not confront patient or any others present. 6. Make every attempt to convince patient to accept transport to the hospital. 7. If patient is transported to the hospital, do not allow others on scene to ride with them in MICU. 8. If patient identifies as a human trafficking victim, notify ED of trafficking victim prior to arrival. 9. If adult patient does not consent to trafficking reporting, you can mention red flags observed or that the patient expressed to hospital staff or ED social worker. 10. Keep in mind that if patient is a minor, consent does not need to be obtained. 11. Transport to a hospital that has an onsite social worker. 12. Document: a. In their own words (in quotation marks) all statements made by the patient and all others on scene, including statements made about the manner of the injuries or illness. b. All injuries and findings of physical exam. c. Any abnormal behavior of the patient or any others on scene. d. The condition of the environment and all others present.
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Human Trafficking
e. If potential minor victim or an adult victim who consents: who received report of human trafficking. 13. Transport Providers a. If notification of human trafficking has been made to law enforcement or The National Human Trafficking Hotline, notify the appropriate Battalion Chief to provide support for the completion of reporting process. 14. If patient refuses help: provide patient information on how they can receive help (Human Trafficking Hotline phone number and information to text BeFree).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 17
Identification Badges
Standard: Identification badges are used by SMHC EMS and all Hays County emergency services, law enforcement and other related government departments (fire marshal, emergency management, etc.). Hays County by agreement has adopted the Southwest Texas Regional Access Card (STRAC) as the primary method for county wide identification of personnel. The goal of the county wide system is to efficiently and quickly identify on scene responders/providers and their specific capabilities. It is the responsibility of any county organization to issue badges to all registered personnel as well as immediately collect the badges of those individuals whose credentials have been revoked, or who are no longer associated with the organization. Collected badges will be destroyed immediately. Purpose: Due to the variety of responders/providers with different levels of training an ID badge system is required to ensure that everyone on scene knows the specific capabilities of each responders/providers. Application: 1. Proper identification of responders/providers is required by the Texas Department of State Health Services. 2. Identification badges serve as the primary identifier for System Credentialed individuals as well as his/her Credential level. 3. These badges are intended for use as organization or department identification. 4. Proper identification of responders/providers will facilitate the exchange of patient information within the guidelines established by Health Insurance Portability and Accountability Act (HIPAA). 5. Badges should be visibly worn by any responder/provider providing any level of patient care. The exception would be when circumstances require the responder to utilize personal protective outerwear (i.e. bunker gear, rain gear, etc.). 6. Badges are valid throughout the System and are not limited to specific venues or defined response areas. 7. A System Provider that is currently system credentialed, but without a badge is, at that point, functioning as a First Aid Provider. In cases where an individual is recognized and known to be a currently credentialed provider in the System, the provider in charge of patient care may, at their discretion, allow the individual to participate in patient care. The lead transport medic and the provider in question are responsible for assuring badge compliance, but all Providers on scene are charged with pointing out any on- scene discrepancies. 8. A System Provider who performs a procedure they are not credentialed to perform is functioning outside the scope of his/her practice. The Provider performing the procedure in question and the provider in charge of the scene should both immediately report the occurrence using your Organization's defined Clinical Error Reporting Process. Failure to do so may be considered a component of falsification of documentation and may result in action against the providers credential and/or State Certification/License. This does not apply to candidates in an approved training program operating under the supervision of their training officer. 9. Carefully read the Southwest Texas Regional Access Card Visual Identification Guide for more information.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 2 CS – 18 Identification Badges
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 18 Infant Abandonment
Standard: Texas law provides a responsible alternative to mothers who might otherwise abandon or harm a newborn child. It states that a parent may leave an unharmed infant, up to 60 days old, at any hospital, fire station or EMS station with “no questions asked.” Sec.262.302 of the Texas Family Code, states…(a) A designated emergency infant care provider shall, without a court order, take possession of a child who appears to be 60 days old or younger if the child is voluntarily delivered to the provider by the child's parent and the parent did not express an intent to return for the child. (b) A designated emergency infant care provider who takes possession of a child under this section has no legal duty to detain or pursue the parent and may not do so unless the child appears to have been abused or neglected. The designated emergency infant care provider has no legal duty to ascertain the parent's identity and the parent may remain anonymous. However, the parent may be given a form for voluntary disclosure of the child's medical facts and history. (c) A designated emergency infant care provider who takes possession of a child under this section shall perform any act necessary to protect the physical health or safety of the child. The designated emergency infant care provider is not liable for damages related to the provider's taking possession of, examining, or treating the child, except for damages related to the provider's negligence. Purpose: To provide: • Protection to infants that are placed into the custody of an EMS provider under this law. • Protection to EMS systems and personnel when confronted with this issue. Application: 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 as soon as infant is stabilized 6. Transport infant to medical facility per protocol 7. Assure infant is secured in appropriate child restraint device for transport 8. Document protocols, procedures, and agency notifications in the PCR.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 19 Interfacility Transfers
Standard: Establish a process for guidance on Emergent Critical-Care, Hospital-to-Hospital transfers. Purpose: The transport of a patient who requires transport from one medical facility to another. These patients often present on multiple medications and infusion pumps and may have medical devices in use which are unfamiliar to EMS personnel. Application: 1. The transporting paramedic should ensure that all appropriate documentation accompanies the patient. Known STEMI patients are an exception to this rule. An MOT must be obtained but all other records may be faxed to the receiving facility if not presented at time of transfer. 2. While in transit to the new facility, all appropriate standing orders shall remain in place. 3. If the patient deteriorates, the transferring facility should be notified via radio or cellular phone. Additional orders if needed should be obtained from the receiving physician or facility whenever possible. 4. For any medication not included in the System Clinical Operating Guidelines, specific orders must be provided by the sending facility. 5. The attending EMS crew is responsible for ensuring that they are familiar with all medications, pumps, or devices prior to departure. Medication or equipment questions should be discussed with the transferring nurse or physician prior to transport. 6. When transporting hospital staff, both the transport crew and accompanying staff are responsible for management of the patient. 7. All EMS rendered treatments must comply with the System Clinical Operating Guidelines and/or instructions from the transporting or receiving physician. 8. An SMHCEMS patient care record will be completed in accordance with the Documentation of the Patient Care Report Standard. 9. All medications/procedures approved by the System Clinical Operating Guidelines are approved for ALS transfer regardless of the method of administration. 10. In addition to medications/procedures included in the System Clinical Operating Guidelines, Appendix “Interfacility Medication and Staffing Requirements lists those medications and devices approved for ALS transfer and those that require the patient to be accompanied by a nurse. If a medication is not on this list or requires a nurse to accompany the patient during transfer contact the Supervisor for consultation with Online Medical Control. The following items are required equipment for all transfers. • Cardiac monitor/defibrillator • Combo kit with oxygen • Obstetrics kit (OB/GYN transfers only) 11. All patients that fall within the intent of this Standard should, at a minimum receive: • Continuous ECG and oxygen saturation monitoring • Non-invasive hemodynamic monitoring (auscultated bold pressure, palpated pulse rate)
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 20 Minimal Equipment to Patient Side
Standard: It is the responsibility of each SMHC EMS provider to ensure that the necessary equipment needed to appropriately care for each patient is available, accessible, and in working order. Purpose: System providers are often faced with patient conditions that require immediate intervention in order to decrease morbidity or prevent mortality. Time dependent interventions are those that must be performed immediately or within seconds/minutes to be effective. Application: System providers will ensure that all appropriate equipment is taken to the patient’s side and immediately available for use based on the call information as relayed by dispatch, other on- scene responders, or bystanders.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 21 On-Scene Patient Care Authority
Standard: Establish the clinical hierarchy of authority for on-scene patient care. Purpose: Credentialed Providers within the System are responsible for providing patient care in accordance with the prescribed protocols, standards and procedures. However there may be times when providers disagree about the care being delivered. Patient safety is the responsibility of every provider and any concerns should be immediately brought to the attention of other caregivers at the scene. In ANY disagreement regarding circumstances relating to patient care a professional demeanor and focus on the best interest of the patient is paramount. In order to maintain an orderly scene and allow rapid resolution of conflict a hierarchy of clinical responsibility must be established. Application: 1. In the event of conflicting approaches to providing patient care, extraction, or transport, it is the responsibility of the on-scene Credentialed Providers to reach consensus as to the most appropriate care for the patient(s). In the event of unresolved conflict, the Senior Credentialed Provider on-scene has final authority and responsibility for decisions regarding patient care. If there is a conflict involving a supervised provider (Cadet/Student) the assigned training officer has authority (at their level of Credential) and should be consulted. 2. Seniority of Credentials (in ascending order) is: • System Responder • Emergency Medical Technician — Basic • Emergency Medical Technician — Intermediate • Paramedic First Responder • Paramedic Transporting Unit • FTO on Transporting Unit • Captain on scene • Clinical Officer/Chief Officer on scene • On-scene Physician (In accordance with the Physician on Scene Standard) • On-Line Medical Control or designee • EMS System Medical Director or designee 3. All significant or unresolved conflicts regarding on-scene management of patients should be reported via the appropriate chain of command and will be retrospectively reviewed in accordance to each organization’s Event Review Process. 4. If any provider, regardless of credential, feels the conflict negatively impacted patient care the incident should be reported to the Office of the Medical Director as soon as practical without causing an additional impediment to care.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 22 Patients with Special Healthcare Needs
Standard: This standard is established to provide quality patient care and EMS services to patients with special health care needs. It is also important for the EMS providers to understand the need to communicate with the patients, family and caregivers regarding health care needs and devices that EMS may not have experience with. Purpose Medical technology, changes in the health care industry, and increased home health capabilities 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. Application: 1. Emergencies involving special needs patients may involve equipment (e.g. LVAD or vagus nerve stimulation device, etc.) that is unfamiliar to the provider. To familiarize themselves with the equipment providers may: • ask family or caregiver to accompany the patient in the ambulance to assist with the equipment. • ask the family, caregiver or patient for any documentation or specific information regarding the condition and/or device; • contact the patient’s primary care physician or OLMC for assistance with specific conditions or devices or for advice regarding appropriate treatment and/or transport specific to the patients condition. 2. Transportation will be to the hospital appropriate for the specific condition of the patient. In some cases this may involve bypassing the closest facility for a more distant yet more medically appropriate destination.
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Standard: The medical direction of prehospital 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 Texas Medical Board of the State of Texas. Purpose: This standard is established to identify a chain of command for System providers when dealing with physicians on scene and to assure the patient receives the maximum benefit of appropriate physician resources. Application: The TMB has specific rules pertaining to the authority of a physician to order specific patient care interventions on the scene of a medical call. There are two different types of situations regarding on-scene physicians. One is when the patient’s own physician is on-scene (“Patient’s Personal Physician”). The other is when a physician that does not have an established relationship with the patient is on-scene (“Intervener Physician”). 1. Physician On-Scene/General Guidelines: • The Credentialed Provider on-scene is responsible for management of the patient(s) and acts as the agent of the Medical Director or OLMC • In order to participate in care, the patient’s personal physician or intervener must present a valid Texas Medical Board License (all physicians are issued a wallet card) or be recognized as a physician by the Provider 2. Patient’s Personal Physician On-Scene: • If the patient's personal physician is present and assumes care, the Credentialed Provider should defer to the orders of the patient’s personal physician if the directed practice is within the scope and training of the credentialed provider • The patient’s personal physician must document his or her interventions and/or orders on the EMS Patient Care Record • OLMC should be notified of the participation of the patient's personal physician either from the scene or on arrival at the emergency department • If there is a disagreement between the patient’s personal physician and the System COGs, the physician shall be placed in direct communication with OLMC at the receiving facility. If the patient’s personal physician and the on-line physician disagree on treatment, the patient’s personal physician must either continue to provide direct patient care and accompany the patient to the hospital, or must defer all remaining care to the on-line physician 3. Intervener Physician On-Scene: • If an intervener physician is present at the scene, has been satisfactorily identified as a licensed physician and has expressed willingness to assume responsibility for care of the patient, OLMC should be contacted. The on-line physician has the option to: • manage the case exclusively • work with the intervener physician • allow the intervener physician to assume complete responsibility for the patient • If there is a disagreement between the intervener physician and OLMC, the Provider will take direction from the on-line physician and place the intervener physician in contact with the on-line physician • The intervener physician must document his or her interventions and/or orders on the EMS Patient Care Record
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• The decision of the intervener physician not to accompany the patient to the hospital shall be made with the approval of the on-line physician • Medical orders are not accepted by any non-physician health care providers unless specifically approved by OLMC
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 24 Provider Clinical Performance Review
Standard: To establish a standardized process for the Medical Director to conduct a thorough review of significant clinical performance concerns to identify potential improvements including revocation of a Provider’s System Credentialing privileges. Purpose: The Medical Director will convene a Clinical Performance Review when he believes sufficient information exists to warrant a more thorough and complete review prior to making decisions regarding a provider’s credentialing privileges. The Office of the Medical Director will conduct the Clinical Performance Review as described in the Clinical Performance Review Process. All Clinical Performance Reviews will be conducted in a fair, objective, respectful, confidential and patient focused manner.
Definition: Clinical Performance Review Team shall consist of the SMHC EMS Medical Director, SMHC EMS Administrative Battalion Chief as well as any other SMHC EMS provider who is asked to participate in the review process with the approval of the Medical Director.
Application: 1. The Medical Director determines the need for a Clinical Performance Review. 2. The Clinical Performance Review Team will meet requirements intended to ensure a fair and objective review. 3. Conflicts of interest will be managed by the SMHC EMS to ensure a fair and objective review. 4. All aspects of the review including the proceedings, recordings and documents are considered confidential under the Texas Health and Safety Code Section 773.095. 5. All persons involved in the Review follow all requirements for confidentiality as described in the Clinical Performance Review Process document. 6. Each System Organization and Individual Provider will fully participate in the Clinical Performance Review as requested by the Medical Director. Failure to do so may result in the suspension or permanent revocation of a providers credentials by the Medical Director. 7. The Clinical Performance Review will be conducted in an expedient manner without compromising the focus on performance improvement and a thorough review. 8. The final recommendation of the Clinical Performance Review Team is considered by the Medical Director in determining the next course of action. 9. Once a course of action is made by the Medical Director, a provider may appeal the decision directly to the Medical Director. No other appeals are available with regard to the status of system credentialing privileges. 10. The Office of the Medical Director will maintain the original Clinical Performance Review records. 11. The credential status of all providers practicing under the license of the Medical Director is at the discretion of the Medical Director.
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Standard: Define credentialing and the credential levels of providers within the System. Definitions: Certification or Licensure: an individual who is certified or licensed by a regulatory body as minimally proficient to perform emergency prehospital care at a particular level that is defined by TDSHS (e.g., system responder, EMT-B, EMT-I, EMT-P). Credential to Practice: a process that is defined by the Medical Director that requires a certified or licensed individual to demonstrate competency to practice at a specified level of prehospital care. The credential to practice does not necessarily match the individual’s certification or license. Purpose: Every Provider that delivers medical care within the System must be "Credentialed to Practice" in addition to holding a current State of Texas Certification or Licensure. Volunteer providers are excluded from certification and licensure requirements. All Credentialed Providers within the System are allowed to provide care under the delegated authority of the Medical Director in accordance with the rules of the Texas Department of State Health Services and the Texas Medical Board. Credentialing is the final approval by the System Medical Director that ensures an individual's competency to care for patients as part of the Emergency Medical Services System. An individual is "Credentialed to Practice" when he or she successfully meets and maintains the defined Credentialing requirements. The levels of Credentialing are: Emergency Medical Dispatch (EMD) System Responder (volunteer and/or EMR) Emergency Medical Technician - Basic (EMT-B) Emergency Medical Technician - Intermediate (EMT-I) Emergency Medical Technician - Paramedic (EMT-P)
Credentialing Requirements: Every provider will be required to demonstrate sufficient knowledge of the Clinical Operating Guidelines in accordance with the provider’s credential level. Following successful completion of the Field Training Evaluation Program (FTEP), every provider will be expected to demonstrate core foundational skills, knowledge and critical decision-making as demonstrated by successful completion of the following: San Marcos Hays County EMS providers (all levels): EMT-B: hands-on skills assessment, BLS written knowledge assessment, and oral interview with System Medical Director EMT-I: hands-on skills assessment, BLS written knowledge assessment, and oral interview with System Medical Director EMT-P: hands-on skills assessment, ALS written knowledge assessment, and oral interview with System Medical Director First Responder Organizations (all levels): EMT-B/I: hands-on skills assessment and BLS written knowledge assessment
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EMT-P: hands-on skills assessment, ALS written knowledge assessment plus oral interview with the System Medical Director within the first year following successful completion of the skills and knowledge assessments. Emergency Medical Dispatchers (Hays County and City of San Marcos) and Other System Providers: EMDs and system responders (e.g. ECA): Current CPR certification. EMDs only: EMD written knowledge assessment administered by their respective dispatch center. Re-credentialing Process: Every provider will be required to maintain up to date knowledge of the clinical operating guidelines, attend all continuing education as required by their respective organizations, and actively participate in any performance improvement processes as requested. In addition, all providers will be expected to demonstrate ongoing core foundational skills, knowledge and critical decision-making as demonstrated by successful completion of the following: San Marcos Hays County EMS providers (all levels): EMT-B: Annual hands-on skills and BLS written knowledge assessments; oral interview with system medical director every two years EMT-I: Annual hands-on skills and BLS written knowledge assessments; oral interview with system medical director every two years EMT-P: Annual hands-on skills and ALS written knowledge assessments; oral interview with system medical director every two years Advanced skills requiring maintenance of competency: 1. Endotracheal intubation: 10 simulated intubations every 6mos 2. Cricothyrotomy: 2 simulated cricothyrotomies per year 3. Needle decompression: 2 simulated decompression attempts every 6mo Preference is given to simulated skills practice on cadavers when possible. First Responder Organizations (all levels): EMT-B/I: Annual hands-on skills assessment and BLS written knowledge assessment EMT-P: Annual hands-on skills and ALS written knowledge assessment Emergency Medical Dispatchers (Hays County and City of San Marcos) and Other System Providers: Maintain and demonstrate current CPR certification. EMDs: Annual EMD written knowledge assessment administered by their respective organization. Skills Assessment: The Skills Assessment is developed by the San Marcos Hay County EMS Training Captain, approved by the System Medical Director, and may be administered by any trained Medical Officers. Skills checklists will be made available to all providers prior to the assessment. The following skills will be considered for inclusion in the assessment: Pit Crew CPR Resource-limited CPR
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Lucas application Automatic/Manual defibrillation BIAD placement Bag-Valve-Mask Ventilations with airway adjunct Spinal motion restriction Blood glucose testing IV placement CPAP administration Needle decompression Intra-osseous needle placement Neonatal resuscitation IM/IN/IV drug administration Foreign body removal ECG acquisition Pacing Intubation Synchronized cardioversion Splint application (including Hare traction) Patient restraint Tourniquet application Cricothyrotomy Vital signs acquisition Orthostatic vital signs
Written Knowledge Assessment: The written knowledge assessment will be used to identify common knowledge gaps to be addressed via continuing education offerings. This assessment will be developed and approved by the San Marcos Hays County EMS Training Captain with System Medical Director Approval. The assessment may be completed online. Results of the assessment will be shared with the provider. Aggregate results will be shared periodically with the larger system. Oral Interview with System Medical Director: The purpose of the oral interview is to assess the provider’s clinical decision-making ability. The discussion will center around common clinical scenarios and management. These interviews will offer an opportunity for the System Medical Director to meet providers who will be providing care under his/her medical license and for the provider to better understand the expectations of the System Medical Director. Failure to Credential Any system provider who fails to successfully fulfill the Credentialing/Re-Credentialing requirements by the timeline will be offered a second attempt within 3 to 6mos of the initial attempt. Failure on the second attempt will result in remediation or reassignment to a lower credential level. Failure on a third attempt will result in reassignment to a lower credential level when applicable or system de-credentialing.
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Standard: Define qualifications in specialty areas that may include additional maintenance requirements or training. Purpose: To establish specific qualifications for specific groups of providers in the system. Qualifications may or may not be tied to specific levels of credential to practice and are requirements that are in addition to the credential to practice requirements. The ability to practice using the knowledge, skills or medications afforded a qualification is at the discretion of the Medical Director. The awarding of system qualification(s) is at the discretion of the Medical Director and may be suspended or revoked in conjunction with or independent of a provider’s system credential or organizational job title. The Qualifications available may change based on the needs of the EMS System. Below are the current qualifications authorized by the Office of the Medical Director for qualifications, maintenance and scope of practice):
• Immunizations • Hazardous Materials Medicine • Tactical Medicine • Advanced Practice Paramedic • Canine medicine
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 27 Refusal of Treatment and/or Transport
Standard: To establish guidelines for Providers when addressing issues of consent or for patients who wish to refuse the treatment and/or transportation offered. Purpose: Adult patients with present mental capacity retain the right to refuse care and/or transport against medical advice. Definitions: Informed Consent Informed consent is based on an individuals appreciation and understanding of the facts, implications and future consequences of an action. In order to provide informed consent or refusal a patient must have adequate reasoning faculties(capacity) and be provided with information (risks/benefits) relevant to the decision making process. They should also be aware of the options available to them if they choose not to accept evaluation and/or treatment. Implied Consent In potentially life-threatening emergency situations where a patient is unable to give informed consent the law presumes that the patient would give consent if able. In potentially life- threatening emergency situations, consent for emergency care is implied if the individual is: • Unable to communicate because of an injury, accident, illness, or unconsciousness and suffering from what reasonably appears to be a life-threatening injury or illness OR • Suffering from impaired present mental capacity OR A minor who is suffering from what reasonably appears to be a life-threatening injury or illness and whose parents, managing or possessory conservator, or guardian is not present Substituted (Surrogate) Consent In some circumstances an individual with legal standing may give consent for a patient when the patient does not have the ability to do so because they are a minor, incarcerated or have been determined by courts to be legally incompetent. Parents or guardians are entitled to provide permission because they have the legal responsibility, and in the absence of abuse or neglect, are assumed to act in the best interests of the child. The following person(s) may consent to, or refuse, the evaluation, treatment, and/or transportation of a minor: • Parent • Grandparent • Adult (> 18) sibling • Adult (> 18) aunt or uncle • A minor who is pregnant and is seeking care related to the pregnancy • Educational institution in which the child is enrolled that has received written authorization to consent/refuse from a person having the right to consent/refuse. • Adult who has actual care, control, and possession of the child and has written authorization to consent/refuse from a person with the power to consent /refuse (i.e., daycare camps, soccer moms, carpools, etc.)
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• Adult who has actual care, control, and possession of a child under the jurisdiction of a juvenile court • A court having jurisdiction over a lawsuit affecting the parent-child relationship of which the child is the subject • A peace officer who has lawfully taken custody of minor, if the peace officer has reasonable grounds to believe the minor is in need of immediate medical treatment. • A managing or possessory conservator or guardian. Application: 1. All patients refusing treatment and/or transport must : • Be at least 18 years of age or an Emancipated Minor; • Be able to demonstrate present mental capacity in accordance with the Determination of Capacity Procedure. • NOT have been declared legally incompetent by a court of law. (If a patient has been declared legally incompetent, his/her court appointed guardian has the right to consent to, or refuse, evaluation, treatment, and/or transportation for the patient.) • NOT be suicidal or homicidal. (A law enforcement officer may arrest a patient who threatens or attempts suicide under Texas Health and Safety Code Section 573.001. The statute also covers other mentally ill patients and a similar statute allows an arrest for chemical dependency. Only a law enforcement officer can make these arrests.) 2. Patients meeting the above criteria who demonstrate present mental capacity retain the right to refuse any or all treatment and/or transportation. All patients should be encouraged to seek care. Additional resources may be employed including but not limited to involving the patients physician, additional providers such as a supervisor or On-line Medical Control. 3. Under no circumstances will SMHC EMS System providers refuse or deny treatment or EMS transportation to any patient (or legal patient representative) who requests medical assistance from the provider or agency. The initiation of treatment should not be dependent on the patient’s willingness to accept transport. (eg Hypoglycemia, Asthma, etc.) This does not include the administration of narcotic pain medications or sedative agents. 4. SMHC EMS System providers shall not discourage any patient (or legal patient representative) from seeking medical care from a physician or from accepting EMS transport to a hospital. 5. When a patient with present mental capacity wishes to refuse care: • The patient will be instructed that the evaluation and/or treatment is incomplete due to the limitations of the pre-hospital care environment; • The providers will attempt to identify any patient perceived obstacles to treatment/transport and make reasonable efforts to address these obstacles. This includes but is not limited to the offer of transportation without treatment, or the offer of transportation to a facility not recommended by protocol. These should be offered only for the purpose of facilitating additional evaluation and/or treatment which would otherwise be refused. • The provider will inform the patient of the risks of refusal and benefits of treatment/transport in accordance with their presenting complaint. It should be explained that the risks described are not comprehensive due to the diagnostic
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limitations of the pre-hospital environment and that their refusal may result in worsening of their condition, serious disability or death. • The patient will be advised that they should seek immediate medical care at an Emergency Department or with their own physician and that they may call 911 again at any time if they wish to be transported to the hospital or if their condition changes or worsens. Documentation: 1. The provider must document facts sufficient to demonstrate the patient’s present mental capacity and understanding of his/her condition and the consequences of refusing treatment and/or transport to include those mentioned above. 2. If a patient wishes to refuse assessment, treatment and/or transport, have the patient sign the AMA form relating to the refusal of specific assessment, treatment, destination recommendation, or transport and have a third party witness the signature. 3. If the patient refuses to sign the refusal form, the provider will document the circumstances under which the patient refused to sign. 4. When 2 or more uninjured patients refuse treatment and/or transport the provider may use the multi-patient refusal form and scan it into the PCR. Any patients with a complaint should sign a full AMA refusal.
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Standard: To provide a safe method of transporting pediatric patients within an ambulance and protect the EMS system and personnel from potential harm and liability associated with the transportation of pediatric patients. Purpose: 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. Application: 1. Drive cautiously at safe speeds observing traffic laws unless patient condition requires emergent transport in accordance with operational standards on emergency response/transport. 2. Tightly secure all monitoring devices and other equipment. 3. Ensure that all pediatric patient less than 40 lbs are restrained with an approved child restraint device secured as per manufacturer’s instructions if not secured by other means as part of patient care. SMHC EMS units are equipped with a pediatric stretcher mounted (Pedi-Mate) transport device. 4. Do not transport the pediatric patient who meets trauma activation criteria in a child seat that was involved in the collision. 5. Ensure that all EMS personnel use the available restraint systems during transport when not otherwise engaged in patient care activities. 6. Transport adults and children who are not patients, properly restrained, in an alternate passenger vehicle, whenever possible. 7. Do not allow parents, caregivers, or other passengers to be unrestrained during transport. 8. Do not hold or allow the parents or caregivers to hold the patient during transport. 9. For patients with medical conditions that may be aggravated by stress, make every attempt to optimize safety when comforting the child.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 1 CS – 29 Suspension or Revocation of Credential to Practice Standard: To identify potential circumstances that may lead to a provider’s credential to practice being suspended or revoked. Purpose: In the SMHC EMS System, a provider’s ability to practice medicine is based on the Medical Director’s authorization. Individuals and agencies that are part of the EMS System must always focus on providing appropriate clinical care. Accountability for actions taken lies with individual providers and agencies. The System strives to be an error-friendly system that will focus on a non-disciplinary approach to support and re-educate members of the System. However, circumstances may arise that require a change in Credential status, such as suspension or revocation. Application: 1. In the System, a provider’s credential to practice may be temporarily suspended, if in the opinion of the Medical Director, the provider’s actions pose a threat to the safety of current or future patients of the System. The providers credential may be permanently revoked, if substantiated through a process of appropriate investigation and review, for any of the following actions: • Falsification of a patient care document • Intentionally withholding care from a patient • Intentionally harming a patient • Providing care while impaired by alcohol or drugs • Failure to remediate and/or participate in required education and/or review 2. Additionally, there may be other circumstances that result in suspension or revocation of System Credentials. These may include, but are not limited to, the following: Lapse, Loss, or Suspension of TDSHS Certification or Licensure In the event that a Provider’s TDSHS Certification/Licensure is allowed to lapse, the following process will apply: • Unless confirmation of renewal, extension or upgrade can be verified and documented on the TDSHS website, the Provider’s Credentials to Practice will be suspended. System Credentialing badges must not be worn. • The suspension will remain in effect for no more than three (3) months from date of TDSHS certification/licensure expiration. Based on extenuating circumstances, documented in writing, and forwarded to the Medical Director for consideration, extensions may be granted. • Without documented proof of renewal or upgrade or extension granted by the Medical Director, the Provider’s Credentials will be revoked at the conclusion of the 3 month suspension period and the provider will be separated from employment or affiliation. The Provider’s System Credentialing Badges must be returned to the SMHC EMS. • Should a Provider renew or upgrade their TDSHS certification/licensure following revocation of Credentials, he/she will be required to complete the current Initial Credentialing Requirements for their level of Practice.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 1 of 2 CS – 30 Suspension or Revocation of Credential to Practice 3. Separation from All System Registered Responder Organizations In order for a Provider to be Credentialed in the System, he/she must be associated with a Registered System Organization. The following outlines the process for Providers who leave or disassociate from a Registered System Organization: • A Provider is required to immediately notify the Office of the Medical Director when he/she is no longer affiliated with a Registered System Organization. When it is determined that a Provider is not associated with a System Organization, his/her Credentials will be suspended for a period of 30 days. System Credentialing badges must not be worn. During this period, the Provider may affiliate with another System Organization without being required to Recredential. The 30 day timeframe may be extended upon written request to the Medical Director. • ILS and ALS Credentialed Providers must continue affiliation with a system organization to maintain ILS or ALS Credentials. • After 30 days without affiliation (unless an extension is granted) with a System Organization, a Provider’s Credentials will be revoked. • Should a Provider affiliate with a System Organization following revocation of Credentials, he/she will be required, to complete the current Initial Credentialing Requirements for their level of practice. New badges will be issued at that time. 4. Activity That May Pose a Threat to Public Health • Criminal or Regulatory activity that may pose a threat to public health, or other circumstances as deemed appropriate, will be reviewed by the Office of the Medical Director. • Individual providers and their respective Organizations are responsible to report any arrests of the provider involving alcohol, drugs or a felony directly to the OMD on or before the 1st business day after the arrest is made. Failure to do so may result in immediate suspension. Reporting the event to the TDSHS is the responsibility of the individual provider and must occur in accordance to specified Rules, with the appropriate form (s) and within the prescribed timelines. • Except for those situations and processes specifically addressed, the process for suspending or revocation of Credentials will be determined by the Office of the Medical Director’s Clinical Performance Review Process. • Suspended and de-credentialed Providers may still be considered “trained citizens” and have the ability to do CPR, use an AED and/or render First Aid as appropriate. 5. Action Taken By TDSHS • Any action taken (administrative review, suspension, revocation, etc.) by the TDSHS must be reported and documentation forwarded to the Office of the Medical Director. Failure to do so may result in suspension/revocation of Credentials. • In all events concerning these issues, the Chief Officer, Director, or Program Manager of the Responder’s Organization will be advised. If deemed appropriate, the leadership of other organizations within the System and/or TDSHS may be notified. 6. The credential status of all providers practicing under the license of the Medical Director is at the discretion of the Medical Director.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 30 System Design
Standard: Define the design of the system and how the organizations integrate to form one System of Care. Purpose: The System is comprised of multiple agencies that include a diverse group of healthcare professionals including Communications Specialists, First Responders, Transport Providers, Hospital Networks (including specialty receiving centers) and Physicians with varying specialties in the community. Together, this “System” provides the basis for seamless delivery of care to acutely ill or injured patients in our community. Application: The System maximizes the opportunity to deliver appropriate care to patients as defined by the Protocols, Procedures and Standards established by the OMD (Collectively the Clinical Operating Guidelines). The goal of these documents is to provide safe consistent and sophisticated care to the citizens and visitors of the Hays County. 1. All medical care within the EMS System should be provided according to the current Clinical Operating Guidelines. 2. All individuals providing medical care as part of the EMS System will be Credentialed according to the Credentialing requirements of the EMS System. 3. Specific medical care in the system will be delivered by appropriately Credentialed AND (if applicable) Qualified individuals within the environment specified in the COGs. 4. Individuals holding current Qualifications may deliver specialty care as defined by the COGs when appropriate equipment and conditions exist. 5. All individuals providing medical care as part of the EMS System will be currently certified or licensed by the Texas Department of State Health Services or the Texas Medical Board. 6. A non-TDSHS certified/licensed and non-Credentialed individual that is trained in an approved CPR/AED Course may respond to and deliver CPR and rapid defibrillation of cardiac arrest patients. 7. All organizations providing medical care as part of the EMS System will comply with Texas Department of State Health Services requirements for Provider or First Responder Organization Licensure. 8. All 9-1-1 requests for care will be managed by 911 Communications according to the requirements of the currently adopted Medical Priority Dispatch System. This includes call triage, pre-arrival instructions and response determinants. 9. All Tier 2 First Response Organizations will be capable of delivering, at a minimum, Basic Life Support care (BLS) as defined by the OMD. 10. Appropriately Credentialed and equipped individuals may provide First Response Intermediate Life Support (ILS) or Advanced Life Support (ALS) level of care according to the COGs. 11. First Response ILS and/or ALS level of care is supplemental to the System minimum requirements. 12. All System First Response Organizations must maintain the BLS supplies identified on the Minimal Equipment List. If a System Registered Organization chooses to equip an ILS or ALS Credentialed Provider, the equipment must be supplied and maintained according to the appropriate Minimal Equipment List for that level of care.
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13. The ground transport component of the EMS System (SMHC EMS Department) will be capable of delivering ALS level care according to the Clinical Operating Guidelines when appropriate for the patient’s condition. 14. Standby and on-site Special Event Providers Minimal Equipment will be determined based on the need of the specific event. 15. Treatment of patients with “Non-prescriptive” medications that are not specifically included in the COG or not approved by specific OLMC is considered practicing outside the scope of practice and the provider’s scope of care. 16. During unusual or extreme conditions or circumstances, the above criteria may be modified by the Medical Director to best meet the needs of the patients of the EMS System.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 31 Transport Destination Decision
Standard: Define how a transport destination decision is reached taking into consideration the specialized care needs of specific conditions and the needs and preferences of our patients. Purpose Patients treated by the SMHC EMS System may have complex clinical conditions that require care at facilities with specialized capabilities or expertise in treating these conditions. In the absence of the need for specialized care patients may want to be transported to facilities based on their personal preference or the location of their physician and records. Whenever possible the providers of the SMHC EMS System will provide transport to a prescribed medical facility or their preference as a patient. Application: 1. The following assumes the patient or the patient’s guardian (in the case of a minor) has decision making capacity in accordance with the Refusal of Treatment/Transportation Standard and the Determination of Capacity Procedure. In the absence of decision making capacity or in cases where consent is implied the patient should be transported to the closest appropriate facility. If a patient wishes to refuse treatment/transport but has been determined to lack the capacity to do so providers should consult their supervisor and OLMC in accordance with the Refusal of Treatment/Transportation Standard. 2. When a patient presents with a clinical condition requiring specialized care the transporting providers will transport the patient to the closest facility that offers the specialized care for that patient’s condition. (STEMI, Stroke, Trauma, Resuscitation Center, Pediatric care, etc). 3. If a patient refuses to go to the recommended facility transport providers will explain the benefit of transport to the recommended facility and the risk of transport to another facility. If the patient still refuses transport to the recommended facility transport providers will recommend transport to the next closest appropriate facility for their condition. 4. If a patient continues to refuse transport to the alternative specialty care facility or requests transport to a facility that lacks the ability to care for the patient condition the transport provider will make every effort to explain the need for the specialty care facility. These efforts may include but are not limited to contacting the patient’s physician, a supervisor, on-call Medical Director or OLMC at the facility the patient wishes to be transported to. 5. If after the efforts described above the patient continues to request transport to a facility not recommended for the patient’s condition the transport providers will transport the patient to the facility of the patients choosing. They should notify their supervisor and the receiving facility of their transport. On arrival at the facility the crew should consult with the attending physician to determine if the patient will be transferred. If such a transfer is imminent the provider should contact their supervisor and remain immediately available to transfer the patient after the required screening examination by the receiving facility. The duration of this availability is t 6. o be determined by the supervisor based on the patient’s condition and the anticipated time to transfer. 7. If a patient does not have a condition that requires transport to a specialized facility as prescribed by protocol the providers will transport the patient to an approved system facility of the patients choosing. When a patient requests transport to a facility other than an approved system facility the transport decision should be made in consultation with a supervisor. If in the providers opinion the patient’s condition warrants transport to a closer facility for rapid stabilization the need for this destination should be explained to the patient
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and every effort made to deliver the patient to the closest appropriate facility. These efforts may include but are not limited to contacting a supervisor or OLMC. If the patient continues to refuse the recommended destination the patient will be advised of the associated risks and transported to the destination of their choosing. 8. If the patient has an MOT or if transport has been arranged by another healthcare provider the transport provider should transport the patient to the destination indicated by the MOT or sending healthcare provider in accordance with the MOT Standard. 9. If the patient does not have a condition that requires specialty care as prescribed by protocol and does not have an expressed preference the transport provider may transport the patient to the closest appropriate facility. 10. In the event multiple patients from the same event are to be transported in one unit the patient with higher acuity determines the transport destination. Where the need for different facilities can be anticipated reasonable efforts should be made to split the patients at the scene as long as doing so does not place either patient in danger. 11. Any refusal of treatment or recommended transport destination should be performed and documented in accordance with the Refusal of Treatment/Transport Standard and Determination of Capacity Procedure.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL STANDARD UPDATED 02012020 PAGE 2 of 2 CS – 32 Transfer of care to Provider of Lesser Credentials Standard: To define circumstances and establish a process for transferring patient care from a higher credentialed provider to one of lesser credentials. Purpose: Providers may be presented with multiple patients, limited resources, or patient conditions requiring early rapid transport in order to maximize potential outcome (for example one critically injured patient and multiple non-injured occupants in a motor-vehicle collision). These situations may require that patients be left in the care of a lesser credentialed provider. The ultimate decision of whether or not to initiate transport of a critically ill or injured patient while awaiting additional resources rests with the on-scene Provider with the most advanced level of system Credentials as defined in Authority for Patient Care. Application: When transferring care to a provider of lesser credentials the following applies: 1. Leaving patients on-scene should not be a routine procedure. It is to be considered only when a patient requires immediate transport in order to maximize potential outcome. 2. The transport Provider may transfer patient care to a Provider of lesser Credentialing when transfer of established care is not beyond the scope and/or training of the Provider(s) assuming care (i.e., an intubated patient may not be left with a System Responder level provider or EMTB Credentialed Provider). 3. All patients should be accounted for, assessed and triaged, and appropriate additional resources requested prior to transport of the critically injured patient. 4. No patient requiring immediate advanced stabilization (i.e., pleural decompression, intubation, defibrillation etc.) is to be left on-scene awaiting additional resources unless an appropriately credentialed and equipped Provider is present and able to perform such care. 5. Mass and Multi-casualty incident transport decisions will be made by the on-scene command structure.
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Clinical Protocols
Transport COG Table of Contents
Universal Protocols: All Patients...... Page Universal Patient Care...... U-01 IV Access...... U-02 Patient Safety...... U-03 Deceased Person...... U-04 Spinal Motion Restriction...... U-05
Adult Protocols: Patients ≥ 37 Kg...... Page Airway, Adult...... R-01 Airway, Adult - Obstruction...... R-02 CHF & Pulmonary Edema...... R-03 Respiratory Distress...... R-04 RSI/Medication Assisted Intubation (>37kg)...... R-05 Asystole/PEA...... CA-01 Ventricular Fibrillation & Pulseless Ventricular Tachycardia...... CA-02 Induced Hypothermia ≥ 18yrs...... CA-03 Suspected Acute Coronary Syndrome...... C-01 Bradycardia ...... C-02 Atrial Fibrillation with RVR...... C-03 Supraventricular Tachycardia...... C-04 Wide Complex Tachycardia (VT) With a Pulse...... C-05 Allergic Reaction ...... M-01 Altered Mental Status...... M-02 Bites and Envenomations...... M-03 Fever/Infection Control...... M-04 Hyperkalemia…………………………………………………………………………………………….……………………………….…..M-05 Hypertensive Crisis………………………………………………………………………………………………………………………….M-06 Hyperthermia...... M-07 Hypothermia ...... M-08 Nausea/Vomiting ...... M-09 Non Traumatic Bleeding...... …...M-10 Overdose/Toxic Ingestion...... M-11 Pain Management...... M-12 Sedation ...... M-13 Seizure ...... M-14 Shock (Non Trauma) ...... M-15 Suspected Stroke...... M-16 Violent/Agitated Patient...... M-17 Burns – Adult and Pedi...... T-01 Drowning / Near Drowning...... T-02 Head Trauma...... T-03 Multiple Trauma...... T-04 Regional Trauma Criterion...... T-05 SMART Triage Algorithm...... T-06 Obstetrical Emergency Protocols...... Page Childbirth / Labor...... OB-01 Obstetrical Emergency...... OB-02 Newly Born...... OB-03
Pediatric Protocols: Patients < 37 Kg...... Page Pediatric Extremity Trauma...... PT-01 Pediatric Head Trauma...... PT-02 Pediatric Multiple Trauma...... PT-03 Airway, Pediatric...... PR-01 Pediatric RSI/Medication Assisted Intubation (<37kg)………………………………………………….……………....… PR-02 Pediatric Respiratory Distress...... PR-03 Pediatric Asystole/PEA...... PCA-01 Pediatric V-Fib/Pulseless V-Tach...... PCA-02 Post Resuscitation...... PCA-03 Pediatric Bradycardia...... PC-01 Pediatric Supraventricular Tachycardia...... PC-02 Pediatric Allergic Reaction...... PM-01 Pediatric Altered Mental Status...... PM-02 Pediatric Fever/Infection...... PM-03 Pediatric Hypotension (Non-Trauma)...... PM-04 Pediatric Sedation...... PM-05 Pediatric Nausea, Vomiting, and Diarrhea ...... PM-06 Pediatric Overdose / Toxic Ingestion...... PM-07 Pediatric Pain Control...... PM-08 Pediatric Seizure...... PM-09
Special Response Protocols (Adult/Pedi)...... Page Toxic Exposure Ammonia (Gas & Liquid)...... TX-01 Carbon Monoxide Exposure...... TX-02 Toxic Exposure Chlorine and Related Compounds...... TX-03 Toxic Exposure Cyanide...... TX-04 Toxic Exposure - Fumigants: Methyl Bromide, Sulfuryl Fluoride, Chloropicrin, & Phosphides ….……… TX-05 Toxic Exposure - Hydrazines...... TX-06 Toxic Exposure - Hydrofluoric Acid...... TX-07 Toxic Exposure - Hydrogen Sulfide, Sulfides, & Mercaptans...... TX-08 Toxic Exposure - Organophosphates/Nerve Agents...... TX-09 Toxic Exposure Sodium Hydroxide...... TX-10 Scene Rehabilitation Protocol Adult ≥ 37 Kg...... REHAB CPR Procedure...... CPR Pediatric CPR Procedure...... Pedi CPR Defibrillation Procedure...... …DEFIB Restraint Procedure...... RESTRAINT
Special Populations Protocols (Adult/Pedi)...... Page Adrenal Insufficency...... SP-1 MCADD 1...... SP-2 MCADD 2...... …SP-3 VAD...... SP-4
Canine Response Protocols……………………………………………………………………………………………………….……..K9
Universal Protocols: All Patients
U 0 Universal Patient Care 1
History: Key Information: Location Primary Assessment Secondary Assessment Differential: Onset Airway HEENT Vascular Precipitating events Breathing Respiratory Infectious/Inflammatory Quality Circulation Cardiovascular Trauma/Toxins Radiation Disability Abdomen Autoimmune Severity Expose Extremities Metabolic Modifying factors Neuro Idiopathic Associated symptoms Neoplastic Prior hx of same/similar Congenital SAMPLE
Legend System Scene/Crew Safety/PPE S S Responder S Bring all necessary Equipment to Patient s Side S Demonstrate Professionalism and Courtesy B EMT - B B I EMT- I I P EMT- P P M Medical Control M Initial Assessment/Physical Exam S - Adult Assessment Procedure S - Pediatric Assessment Procedure Consider Spinal Motion Restriction Protocol (U-05)
Vital Signs BP, pulse, resp. rate, pulse ox, at least every 15 minutes Temperature if pt. with hx fever or hot to touch, Monitor ECG, Pain level and ETCO2 as appropriate S Consider Glucose Measurement S
Consider Airway Protocol (R-01)
Consider 12 Lead ECG if equipped
I Consider IV Protocol (U-02) I
P Consider Cardiac Monitor P Maintain all appropriate medications and procedures Appropriate Protocol Adult or Pedi that have been initiated at the referral agency or institution
Contact Destination or M Medical Control if Patient does not fit a protocol M
Pearls: An exam is defined at a minimum of: V/S, mental status, GCS, location of injury or complaint and pain scale. This is required on every patient. For the dosing of medications or electrical therapy an adult is defined as 37 Kg. For the dosing of medications or electrical therapy a pediatric patient is < 37 Kg and also defined by the Broselow-Luten Tape. If the patient does not fit on the tape, they are considered an adult Patients should be assessed for history of motion sickness and may be treated per nausea/vomiting protocol
Clinical Operating Guidelines VTRANS02012020 U 0 2 IV Access
Universal Patient Care Protocol (U-01) Legend System S S Responder IV Procedure (CP-23) B EMT - B B I EMT- I I P EMT- P P M Medical Control M B Peripheral IV access B
Successful Unsuccessful 1st attempt and IV Continued Unsuccessful access required & Stable or Unstable
Monitor B B Continued Peripheral saline locks on transfers only I IV attempts (2) I IO Placement B B I Monitor IV infusion I
External Jugular IV for Contact Destination or life-threatening event only M Medical Control as needed M P and/or unable to gain IO P access
Pearls EMT-B providers are not permitted to take the lead provider role when IV access has been established on emergency responses. EMT-B providers are not permitted to take the lead provider role on transfers when the patient has received vasoactive and/or narcotic medications within the past 30 minutes. All others will be at the discretion of the lead paramedic level provider. In the cardiac arrest patient, any preexisting dialysis shunt or external venous catheter may be used. Intraosseous with the appropriate adult /pedi device. May use 40 mg of Lidocaine IO to reduce pain of infusion. Any pre-hospital fluids or medications approved for IV use, may be given through an intraosseous access. All IV rates should be kept at KVO (minimal rate to keep vein open) unless administering fluid bolus Upper extremity IV sites are preferable to lower extremity sites (except Cardiac Arrest). Lower extremity IV sites are contraindicated in patients with vascular disease or diabetes. Vasoactive drips should be infused through large bore IV catheter through the antecubital or larger vein In post-mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side. The IO may be the initial access for all Cardiac Arrest patients. In transported Trauma Arrest patients the IO should be performed en route to the hospital.
Clinical Operating Guidelines VTRANS02012020 U 0 Patient Safety 3
Follow Universal Patient Care Protocol (U-01)
Legend System S S Refer to Minimal Equipment to Patient/Bedside Procedure Responder B EMT - B B I EMT- I I For all weight-based drug administration P EMT- P P verify correct drug and dose prior to administration M Medical Control M
Document at the beginning of each shift the presence of all equipment, medications, and supplies. Ensure that system credentials are on your person.
In the event supplies fall below required levels, restock at the nearest appropriate location. If dispatched to a call that may require depleted supplies, contact your Command Staff.
In the event you are unable to restock vital supplies and/or decontamination is necessary, go out-of-service, clean your unit (if needed) and contact your Command Staff for resupply.
In the event of equipment failure, utilize equipment failure procedure and create an incident report appropriately tag the equipment and notify your Command Staff
In the event of a medication error, clinical error, or other adverse patient outcome, contact the Command Staff via the sequence listed below.
Contact Destination or Appropriate protocol M Medical Control if the patent M does not fit a Protocol
Transport patient per Patient Transport Policy
Pearls Notification Sequence: Medication error, clinical error or other adverse patient outcome notify the Command Staff @ (512) 618-1019 and fill out an incident report immediately. If an error occurs without adverse patient outcome and/or a "near miss" occurs, complete an incident report only.
Clinical Operating Guidelines VTRANS02012020 U 0 4 Deceased Person
History: Key Information: Differential: Past Medical History Signs/Symptoms Primary Cardiac Disease Recent Illness Dependent Lividity Homicide Last seen alive Pulseless Diving Mechanism Trauma/Medical Apneic Trauma Resuscitation efforts PTA Decapitation Asphyxiation
Universal Patient Care Protocol Legend System Meets System Responder criteria for S S S S No Responder Obvious Death, including valid DNR: Begin or continue CPR. B EMT - B B I EMT- I I Yes P EMT- P P M Medical Control M 1. Stop or do not start CPR Meets EMT-P criteria for P P No 2. Cancel First Response Pronouncement 3. Reduce all others to Code 1 Yes
Stop CPR if started and document the time provided Appropriate Arrest by communications as the Protocol pronouncement time in the PCR.
Anytime a provider feels the need to have Law Enforcement on the scene they should make the request via EMS Communications (suspicious death or assistance with family/bystanders). Criteria for withholding resuscitation; one or more of the following is present: Rigor mortis and/or dependent lividity; Decomposition, Decapitation, Incineration; Obvious mortal wounds (severe trauma with obvious signs of organ destruction) Patient submersion > 20 minutes from arrival first Public Safety to patient positioned for resuscitation. Patients with suspected traumatic mechanism found pulseless and apneic by first provider on scene with no respiratory effort after basic airway maneuvers . Fetal death with a fetus < 20 weeks by best age determination available at scene.
Clinical Operating Guidelines VTRANS02012020 U Spinal Motion Restriction 0 5 (SMR) Legend System S S Responder B EMT - B B I EMT- I I Did you find ANY of these? P EMT- P P Blunt trauma and altered level of consciousness M Medical Control M Spinal pain or tenderness Neurological complaint (e.g. numbness or weakness) Immobilization with a Long S Anatomic deformity of the spine S Spine Board (LSB) and C- High-Energy mechanism of injury AND the following: Collar IS appropriate 1. Drug or alcohol intoxication 2. Inability to communicate 3. Distracting injury
Did you find ALL of these? Normal level of consciousness (GCS of 15) Immobilization with a Long No spine tenderness S No neurological findings or complaints S Spine Board (LSB) is NOT No distracting injury necessary No intoxication
No Do not Evidence of spinal injury? No immobilize Yes with LSB Did you find this? S S Yes Penetrating trauma to the head, neck, or torso Immobilize with LSB No Did you find ANY of these and evidence of spinal Spinal precautions can be injury? maintained by application S Patients who are found ambulatory at the scene S Yes of a rigid cervical collar Patients transported for a long period of time and securing the patient Patients where a backboard is not otherwise indicated firmly to the EMS stretcher No at the providers discretion SMR at the Provider s/Responder s discretion when S concern for spinal cord injury is not addressed by S these criteria
Pearls: High-energy mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes and may indicate the need for spinal immobilization in the absence of symptoms. Ground level falls are considered to be a significant mechanism in elderly patients (>65 yrs). SMR with a c-collar should be considered. Neurologic findings or complaints may include generalized weakness, paresthesias, burning pain, or altered sensation. Consider the following guidelines on the use of a Long Spine Board (LSB): 1. Long spine boards (LSB) have both risks and benefits for patients. 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 occur in consideration of the individual patient s benefit vs. risk. Refer to CP-57 for more details including the Position Statement from the National Assoc. of EMS physicians and the American College of Surgeons. If a patient has been placed in SMR it should not be removed pre-hospital.
Clinical Operating Guidelines VTRANS02012020
Adult Protocols: Patients 37 Kg
Airway
History Signs and Symptoms Differential Past Medical History Increased Respiratory Rate Determine Mechanism of Medications Increased Work of Breathing Injury vs. Nature of Illness R Allergies Generalized Cyanosis 0 Events Leading to Current Status Altered Mental Status 1 DNR/Code Status Presence of CHF and/or SpO2 less than 85%
Assess airway and adequacy of Legend Supplemental respiration System Adequate S S Oxygen PRN Respiratory Rate, Responder Effort, Adequacy, B EMT - B B Pulse Oximetry & ETCO2 PRN I EMT- I I Inadequate Unsuccessful/Inadequate P EMT- P P
Medical Control BIAD(i-Gel) Basic Maneuvers First (BLS) M M B If unconscious B - High flow Oxygen - Open Airway/Suction without a gag relfex B B - Nasal or Oral Airway - Bag Valve Mask (BVM) Consider: - Proper Position RSI Protocol for conscious Ventilate at 8-10 bpm and patients where intubation is maintain an ETCO2 between required to maintain airway (R-05) Successful 35-45 and an SPO2 >90%
Preoxygenation with 100% O2 S Continue BVM S For 3-5 min until SPO2 >90% (2) Failed If pulse present Attempts Consider: All other Airway Interventions Surgical Airway Unsuccessful Oral-Tracheal Procedure (CP-53) I Intubation I Consider: Gastric Tube Nasal-Tracheal Procedure (CP-26) P P Contact Destination Intubation Refer to Sedation M M or Medical Control Successful Protocol (M-13)
PEARLS: An intubation attempt is defined as the ET Tube passing the teeth. This protocol is only for use in the patients with age >10 or 37 Kg or patients longer than the Broselow-Luten Tape. Capnography (EtCO2) is mandatory with all methods of intubations. Document Results. (if available) Capnography (EtCO2) is mandatory with all BIADS. Document Results. (if available) If an airway is being maintained by BVM with Pulse Oximetry >90%, it is acceptable to maintain basic airway measures instead of using a BIAD or ET. Ventilatory rate should be 8-10 bpm OR to maintain ETCO2 or 35-45 (when appropriate). Maintain SMR in those patients with suspected spinal injury. Do not assume hyperventilation is psychogenic – Use Oxygen, never a paper bag. The routine use of cricoid pressure is no longer recommended. Hyperventilation in head trauma patients should only be done to maintain ETCO2 of 35-45 Secure ET or BIAD with holder, c-collar should be used on all BIAD or intubated patients. The use of the Bougie is at the discretion of the ALS provider. Whenever a BVM is used with a Supraglottic or ET Airway, a PEEP adapter should be added to the BVM. Set at 5 mm H2O
Clinical Operating Guidelines VTRANS02012020 Airway Obstruction
R 0 2
Foreign Body Airway Obstruction Procedure (CP-3) Direct I I Laryngoscopy Legend Successful System S S Resume Good air movement Responder S BVM Ventilation S Yes and/or SPO2 >90% B EMT - B B with OPA/NPA With BVM Ventilation? Unsuccesful I EMT- I I No P EMT- P P M Medical Control M Facial Trauma/Swelling If SPO2 drops < 90% that prevents use of BVM or it becomes difficult and/or adjunct or to ventilate with BVM advanced airway?
No Yes
Adult Airway Protocol (R-01) Surgical Airway Procedure (CP-53)
Contact Destination or M Medical Control M
PEARLS:. Capnography (EtCO2 or Color Metric) is mandatory with all BIADS, Endotracheal intubations & Surgical airways. Continuous ETCO2 when available should be used on all Advanced Airways. If an airway is being maintained by BVM with Pulse Oximetry >90%, it is acceptable to maintain basic airway measures instead of using a BIAD or ET. Maintain SMR in those patients with suspected spinal injury. Continuous pulse oximetry should be used and documented. Notify Medical Control ASAP regarding patient s difficult airway or if a surgical airway has been established.
Clinical Operating Guidelines VTRANS02012020 CHF & Pulmonary Edema R History: Signs & Symptoms: Differential: Congestive heart failure Respiratory distress, bilateral Myocardial infarction 0 Past medical history rales Congestive heart failure 3 Medications (digoxin, lasix) Apprehension, orthopnea Asthma Viagra, Levitra, Cialis Jugular vein distention Anaphylaxis Cardiac history --past Pink, frothy sputum Aspiration COPD myocardial infarction Peripheral edema, diaphoresis Pleural effusion Diuretic medication use Hypotension, shock Pneumonia Urine output Chest pain Pulmonary embolus Hypertension Pericardial tamponade Tachycardia Toxic Exposure
Universal Patient Care Protocol (U-01) Legend System S S Responder Consider CPAP B EMT - B B Monitor B B up to 10 cm H2O PEEP I EMT- I I ETCO2 in patients with P 12 Lead ECG P P EMT- P P CPAP applied M Medical Control M
B NTG SL q 5min if MAP 90 B If acute Ischemic Changes with ST Elevation: declare a STEMI Alert and expedite I NTG paste 1" Hold if MAP < 90 I transport to appropriate STEMI Center. 5 Min post NTG paste, if MAP>145 P Enalapril 1.25mg (IV/IO) over 5 min P ADULT PATIENTS ONLY Consider Sedation Protocol ONLY if extreme difficulty tolerating CPAP (M-13) IF SYMPTOMS PERSIST Consider Hypotension Protocol if MAP<65 Contact Destination or (M-15) M M Medical Control
Pearls: Avoid Nitroglycerin in any patient who has used Viagra or Levitra in the past 24 hours or Cialis in the past 36 hours due to possible severe hypotension. Careful monitoring of level of consciousness, BP, and respiratory status including ETCO2 with above interventions is essential. Consider use of sedation protocol if patient is having difficulty tolerating CPAP. Consider myocardial infarction in all these patients. If suspected give ASA. Allow the patient to be in their position of comfort to maximize their breathing effort. This protocol applies to edema of presumed cardiac etiology. For non-cardiac pulmonary edema refer to Respiratory Distress Protocol.
Clinical Operating Guidelines VTRANS02012020 Respiratory Distress
History: Signs & Symptoms: Differential: R Asthma; COPD – chronic Shortness of breath Asthma 0 bronchitis, emphysema, Pursed lip breathing Anaphylaxis 4 congestive heart failure Decreased ability to speak Aspiration Home treatment (oxygen, Increased respiratory rate and COPD (Emphysema, Bronchitis) nebulizer) effort Pleural effusion Medications (theophylline, Wheezing, rhonchi, rales, stridor Pneumonia steroids, inhalers) Use of accessory muscles Pulmonary embolus Toxic exposure, smoke Fever, cough Pneumothorax inhalation. Tachycardia Cardiac (MI or CHF) Pericardial tamponade Hyperventilation – Behavioral/Anxiety Inhaled toxin (Carbon monoxide, etc.)
Universal Patient Care Protocol (U-01) Legend System S S Respiratory Insufficiency? Responder Airway B B Yes Obtain and record ETCO2 and Pulse Oximetry EMT - B Protocol (R-01) I EMT- I I No Pulmonary P EMT- P P Yes Edema Rales or signs of CHF M Medical Control M Protocol (R-03) No
Wheezing Position of comfort Stridor Albuterol 2.5 mg Neb, B (continuous if needed) B Albuterol 2.5 mg with I I Albuterol 2.5 mg with Atrovent 0.5 mg Neb I Atrovent 0.5 mg Neb I
Consider CPAP 5 cmH2O PEEP B (if refractory to NEB) B Consider : 12 lead ECG P 12 Lead ECG P P Methylprednisolone 125 mg IV, P Epi Neb (2mg 1:1000 in 1ml NS)
Consider : P Methylprednisolone 125 mg IV P
Contact Destination or Magnesium Sulfate M M P 2 grams IV over 20 min P Medical Control as needed
PEARLS: ETCO2 & Pulse Oximetry must be monitored continuously if initial saturation is less than 95%, or there is a decline in patients status despite normal pulse oximetry readings. Epinephrine may precipitate cardiac ischemia. 12-lead ECG must be performed on these patients. A silent chest in respiratory distress is a pre-respiratory arrest sign. All that wheezes is not Asthma , Consider Pulmonary Edema/CHF in patients with wheezing.
Clinical Operating Guidelines VTRANS02012020 RSI / Medication Assisted Intubation (> 37 kg) R Indications: Contraindications: 0 May be utilized in conjunction with Airway Protocol Advanced airway can be achieved without RSI 5 and Failed Airway Protocol to assist in intubation in the conscious or clenched patient requiring intubation
Legend System Referred from Airway Protocol (R-01) S S Responder B EMT - B B I EMT- I I Prepare equipment, suction, BIAD P EMT- P P M Medical Control M S Preoxygenation with 100% O2 S For 3-5 min until SPO2 >90% Consider Apneic Oxygenation Paralyzed patients in this protocol MUST be sedated Etomidate 0.3 mg/kg IV P OR P Monitor pulse, BP and respiratory Ketamine 2 mg/kg Slow IV Push efforts for indications of sedation
P Rocuronium 1 mg/kg IV P
Intubation per Adult Airway Protocol P (Max 2 attempts post rocuronium administration) P Confirm placement Pulse Ox and ETCO2
P If Etomidate given P Midazolam 2 – 5 mg IV
P Confirm and Monitor tube placement P
Go To Sedation Protocol for Ongoing Management (M-13) Contact Destination or M M Medical Control
Pearls: Continuous cardiopulmonary monitoring is required for all intubated patients. Careful monitoring of level of consciousness, BP, and respiratory status with above interventions is essential. Etomidate should be avoided when septic shock suspected or other infection present Paralyzed patients in this protocol MUST be sedated Monitor pulse, BP and respiratory efforts for indications of sedation
Clinical Operating Guidelines VTRANS02012020 Asystole/PEA
History: Signs and Symptoms: Differential: Past medical history Pulseless Medical or Trauma Medications Abnormal Breathing (gasps) Hypoxia Events leading to arrest No electrical activity on ECG Potassium (hyper/hypo) End stage renal disease No auscultated heart tones Drug overdose Estimated downtime Acidosis C Suspected hypothermia Hypothermia A Suspected overdose Device (machine error) DNR Obvious Death 0 1 Universal Patient Care Protocol (U-01) Legend System S S S CPR Procedure S Responder B EMT - B B I EMT- I I P EMT- P P Check rhythm and pulse q 2 minutes M Medical Control M
Treatment of Correctable Epinephrine 1 mg 1:10,000 IV/IO Causes: B B q 5-8 minutes EMT and above: Sodium Bicarbonate 1meq/kg IV (Hyperkalemia,TCA OD, Renal B B Failure). Identify/Treat Correctable Causes Narcan 2 mg IV (Suspected Opiate OD) P P D10W 25g IV (Hypoglycemia) Temperature
ALS ONLY Calcium 1gram IV (Hyperkalemia, CCB OD) Glucagon 2 mg IV (Beta blocker or CCB OD) Chest Decompression No Consider Criteria for ROSC ? Termination of resuscitation guideline Yes (CS-9) AT ANY TIME Obtain 12-Lead P P Change in Rhythm go to : Declare ROSC Alert Appropriate Protocol
Contact Medical Control M M and Transport to appropriate facility
Pearls: Always confirm asystole in more than one lead. If hypothermia preceded cardiac arrest consider withholding medications until a normal core temperature has been reached. Correctable causes must be addressed.
Clinical Operating Guidelines VTRANS02012020 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 Pulmonary C A Cardiac Arrest Protocol Legend 0 System S S 2 S Defibrillation Procedure q 2 min s: S Responder AED B EMT - B B Defibrillation Procedure q 2min s: I EMT- I I Escalating 200J, 300J, 360J P EMT- P P P manual device. P Resume CPR Procedure M Medical Control M
Check rhythm and pulse q 2 minutes Only
Epinephrine 1 mg 1:10,000 IV/IO B B q 5-8 minutes
Amiodarone 300mg IV/IO push AT ANY TIME Repeat q 4 mins at 150 mg IV/IO push Change in Rhythm go to : (Max total 600 mg) Appropriate Protocol P P Consider: Sodium Bicarbonate 1 meq/kg
Consider: Magnesium Sulfate 2 grams P slow IV/IO push for Polymorphic VT (Torsades) P
Conversion? P Amiodarone 150 mg IV/IO push over 10 P mins
Obtain 12-Lead P P Declare ROSC Alert ROSC ?
Contact Medical Control and Transport M M to appropriate facility
Pearls: If hypothermia preceded cardiac arrest consider withholding medications until a normal core temperature has been reached. ECAs, EMT-Basics and EMT-Intermediates may only use automated defibrillation (AED). Reassess and document ETT placement and ETCO2 q 5 minutes and after every move and at transfer of patient care. Calcium and sodium bicarbonate if hyperkalemia is suspected (renal failure, dialysis, excited delirium, acidosis) Tx priorities: uninterrupted compressions, defibrillation, then IV/IO and airway control. Utilize LUCAS whenever appropriate.
Clinical Operating Guidelines VTRANS02012020 Induced Hypothermia 18 yrs
History: Signs and Symptoms: Differential: Nom-Traumatic Cardiac Arrest Return of pulse Continue to address specific differentials associated with original dysrhythmia
Return Of Spontanous Circulation (ROSC) Legend System C S S A Criteria for Induced Hypothermia? Responder B B 0 Yes EMT - B 3 I EMT- I I Advanced Airway Placed and ETCO reading > 20 mmHg P EMT- P P Airway Protocol No 2 M Medical Control M (R-01) Yes
Successful Complete Checklist For ALL ROSC – Whether candidate for Hypothermia Expose patient S S or not Apply Ice Packs to Axilla, Neck & Groin
Midazolam 5 mg IV/IO titrate to effect with P P Monitor ETCO2 Target SBP > 100 mmHg P Identify/Treat P 40 mmHg Correctable Causes DO NOT P Rocuronium 1 mg/kg P HYPERVENTILATE Treatment of Correctable Cold Saline Bolus 30 mL/kg Causes: Perform 12 Lead P to max of 2 liters P Sodium Bicarbonate 1meq/kg IV Activate STEMI Alert Cold Saline should be infused @ 100ml/min. PRN (Hyperkalemia,TCA OD, Renal Failure). Narcan 2 mg IV (Suspected Levophed 3-15 mcg/min Opiate OD) AT ANY TIME P to maintain Systolic BP 90-100 or MAP 65 P D10W 25g IV (Hypoglycemia) Loss of Spontaneous Temperature Circulation: Calcium 1gram IV (Hyperkalemia, Discontinue cooling and CCB OD) Glucagon 2 mg IV (Beta blocker go to Contact Medical Control if needed. M M or CCB OD) appropriate protocol Notify Resuscitation Center ASAP Chest Decompression
PEARLS: Criteria for Induced Hypothermia: - ROSC after cardiac arrest not related to trauma or hemorrhage. - Age greater than 18 - Initial temperature > 34C/93.2F - Patient remains comatose or unable to follow commands - Advanced Airway (ETT or BIAD)
If patient meets other criteria for induced hypothermia and does not have Advanced Airway, then establish Advanced Airway according to protocol before inducing cooling. If unable to establish Advanced Airway DO NOT initiate induced hypothermia. When exposing patient for purpose of cooling undergarments may remain in place. Be mindful of your environment and take steps to preserve the patient s 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. These patients should only be transported to the predefined destination . Refer to the Transport Guidelines Clinical Standard. Notify destination ASAP when this protocol is utilized so that the receiving unit can prepare to receive patient.
Clinical Operating Guidelines VTRANS02012020 Acute Coronary Syndrome
History Signs & Symptoms Differential Hypertension CP (pain, pressure, aching, vice-like Trauma vs. Medical Hyperlipidemia tightness) Angina vs. Myocardial infarction Viagra, Levitra, Cialis Nausea, vomiting, dizziness Pericarditis Past medical history (MI, Angina, Shortness of breath Pulmonary embolism Diabetes, Post Menopausal) Pale, diaphoresis Asthma / COPD Family HX cardiovascular disease Location (substernal, epigastric, Pneumothorax arm, jaw, neck, shoulder) Recent physical exertion Aortic dissection or aneurysm Radiation of pain Smoker GI reflux or Hiatal hernia Stimulants Esophageal spasm Chest wall injury or pain Universal Patient Care Protocol (U-01) Pleural pain Overdose (Cocaine) C S Aspirin 324 mg PO chewed X1 S If Inferior MI 0 STEMI **12 Lead ECG < 5 mins** (II,III,aVF) 1 NTG SL q 5min if MAP 90 Consider B B until patient is pain free withholding NTG treatments due to If STEMI criteria is met: I NTG paste 1" Hold if MAP < 90 I preload dependence declare a STEMI Alert and expedite transport to Consider Nausea/Vomiting appropriate Protocol (M-09) Patient may develop: STEMI Center Hypotension (M-15) OR Dysrhythmia If transport time will be PRN for Pain - Fentanyl 1-2 mcg/kg N/V (M-09) greater than 60 min s IV/IM/IN/IO consider transport to the P May repeat q 10 min. P Treat per appropriate closest Non-PCI facility (Max single dose 300 mcg protocol Max total dose 1000mcg) Complete fibrinolytic checklist Consider Sedation protocol (M-13)
STEMI? Legend No System Contact receiving facility and request below S S Responder Yes B EMT - B B I EMT- I I P Brilinta (Ticagrelor) 180 mg PO P P EMT- P P Contact Destination or P Heparin 70 units/kg IV P M M M Medical Control M (max. dose 7000 units) Medical Control
Pearls: Do not administer 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 Target: Contact to PCI facility time is less than 60 minutes. If patient has ECG changes, or is going directly to cardiac cath lab, establish a second IV if possible. Monitor for hypotension and respiratory depression after administration of nitroglycerin, and fentanyl. Females, diabetics and geriatric patients often have atypical pain, or only generalized complaints. Hypersympathetic state from amphetamine, cocaine or PCP use usually presents with sustained HR >120 bpm and HTN If CP in setting of stimulants utilize benzodiazepine per Sedation Protocol
Clinical Operating Guidelines VTRANS02012020 Bradycardia
History Signs & Symptoms Differential Past Medical History HR <60/min with: Acute MI Medications Hypotension Hypoxia Beta Blockers Acute altered LOC Pacemaker Failure Hypothermia Calcium Channel Blockers Chest pain Sinus Bradycardia Digoxin CHF Electrolyte Abnormality (K+) Cholineregics SZ CVA, increased ICP, Head Injury Clonidine Syncope or shock Spinal Cord Lesion Pacemaker Sick Sinus Syndrome Events Leading to Current Status AV Blocks OD
Legend C Universal Patient Care Protocol (U-01) System 0 S S 2 Responder P 12 Lead ECG P B EMT - B B I EMT- I I P EMT- P P Calcium Channel Blocker OD/Beta Blocker OD ? M Medical Control M
Yes NO
Beta Blocker or Calcium Channel Blocker Overdose IV NS 500mL Bolus Glucagon 2mg IV P YES P I May repeat PRN to I Calcium Channel Blocker overdose SBP 100 mmHg (max. 2 Liters) Calcium Gluconate 1 gram IV External Transcutaneous Pacing starting at 60/min. and adjust to achieve capture & MAP >65. Set TCP dose at 2mA above capture dose
P Consider Sedation protocol (M-13) P
Consider Atropine 0.5 mg q 3 minutes max of 0.04 mg/kg if TCP not immediately available
Contact Destination or M Medical Control M
Pearls: The use of lidocaine in heart block can worsen bradycardia and lead to asystole and death. Treatment of bradycardia is based on the presence of symptoms. If asymptomatic, monitor only. Remember: The use of Atropine for bradycardia in the presence of an MI may worsen ischemia. Consider treatable causes for bradycardia (Beta blocker OD, Calcium channel blocker OD, etc.) - treat appropriately Be sure to aggressively oxygenate the patient and support respiratory effort. If wide complex bradycardia consider hyperkelemia (M-05).
Clinical Operating Guidelines VTRANS02012020 Atrial Fibrillation with RVR
History: Signs and Symptoms: Differential: Medications HR > 150/Min Heart disease (WPW, Valvular) (Aminophylline, Diet pills, QRS less than 0.12 sec Sick sinus syndrome Thyroid supplements, QRS greater than 0.12 sec or history of Myocardial infarction Decongestants, Digoxin) WPW go to V-Tach with pulse Protocol Electrolyte imbalance Diet (caffeine, chocolate) Dizziness, CP, SOB Exertion, Pain, Emotional stress Drugs (nicotine, cocaine) Syncope / near syncope Fever Past medical history Hypoxia History of palpitations / heart racing Hypovolemia or Anemia Drug effect / Overdose (see Hx) Hyperthyroidism Pulmonary embolus
Legend C System S S Universal Patient Care Protocol (U-01) Responder 0 B EMT - B B 3 QRS greater than 0.12 sec I EMT- I I VT with Pulse Consider using Valsalva OR P EMT- P P maneuver to rule out SVT Protocol (C-05) History of WPW M Medical Control M
Stable and Unstable Symptomatic Severely altered or no palpable radial pulse P 12 Lead ECG P
Consider NS Bolus Consider Sedation I I 250ml protocol (M-13) P Synchronized Cardioversion P 100J x 1, then 360J Repeat PRN Consider Diltiazem 0.25 mg/kg IV over 2 minutes if SBP >140 (Max = 20 mg)
P If unsuccessful after 15 min. P Diltiazem 0.35 mg/kg over 2 minutes (Max = 25 mg) if SBP >140 Treat 12 Lead ECG P P symptomatic after rate control or conversion A-Fib
Contact Destination or M Medical Control M
PEARLS: If patient has history of or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer Diltiazem. Adenosine may not be effective in identifiable atrial flutter/fibrillation, but is not harmful. Monitor for hypotension after administration of Diltiazem. Monitor for respiratory depression and hypotension associated with Midazolam. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Continuous pulse oximetry is required for all Atrial Fibrillation Patients. Maximum HR calculation 220 minus (-) age in years = Max HR Rate related S/S are uncommon with HR 150/min in patients with healthy heart. Consider rate control at lower heart rates if symptomatic.
Clinical Operating Guidelines VTRANS02012020 Supraventricular Tachycardia
History: Signs and Symptoms: Differential: Medications HR greater than 150/Min Heart disease (WPW, Valvular) (Aminophylline, Diet pills, QRS less than 0.12 Sec (QRS greater Sick sinus syndrome Thyroid supplements, than 0.12 sec go to V-Tach Protocol) Myocardial infarction Decongestants, Digoxin) If history of WPW, go to V-Tach Electrolyte imbalance Diet (caffeine, chocolate) Protocol Exertion, Pain, Emotional stress Drugs (nicotine, cocaine) Dizziness, CP, SOB Fever Past medical history Potential presenting rhythm Hypoxia History of palpitations / heart racing Sinus tachycardia Hypovolemia or Anemia Syncope / near syncope Atrial fibrillation / flutter Drug effect / Overdose (see Hx) Multifocal atrial tachycardia Hyperthyroidism Pulmonary embolus C Legend 0 Universal Patient Care Protocol (U-01) System S S 4 Responder VT with Pulse QRS > 0.12 sec B EMT - B B OR Protocol (C-05) I EMT- I I History of WPW P EMT- P P Medical Control Stable Pre-Arrest M M Severely altered or no palpable radial pulse
Consider Adenosine 12 Lead ECG 12 mg rapid IV Valsalva's maneuver initially with 10 mL flush if readily available and after each before cardioversion drug administration P P P Consider Sedation protocol (M-13) P
Adenosine Synchronized Cardioversion 12 mg rapid IV may repeat once 100J x1 then 360J Use 10 mL flush after each dose Repeat PRN
Diltiazem 0.25 mg/kg IV over 2 minutes (Max = 20 mg) if SBP >140 Diltiazem 0.35 mg/kg IV over 2 minutes P (Max = 25 mg) if SBP >140 P Any change in rhythm, go to appropriate protocol 12 Lead ECG
Contact Destination or M M Medical Control as needed
PEARLS: If patient has history of or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer Diltiazem, go to VT with Pulse. If patient requires multiple conversion attempts without resolution consider alternative cause of dysrhythmia Adenosine may not be effective in identifiable atrial flutter/fibrillation, but is not harmful. Monitor for respiratory depression and hypotension associated with Midazolam. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Continuous pulse oximetry and ETCO2 is required for all SVT Patients. Serious S/S are uncommon with HR < 150. Patients with impaired cardiac function may become symptomatic at lower HR. Sinus Tachycardia usually results from physiologic stimulus i.e. fever, anemia, or shock. ST is typically HR <120 while at rest.
Clinical Operating Guidelines VTRANS02012020 Wide Complex Tachycardia (VT) With A Pulse
History: Signs and Symptoms: Differential: Past medical history / medications, Ventricular Tachycardia on EKG (Runs or Artifact / Device Failure diet, drugs Sustained) Cardiac Conscious, rapid pulse Syncope / Near syncope Chest Pain, Shortness of Breath Endocrine / Medicine Palpitations Dizziness Drugs Pacemaker Rate usually 150-180 bpm for sustained V- Pulmonary Allergies: Lidocaine / Novocaine Tach QRS > 0.12 sec Legend Universal Patient Care Protocol (U-01) System S S Responder B EMT - B B - Palpable Pulse ? I EMT- I I Appropriate C Protocol No - Wide, regular rhythm with P EMT- P P 0 QRS >0.12 sec? M Medical Control M 5 Yes Stable Unstable/Pre-Arrest Severely altered or no palpable radial pulse
12 Lead ECG Consider Sedation protocol (M-13) Amiodarone 150mg IV P P P P over 10 minutes. Synchronized Cardioversion Repeat q10 min 100J x1 then 360J (max. dose of 600 mg) Repeat PRN No
If refractory begin transport Amiodarone 150mg IV over 10 minutes. PATIENT STABLE ? P Repeat q10 min P (max. dose of 600 mg)
Yes
12 lead ECG Consider: P Post conversion P P Magnesium Sulfate 50% 2 grams P Slow IV/IO over 5 mins
Contact Destination M M or Medical Control
Pearls: For witnessed / monitored ventricular tachycardia, try having patient cough If torsades de pointes: Magnesium Sulfate 50% 2 gms slow IV /IO push over 5 minutes. If hyperkalemia or tricyclic OD refer to Hyperkalemia (M-05)
Clinical Operating Guidelines VTRANS02012020 Allergic Reaction
History Signs & Symptoms Differential Medication history Edema / Voice Changes Urticaria (rash only) Onset and location Itching or hives Anaphylaxis (systemic effect) Past medical history Coughing / wheezing or respiratory Shock (vascular effect) Past history of reactions Angioedema (drug induced) distress New clothing, soap, detergent Aspiration / Airway obstruction Medication allergy / exposure Chest or throat constriction Vasovagal event Food allergy / exposure Difficulty swallowing CHF Insect sting or bite Hypotension or shock Asthma or COPD
Universal Patient Care Protocol (U-01)
Severe Respiratory Distress Hives/Rash or GI Distress Mild to Moderate Distress and/or Hypotension No Respiratory Distress
Diphenhydramine Epi 0.3 mg 1:1000 Albuterol 2.5 mg Neb, B B M B IM or Epi Pen (if B continuous if needed 25 mg PO available) B B Diphenhydramine 0 Diphenhydramine I 25 mg IV/IM I 1 50 mg PO Diphenhydramine Reassess patient 50 mg IV/IM I I Consider NS bolus titrated to perfusion ( SBP 100 mmHg)
Cardiac monitor, SPO2, ETCO2 P P Methylprednisolone 125 mg IV Legend System S S Continue to reassess airway Responder Continued Respiratory Distress B EMT - B B Consider CPAP I EMT- I I B B Max. 5 cm H2O PEEP P EMT- P P M Medical Control M
Epi 0.3 mg 1:1000 P EPI Pen / IM. May repeat P Max total EPI 1.2 mg
Contact Destination or M Medical Control M
PEARLS: Recommended Exam: Mental Status, Skin, Heart, Lungs These patients should receive a 12 lead ECG and should be continually monitored. Any patient with respiratory symptoms or hypotension should receive IV or IM diphenhydramine. The shorter the onset from exposure to symptoms, the more severe the reaction. Vomiting may be a symptom of an allergic reaction.
Clinical Operating Guidelines VTRANS02012020 Altered Mental Status
History: Signs/Symptoms: Differential: Known diabetic, medic alert Decreased mental status Head trauma CNS (stroke, tumor, seizure, infection) tag Change in baseline mental status Cardiac (MI, CHF) Drugs, drug paraphernalia Bizarre behavior Infection Report of illicit drug use or Hypoglycemia (cool, diaphoretic Thyroid (hyper / hypo) toxic ingestion skin) Shock (septic, metabolic, traumatic) Legend System Diabetes (hyper / hypoglycemia) S S Past medical history Hyperglycemia (warm, dry skin; Toxicologic Responder Medications fruity breath; Kussmaul resp; Acidosis / Alkalosis B EMT - B B History of trauma signs of dehydration) Environmental exposure I EMT- I I Change in condition Pulmonary (Hypoxia) P EMT- P P Electrolyte abnormatility M Medical Control M Psychiatric disorder Universal Patient Care Protocol (U-01) Consider other causes: Head injury (T-03) Consider Overdose (M-11) Spinal Motion Restriction Protocol (U-05) Stroke (M-16) Hypoxia (R-01) Transport to Appropriate Blood Glucose Analysis Procedure (CP-8) M Facility 0 Glucose > or = 250 or Glucose < or = 60 Glucose 2 61 - 250 Signs of dehydration Consider: Naloxone B 0.4-2 mg slow Intranasally Only B If respirations depressed IV NS 1000 mL Bolus Oral Glucose if patient is not Consider: Naloxone No S Obtunded S May repeat PRN to 0.4-2 mg slow IV/IN I I I I SBP 100 mmHg If respirations depressed (max. 2 Liters) Q 10 minutes PRN Dextrose Assess Assess 25 grams IV or until patient P Cardiac Monitor & 12 Lead P P Cardiac Monitor P returns to baseline Consider orthostatic vital signs I mental status I & 12 Lead If signs of hyperkalemia Consider for etoh Withdrawl If no IV access Refer to Hyperkalemia (M-15) Glucagon 1 mg IM P Midazolam 2 mg IV/IM/IN P May repeat X 1 dose. Return to baseline ?
Yes
Monitor and Reassess Contact Destination M M or Medical Control
Pearls: Be aware of AMS 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 D50 or Glucagon. Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia. Low glucose (less than 60), normal glucose (61 - 120), high glucose ( greater than 250). Dextrose should only be given with documented hypoglycemia (glucose less than 60 mg/dL) in the presence of head injury due to the risk on increasing cerebral edema Hyperglycemia is treated with fluids. These patients are volume depleted, glucose will begin to clear with adequate hydration. Patents on oral hypoglycemics are at risk for repeat episodes of hypoglycemia, monitor closely. Assess for signs and symptoms of trauma if associated or questionable fall with syncope. Clinical Operating Guidelines VTRANS02012020 Bites and Envenomations History: Signs and Symptoms: Differential: Type of bite / sting Rash, skin break, wound Animal bite Description / photo with patient for Pain, soft tissue swelling, redness Human bite identification of animal involved Blood oozing from the bite wound Snake bite (poisonous) Spider bite (poisonous) Time, location, size of bite / sting Evidence of infection Insect sting / bite (bee, wasp, Previous reaction to bite / sting Shortness of breath, wheezing ant, tick) Domestic vs. Wild Allergic reaction, hives, itching Infection risk Tetanus and Rabies risk Hypotension or shock Rabies risk Immunocompromised patient Tetanus risk
Legend Universal Patient Care Protocol System S S Responder Insect Snake B EMT - B B I EMT- I I Carefully remove any stinger If bite is to an extremity splint P EMT- P P by raking a straight edge limb, bandage and place at M Medical Control M level below heart. across the stinger, do not S S S squeeze it. Apply Ice pack S Do not apply ice and M and minimize movement. minimize movement. 0 Remove constricting items Remove constricting items 3
Consider: Allergic Reaction Protocol (M-01) Hypotension Protocol (M-15) Seizure Protocol (M-14) Nausea/Vomiting Protocol (M-09) Pain Management Protocol (M-12)
For black widow spider bites consider Midazolam P 2 mg IV P Q 10min PRN with SBP>100 mmHg
Contact Destination or M M Medical Control Pearls: Human bites have a very high risk of infection due to oral bacteria. Carnivore bites are much more likely to become infected and all have risk of Rabies exposure. Cat bites may rapidly progress to infection due to a specific bacteria (Pasteurella multicoda). Venomous snakes in this area are generally of the pit viper family: rattlesnake, copperhead, and water moccasin. -- Coral snake bites are rare: Very little pain but very toxic. "Red on yellow - kill a fellow, red on black - venom lack." -- Amount of envenomation is variable, generally worse with larger snakes and early in spring. -- If no pain or swelling, envenomation is unlikely. -- It is NOT necessary to take the snake to the ED with the patient. Black Widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may develop (spider is black with red hourglass on belly). Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle shape on back). Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound. Immunocompromised patients are at an increased risk for infection: diabetes, chemotherapy, transplant patients. Consider contacting the US/Texas Poison Control Center for guidance. 1-800-222-1222
Clinical Operating Guidelines VTRANS02012020 Fever/Infection Control
History Signs & Symptoms Differential: Age Warm Infections / 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 (Helpful to Arthritis Immunocompromised (transplant, localize source) Vasculitis HIV, diabetes, cancer) myalgias, cough, chest pain, headache, Hyperthyroid Environmental exposure dysuria, abdominal pain, Heat Stroke Last acetaminophen or ibuprofen mental status changes or rash Meningitis
Universal Patient Care Protocol (U-01) Legend System S S Responder Consider Droplet or Airborne PPE B EMT - B B I EMT- I I S Temperature S P EMT- P P M 0 > 101°F M Medical Control M 4 Encourage PO fluid intake and S cooling measures S
B 500-650 mg Acetaminophen PO B
Consider IV NS Bolus I titrate to SBP 100 mmHg I (max. 2 Liters)
Appropriate Protocol by Complaint
Contact Destination M M or Medical Control
PEARLS: Patients with a history of Liver failure should not receive Acetaminophen. Rehydration with fluids increased the patient s ability to sweat and improves heat loss.
Clinical Operating Guidelines VTRANS02012020 Hyperkalemia
History: Signs and Symptoms: Differential: ESRD Cardiac conduction disturbances Cardiac Rhythm Disturbance Medications – Potassium – Idioventricular, Wide complex Renal Failure sparing diuretics, ACE bradycardia, Peaked T-waves, Dialysis Inhibitors Sine wave Trauma Dialysis Weakness Burn Burns Paralysis Crush Injuries Oliguria Excited Delirium Rhabdomyolysis Acidotic States Compartment Syndrome
Universal Patient Care Protocol (U-01) Legend System S S Responder B EMT - B B M P 12-Lead ECG P 0 I EMT- I I 5 P EMT- P P ECG Changes indicative of Hyperkalemia M Medical Control M
Calcium Gluconate 1 G (IV/IO)
Sodium Bicarbonate 1 mEq/kg (IV/IO) P P Albuterol 2.5 mg (Neb) Continuous CONTRAINDICATED IN CAD & Cardiac Failure
Treat arrhythmia per appropriate protocol
Contact Destination M or Medical Control M
Pearls: Confirm IV patency prior to Calcium Gluconate administration Hyperkalemia should be considered in any dialysis patients in bradycardia and patients with wide complex rhythms. Drugs that can cause Hyperkalemia include: NSAID s, ACE Inhibitors, Potassium sparing diuretics (e.g. Spironolactone), Succinylcholine. Albuterol can exacerbate cardiac ischemia via tachycardia. Crush injury patients may require aggressive treatment of Hyperkalemia (i.e. Death by Rescue ) Hyperkalemia patients may require additional dosing of Calcium Gluconate, consider contacting OLMC. Slow administration of Calcium Gluconate is recommended in any patient taking Cardiac Glycosides. Supportive measures such as pacing, fluids, and pressors may not work or may require aggressive dosing. Treat underlying hyperkalemia first.
Clinical Operating Guidelines VTRANS02012020 Hypertensive Crisis
History: Signs and Symptoms: Differential: Previous CVA, TIAs Hypertension Hypertensive Crisis Previous cardiac / vascular surgery Vomiting Stroke Associated diseases: diabetes, Headache Tumor hypertension, CAD Blurred Vision Trauma Ringing in Ears Seizure Flushed Skin TIA Dizziness PE CHF Migrane
Legend System S S Universal Patient Care Protocol (U-01) Responder S S B EMT - B B Stroke Scale I EMT- I I (CP-52) M P EMT- P P P 12 Lead ECG P 0 Medical Control M M 6
Negative Stroke Scale & Baseline Mental Positive Stroke Scale or Altered Mental Status Status
If Systolic BP >200 Consider other protocols as indicated: P Administer 5mg Labetalol IV (Slowly) P Altered Mental Status (M-02) q 10 min. Max dose 10mg. Suspected Stroke (M-16) Pulmonary Edema (R-03)
Contact Destination M M or Medical Control
Pearls: If any Stroke Symptoms are present, do not administer Labetolol. Be alert for airway problems (swallowing difficulty, vomiting). Consider other protocols as indicated: Altered Mental Status, Seizures, Stroke.
Clinical Operating Guidelines VTRANS02012020 Hyperthermia
History: Signs and Symptoms: Differential: Age Altered LOC Fever Past medical history Hot, Dry or sweaty skin Dehydration Medications Mental status changes Medications Exposure to environment even in Hyperthyroidism (Storm) Seizures normal temperatures Aggitated Delirium Exposure to extreme heat Hypotension or shock Heat Cramps Extreme exertion Heat exhaustion Drug use Heat stroke Fatigue/Muscle Cramping CNS Lesion
Universal Patient Care Protocol (U-01) Legend System S S M Remove from heat source Responder 0 B EMT - B B 7 Document patients temperature I EMT- I I S S P EMT- P P Remove clothing M Medical Control M Apply room temperature water over patient and increase air flow
Consider IV NS Bolus I (max. 2 Liters) I
Monitor and continue to reassess
Appropriate Protocol Based on patient symptoms
Contact Destination M M or Medical Control
Pearls: Extremes of age are more prone to heat emergencies (i.e. young and old). Drugs may contribute to hyperthermia: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. Cocaine, Amphetamines, and Salicylates may elevate body temperatures. Sweating generally disappears as body temperature rises above 102° F. Intense shivering may occur as patient is cooled. Use Benzodiazapines per sedation protocol. Heat Cramps consists of benign muscle cramping 2° to dehydration and is not associated with an elevated temperature. Heat Exhaustion consists of dehydration, water depletion, dizziness, fever, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature. <104 ° F. Heat Stroke hyperthermia and an altered mental status. Seizures may occur and may be associated with hyponatremia. Temp >104° F.
Clinical Operating Guidelines VTRANS02012020 Hypothermia
History: Signs and Symptoms: Differential: Past medical history Cold, clammy Metabolic disorder Medications Shivering Toxins Exposure to environment even in Mental status changes Environment normal temperatures Extremity pain or sensory Exposure to extreme cold Extremes of age abnormality Drug use: Alcohol, barbiturates Bradycardia Infections/sepsis Hypotension or shock Length of exposure/wetness
Universal Patient Care Protocol (U-01) Legend System S S Remove wet clothing Responder S S B EMT - B B Temperature less than 95 F (<35 C) M I EMT- I I 0 Yes P EMT- P P 8 M Medical Control M Handle very gently if 88 F (< 30C) Blankets-especially around head S S Check blood glucose prior to transport
No Hypothermia: Mild: 91-95 F I Warm IV fluids if available I Moderate: 83-90 F Severe: <82 F
Appropriate Protocol Based on patient symptoms
Contact Destination M M or Medical Control
Pearls: Extremes of age are more susceptible (young & old) < 93 F Shivering may diminish. At < 88 F shivering may stop. With temperature less than 88 F (30 C) ventricular fibrillation is common cause of death. Handling patients gently may prevent this (rarely responds to defibrillation). Transport immediately for re-warming. If the temperature is unable to be measured, treat the patient based on the suspected temperature. Hypothermia may produce severe physiologic bradycardia. Do not treat unless profound hypotension unresponsive to fluids.
Clinical Operating Guidelines VTRANS02012020 Nausea/Vomiting
History: Signs and Symptoms: Differential: Age Pain CNS (Increased pressure, headache, Time of last meal Character of Pain ( Intermittent, stroke, CNS Lesions, trauma or hemorrhage, vestibular) Last bowel movement / emesis constant, sharp, dull, etc.) Distension AMI Improvement or worsening with Constipation Drugs (NSAIDs, antibiotics, narcotics, food or activity Diarrhea chemotherapy.) GI or Renal disorders Duration of problem Anorexia Diabetic Ketoacidosis Other sick contacts Radiation Gynecologic disease (Ovarian Cyst / Past Medical History ASSOCIATED SYMPTOMS PID) Past Surgical History Infections (pneumonia, influenza) Medications Electrolyte abnormalities Menstrual history / Pregnancy Food or Toxin induced Travel history Medication or Substance abuse Bloody Emesis or diarrhea Pregnancy Psychological
Universal Patient Care Protocol (U-01) Legend M System S S 0 Blood Glucose Procedure (CP-8) Responder 9 B EMT - B B Altered Mental Status I EMT- I I Blood Glucose < 60 Protocol (M-02) P EMT- P P Consider M Medical Control M Hypotension Protocol (M-15)
Ondansetron I 4-8 mg IM/IV q 10min I Max 12 mg
Contact Destination M M or Medical Control
PEARLS: Ondansetron should not be given to a patient with a history of long QT syndrome. Ondansetron should not be given to pregnant patients in their first trimester, unless already prescribed by their physician. Consider organophosphate toxicity as a cause for n/v.
Clinical Operating Guidelines VTRANS02012020 Non Traumatic Bleeding History: Signs & Symptoms: Differential: GI Bleeding Pain, swelling GI Bleeding Peptic Ulcers Deformity, lesions, bleeding Peptic Ulcers Esophageal Varices Altered mental status Esophageal Varices Palate Surgery Oropharyngeal Bleeding Oropharyngeal Surgery (Tonsillectomy, Adenoidectomy) Severe Epistaxis
Universal Patient Care Protocol (U-01) Legend System S S Responder B EMT - B B I EMT- I I P EMT- P P Bleeding uncontrolled by pressure or unable to apply pressure to area M Medical Control M
Non Traumatic uncontrolled M internal bleeding 1 0 Contact Medical Control for Uncontrolled oropharyngeal bleeding related to bleeding pregnancy/birth prior to TXA administration
If MAP >70 P 1 G TXA (IV/IO) over 10 P P 500 mg TXA (Nebulized) P minutes
Contact Destination M M or Medical Control
PEARLS:
Contact Medical Control for bleeding related to pregnancy/birth prior to TXA administration.
Clinical Operating Guidelines VTRANS02012020 Overdose/Toxic Ingestion
History: Signs and Symptoms: Differential: Ingestion or suspected ingestion of a Mental status changes Tricyclic antidepressants possibly toxic substance hypotension/ hypertension Acetaminophen (Tylenol) Substance ingested, route, quantity Decreased respiratory rate Depressants Time of ingestion Tachycardia, dysrhythmias Stimulants Reason (suicidal, accidental, criminal) Seizures Anticholinergic Available medication in home Cardiac medications Past medical history, medications Solvents, alcohols, cleaning agents Insecticides (organophosphates)
Legend System S S Universal Patient Care Protocol (U-01) Responder B EMT - B B I EMT- I I P EMT- P P P 12 Lead ECG P M Medical Control M M 1 Other 1 Narcotic OD Stimulant OD Dystonic Reaction I I Altered Mental Status Diphenhydramine 50 mg IV/IM Protocol (M-02) Midazolam 2 mg IV Tricyclic overdose: Sodium Bicarbonate 50 mEq IV May repeat x 2 followed by a maintenance drip. (Max dose 6 mg) (100 mEq in 1000 mL of NS and run at 100mL/hr) P P P - OR - P Beta Blocker overdose: Glucagon 2 mg IV Midazolam 5 mg IM/IN Calcium Channel Blocker OD: May repeat x 2 Calcium 1 gram IV (Max dose 15 mg)
Contact Destination or M Medical Control as M needed
Hypotension (M-15), Seizures (M-14), Ventricular dysrhythmias, Chest pain (C-01) or Mental status change treat per protocol
Pearls: Do not rely on patient history of ingestion especially in suicide attempts. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils. Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures. Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes. Cardiac Meds: dysrhythmias and mental status changes. Solvents: Nausea, vomiting, and mental status changes. Insecticides/Organophosphate: decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils. Consider contacting the US/Texas Poison Control Center for guidance. 1-800-222-1222
Clinical Operating Guidelines VTRANS02012020 Pain Management
History: Signs and Symptoms: Differential: Age Severity ( pain scale) Per the specific protocol Location Quality Musculoskeletal Duration Radiation Visceral (abdominal) Severity ( 1-10 ) Relation to movement, Cardiac Past Medical History respiration Pleural / Respiratory Medications Increased with palpation of Neurogenic Drug allergies area. Renal ( colic ) Medications taken prior to arrival
Universal Patient Care Protocol Legend System S S Responder B EMT - B B Assess Degree of Pain I EMT- I I Immobilize extremity if indicated P EMT- P P M Medical Control M
M Pn 1-4 Pn 5-7 1 Pn 8+ 2 Acetaminophen B B Fentanyl 1- 2 mcg/kg IV/IM/IN/IO 500-650mg PO May repeat q 10 min Max Single Dose 300 mcg Ketamine 0.5 mg/kg IM Max Total Dose 1000 mcg - OR - May repeat Q 5 min x 1 P Ketamine 0.25 mg/kg IM P Max dose 100mg May repeat Q 5 min x 1 If pain from muscle spasm, Max dose 100 mg P - AND/OR - P consider Midazolam 2 mg IV - OR - May repeat x 2 Toradol 0.5 mg/kg IM/IV Fentanyl 1- 2 mcg/kg IV/IM/IN/IO (Max dose 6 mg) Max dose 30 mg May repeat q 10 min P - OR - P Max Single Dose 300 mcg Midazolam 5 mg IM/IN Max Total Dose 1000 mcg May repeat x 2 (Max dose 15 mg)
P Continuous Monitoring P
Consider fluids if kidney stones suspected Contact destination or M Medical Control as needed M
Pearls: Pain severity (0-10) is a vital sign to be recorded pre and post medication delivery and at disposition. In patients >60 yrs or with liver disease, limit Fentanyl dosing to 1 mcg/kg. Vital signs should be obtained q 5 min with all narcotic pain medications. Monitor patient closely for hypotension and respiratory depression - refer to overdose protocol if needed. Patients receiving pain and/or anxiety management must have ETCO2 & Cardiac Rhythm continuously monitored. Ensure thorough neuro exam prior to administration of narcotic pain medications. These may interfere with future assessments. Abdominal pain in women of childbearing age should be treated as an ectopic pregnancy until proven otherwise The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 Y/O.
Clinical Operating Guidelines VTRANS02012020 Sedation
History Signs & Symptoms Differential: Situational crisis Anxiety, agitation, confusion see Altered Mental Status differential Psychiatric illness/medications Affect change, hallucinations Hypoxia Alcohol Intoxication Injury to self or threats to others Delusional thoughts, bizarre Toxin / Substance abuse Medic alert tag behavior Medication effect / overdose Substance abuse / overdose Combative violent Withdrawal syndromes Diabetes Expression of suicidal/homicidal Depression thoughts Bipolar (manic-depressive) Schizophrenia, anxiety disorders, etc.
Scene Safety Legend System S S Responder Consider protocol: B EMT - B B Universal Patient Care Protocol (U-01) Overdose (M-11) I EMT- I I Violent Patient (M-17) P EMT- P P M Medical Control M M Remove patient from stressful environment, 1 verbal techniques (reassurance, calm, rapport) 3 GCS & Respiratory status on all patients Advanced Restraint Procedure as needed (CP-42) GCS>14 and Airway in maintaining own Place airway SBP>100mmHg and no wheezing Midazolam 2 mg IV May repeat x 2 Midazolam 2 mg IV/IO SBP<100mmHg or wheezing (Max dose 6 mg) May repeat q 10 minutes PRN P P - OR - P And P Fentanyl 1-3 mcg/kg IV/IO Midazolam 5 mg IM/IN May repeat q 10 minutes Ketamine 2 mg/kg IV/IO May repeat x 2 PRN P May repeat q 20 minutes P (Max dose 15 mg) PRN
Contact Destination or M M Continuous ETCO2, Pulse OX, Medical Control Cardiac Monitor and Document
PEARLS: Midazolam should be titrated to effect with SBP 100 mmHg or peripheral pulses present. Fentanyl & Versed is preferred for sedation in patients with a head injury unless otherwise contraindicated. Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) Do not overlook the possibility of associated domestic violence or child abuse. All patients who receive chemical sedation must be continuously monitored by ALS personnel on scene. ECG, ETCO2 and Pulse Ox should be obtained q 5 min.
Clinical Operating Guidelines VTRANS02012020 Seizure History: Signs and Symptoms: Differential: Reported / witnessed seizure Decreased mental status CNS (Head) trauma activity Sleepiness Tumor Previous seizure history Incontinence Metabolic, Hepatic, or Renal failure Medical alert tag information Observed seizure activity Hypoxia Seizure medications Evidence of trauma Electrolyte abnormality (Na, Ca, Mg, K+) History of trauma Unconscious Drugs, Medications, Non-compliance History of diabetes Infection / Fever History of pregnancy Alcohol withdrawal Eclampsia Stroke Hyperthermia Hypoglycemia
Legend Universal Patient Care Protocol (U-01) System S S Responder B EMT - B B Consider Spinal Motion Restriction Protocol (U-05) I EMT- I I M P EMT- P P 1 Active Seizure M Medical Control M 4
Assist with Vagus Nerve Post-ictal B Stimulator (VNS) X 3 q 3-5 min B
S Blood Glucose S Midazolam 2 mg IV May repeat x 2 (Max dose 6 mg)
P - OR - P Altered Mental Status Protocol as needed (M-02) Midazolam 5 mg IM/IN May repeat x 2 (Max dose 15 mg)
Contact Destination M M or Medical Control as needed
PEARLS: Status epilepticus is defined as seizures lasting more than 5 minutes or two or more successive seizures without return to baseline. 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 Jacksonian seizures are seizures which start as a focal seizure and become generalized. Assess possibility of occult trauma and substance abuse. Be prepared to assist ventilations, seizures and associated treatments may cause hypoventilation. For any seizure in a pregnant or recently post partum patient, follow the OB Emergencies Protocol. Midazolam are to be titrated to effect with SBP >100 mmHg or peripheral pulses present
Clinical Operating Guidelines VTRANS02012020 Shock (Non trauma)
History: Signs and Symptoms: Differential: Blood loss- vaginal or Restlessness, confusion Shock gastrointestinal bleeding, AAA, Weakness, dizziness Hypovolemic ectopic pregnancy Weak, rapid pulse Cardiogenic Fluid Loss- vomiting, diarrhea, Pale, cool, clammy skin Septic fever Delayed capillary refill Neurogenic Infection Hypotension Anaphylactic Cardiac ischemia (MI, CHF) Coffee-ground emesis Ectopic pregnancy Medications Tarry stools Dysrhythmias Allergic Reaction Pulmonary embolus Pregnancy Tension pneumothorax
Legend System Universal Patient Care Protocol (U-01) S S Responder B EMT - B B I EMT- I I Hypovolemic M Cardiogenic P EMT- P P 1 Distributive Obstructive 5 M Medical Control M
Treat Obstructive Shock per Treatment per appropriate appropriate Clinical Procedure Cardiac Protocol
Normal Saline IF NO Rales 500 - 1000 ml bolus I Normal Saline I I If SBP<100mmhg I 250 - 500 ml bolus May repeat (Max 2 Liters) May repeat (Max 1 Liters)
Consider Epinephrine 1:100,000 (IV/IO) P 5-10 mcg q 1min P Max 10 doses Titrate to MAP 65
Levophed (IV/IO) 3 - 15 mcg/min OR P Epinephrine (IV/IO) P 2-10 mcg/min Titrate to MAP 65
Contact Destination M or Medical Control M
Pearls: Hypotension can be defined as a mean arterial pressure of less than 65 Consider all possible causes of shock and treat per appropriate protocol Patients should always have adequate intravascular fluid load prior to the use of vasopressors In early stages of shock, hypotension may not be present. (Compensated Shock) Not all forms of shock are associated with tachycardia. (Neurogenic & Cardiogenic) Consider Levophed in warm shock or shock of cardiogenic origin. Consider Epinephrine in cold shock or other shock of non cardiogenic origin.
Clinical Operating Guidelines VTRANS02012020 Suspected Stroke
History: Signs and Symptoms: Differential: Previous CVA, TIAs Altered mental status Altered Mental Status Previous cardiac / vascular surgery Weakness / Paralysis TIA (Transient ischemic attack) Associated diseases: diabetes, Blindness or other sensory loss Seizure Aphasia / Dysarthria hypertension, CAD Hypoglycemia Syncope Atrial fibrillation Stroke Vertigo / Dizziness (~ 85%) Medications (blood thinners) Vomiting Thrombotic History of trauma Headache Embolic DNR/Code status Seizures Hemorrhagic (~ 15%) Respiratory pattern change Tumor Hypertension / hypotension Trauma
Legend System S S Universal Patient Care Protocol (U-01) Responder B EMT - B B S Stroke Scale (CPSS & VAN) S I EMT- I I (CP-52) M P EMT- P P Blood Glucose Procedure (CP-8) 1 Medical Control M M 6
All Suspected Strokes Not Described to Right Onset of symptoms 24 hours AND positive (document time last normal) VAN score (document time last normal)
If Positive Stroke Screen and Glucose > 60 declare If Positive Stroke Screen and Glucose > 60 declare Stroke Alert and expedite transport to closest Stroke Alert and expedite transport to closest Primary Stroke Center (PSC) Comprehensive Stroke Center (CSC) < 10 minute on-scene time < 10 minute on-scene time
P 12 Lead ECG P Monitor BP & CPSS q 15 min.
Consider other protocols as indicated: INTERFACILITY TRANSFERS ONLY Altered Mental Status (M-02) Post Thrombolytic therapy BP goal is 180/105 Seizures (M-14) mmHg or less P P Perform BP & CPSS checks q 15 min. Contact Destination Labetalol 10 mg slow IV (over 2 min) may M M repeat once to maintain goal BP or Medical Control
Pearls: Labetalol restricted to patients being transferred after receiving Thrombolytic therapy infusion. Only allow for a 20% drop in BP or MAP. Any patient with onset of symptoms greater than 8 hours may be transported to a primary stroke center (PSC). 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 of the previous night when patient was symptom free). Be alert for airway problems (swallowing difficulty, vomiting). Hypoglycemia can present as a localized neurological deficit, especially in the elderly. Consider other protocols as indicated: Altered Mental Status, Hypertension, Seizures.
Clinical Operating Guidelines VTRANS02012020 Violent/Agitated Patient
History Signs & Symptoms Differential: Situational crisis Anxiety, agitation, confusion see Altered Mental Status differential Psychiatric illness/medications Affect change, hallucinations Hypoxia Alcohol Intoxication Injury to self or threats to others Delusional thoughts, bizarre Toxin / Substance abuse Medic alert tag behavior Medication effect / overdose Substance abuse / overdose Combative violent Withdrawal syndromes Diabetes Expression of suicidal/homicidal Depression thoughts Bipolar (manic-depressive) Very hot to touch Schizophrenia, anxiety disorders, etc
Scene Safety Legend System S S Responder Go to appropriate protocol: B EMT - B B Altered Mental Status (M-02) Universal Patient Care Protocol (U-01) I EMT- I I
Overdose (M-11) P EMT- P P M Medical Control M M Do not physically restrain patient except to 1 administer medication 7 Ketamine 4 mg/kg IM Max 400mg P OR Midazolam 2-5 mg IN/IM P OR Diphenhydramine 1-1.25 mg/kg PO/IM
Continuous ETCO2, Pulse OX, P Cardiac Monitor and Document P Midazolam Obtain 12-lead ECG - If signs of hyperkalemia P 2 mg IN to maintain sedation P Consider Calcium 1g IV & Sodium Bicarb 1 meq/ Q 10min PRN with SBP>100 mmHg P kg IV P Temperature > 101 ? S Initiate cooling measures S Normal Saline I 500 - 1000 ml bolus I May repeat (Max 2 Liters)
Contact Destination or M Medical Control M
PEARLS: Recommended Exam: Mental Status, Skin, Heart, Lungs, Neuro Consider your safety first. When used, physical restraints should be preformed/assisted by Law Enforcement when available. Never restrain a patient in a prone position. Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) If patient is suspected of agitated delirium suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early. Do not overlook the possibility of associated domestic violence or child abuse. All patients who receive chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. If possible and when safe to do so ECG, ETCO2, Pulse Ox, Blood Glucose. Any patient who is handcuffed or restrained by Law Enforcement and transported by EMS should be accompanied by law enforcement in the ambulance whenever possible. Do not position or transport any restrained patient in such a way that could impact the patient s respiratory or circulatory status.
Clinical Operating Guidelines VTRANS02012020 Burns – adult and pedi History: Signs & Symptoms: Differential: Superficial (1°) red and Type of exposure (heat, gas, Burns, pain, swelling painful chemical) Dizziness Partial thickness (2°) Inhalation injury Loss of consciousness blistering Time of Injury Hypotension/shock Full thickness (3°) painless Past medical history and Airway compromise/distress singed facial and charred or leathery skin Medications or nasal hair Chemical Other trauma Hoarseness / wheezing Thermal Loss of Consciousness Carbonaceous Sputum Electrical Tetanus/Immunization status Radiation
Universal Patient Care Protocol (U-01) Legend System S S Airway Protocol (R-01) Responder B EMT - B B I EMT- I I Remove rings, bracelets, and S S P EMT- P P other constricting items M Medical Control M
Thermal Chemical
If burn < 10% body surface area (using rule of nines) S S Cool down the wound with Normal Saline or Sterile Water T Remove clothing or expose area S S 0 S Cover burn with a Dry sheet or dressings S Brush off any dry chemicals or powder 1 Eye involvement? S S Eye Injury complaint protocol (CP-24) If >10% BSA, give NS 500ml Bolus q 20 I I minutes S Continuously flush area with NS S
Refer to appropraite pain protocol Contact Destination or M Medical Control M
Pearls: Evaluate BSA : Use chart or use one side of patients hand = 1% BSA Critical Burns: - >20% body surface area (BSA) age > 10; - >10% BSA age < 10; - 3° burns >5% BSA; - 2° and 3° burns to face, eyes, hands or feet; electrical burns; respiratory burns; deep chemical burns; - burns with extremes of age or chronic disease; and burns with associated major traumatic injury. These burns may require direct transport to a burn center (refer to the Hospital Transport Guidelines Appendix A-2). Early intubation is required in significant inhalation injuries. Potential CO exposure should be treated with 100% oxygen. Cardiac Monitoring is required for all electrical burns. Circumferential burns to extremities are dangerous due to potential vascular compromise 2° to soft tissue swelling. Burn patients are prone to hypothermia - Never apply ice or cool burns that involve >10% body surface area. Do not overlook the possibility of multiple system trauma. Do not overlook the possibility for child abuse with children and burn injuries. If the patient has been accepted by a phycisian, transport to the accepting/receiving facility.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Adult Near Drowning
History: Signs and Symptoms: Differential: Submersion in water Unresponsive Trauma regardless of depth Mental status changes Pre-existing medical problem Possible history of trauma ie: Decreased or absent vital signs Pressure injury (diving) diving board Vomiting Barotrauma Duration of immersion Coughing Decompression sickness Temperature of water Fresh/Salt Water
Legend System S S Responder Universal Patient Care Protocol (U-01) CONSIDER B EMT - B B Adult Airway Protocol (R-01) I EMT- I I Hypothermia Protocol Spinal Motion Restriction Protocol P EMT- P P (M-08) (U-05) M Medical Control M
Pulseless and Apneic? Yes
T 0 Respiratory Distress ? Go to appropriate 2 Continue close cardiac arrest protocol monitering with: No Cardiac Moniter CPAP up to 10 cmH2O PEEP. Pulse OX B BVM if CPAP not tolerated or does not fit B ETCO2 Cardiac Monitor P P Refer to Shock PRN (M-15)
Contact Destination or M M Medical Control
Pearls: All victims should be transported for evaluation due to potential for worsening over the next several hours. 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 pressure injuries (decompression / barotrauma), consider transport or availability of a hyperbaric chamber. (University Hospital in San Antonio is the only 24 hr hyperbaric chamber available.) Consider CPAP early if respiratory distress. Consider transition from rescue to recovery after 20 minutes of submersion from the time the first public safety rescuer arrives – unless patient is possible trapped with an air source. ( diver or other circumstance ).
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Head Trauma History: Signs and Symptoms: Differential: Time of injury Pain, swelling, bleeding Skull fracture Mechanism: blunt / penetrating Altered mental status Brain injury (concussion, contusion, Loss of consciousness Unconscious hemorrhage, or laceration) Epidural/subdural hematoma Bleeding Respiratory distress / failure Alcohol Intoxication Medical history Vomiting Subarachnoid/intracranial Medications Significant mechanism of injury hemorrhage Allergies Pupillary abnormalities Spinal injury Evidence of multi-trauma CSF leaking from ears, nose, mouth Abuse Helmet use or damage to helmet
Universal Patient Care Protocol (U-01) Legend System Multiple Trauma S S No Isolated Head Trauma? Responder Protocol (T-04) B EMT - B B Yes I EMT- I I Spinal Motion Restriction Protocol (U-05) P EMT- P P M Medical Control M Airway Obtain and Record GCS Protocol (R- Yes S S 01) SAO2 < 90 % or ETCO2 > 45 ? No Yes S Hypotension SBP < 100 ? S No T Yes Seizure Protocol (M-14) Seizure ? 0 3 No Altered Mentation Yes S Blood Glucose < 60 ? S Protocol (M-02) No S Monitor and reassess patient q 5 min S
Contact Destination or M M Medical Control
Pearls: If evidence of brain herniation (blown pupil, Cushings reflex, rapid decline in GCS, or bradycardia) hyperventilate the patient to titrate ETCO2 to 30 - 35 mmHg. Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). The most important item to monitor and document is a change in the level of consciousness and GCS.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Multiple Trauma History: Signs & Symptoms: Differential (Life threatening): Time and mechanism of Pain, swelling Chest Tension pneumothorax injury Deformity, lesions, bleeding Flail chest Damage to structure or Altered mental status or Pericardial tamponade vehicle Open chest wound unconscious Location in structure or Hemothorax vehicle Hypotension or shock Intra-abdominal bleeding Others injured or dead Cardiac Arrest Pelvis / Femur fracture Speed and details of MVC Spine fracture / Cord injury Restraints / protective Head injury (see Head Trauma) equipment Extremity fracture / Dislocation Past medical history HEENT (Airway obstruction) Medications Hypothermia
Universal Patient Care Protocol (U-01) Legend System S S Airway Responder Protocol (R-01) Rapid trauma assessment and GCS B EMT - B B S S On Scene Time <10 minutes I EMT- I I Spinal Motion P EMT- P P S Declare Trauma Alert/Transport S Restriction (U-05) M Medical Control M
SBP < 100 mmHg SBP 100 mmHg
Consider: Consider: Crush injuries: S Binding for Pelvic Fracture S Realignment of Long Bone Obtain 12-Lead ECG T Fracture Control of External Hemorrhage P Signs of Hyperkalemia - P S S 0 Binding for Pelvic Fracture Compressible Hemorrhage: Consider Calcium 1g IV & Control of External 4 Consider NS Bolus 20ml/kg to Sodium Bicarb 1 meq/kg IV I I Hemorrhage Maintain MAP>55 mmHg Tourniquet Procedure (CP-56) Crush Wound Packing Procedure (CP-27) NON-Compressible Hemorrhage: Injury < 3h Uncontrolled I 250ml NS Boluses PRN to Maintain I P oropharyngeal bleeding: P MAP>55 mmHg Non-Compressible 500 mg TXA (Nebulized) Consider Hemorrhage below the P neck: P Chest Decompression Procedure (CP-43) 1 G TXA over 10 minutes Suspected Spinal Cord Injury Contact Destination P Levophed 3-15 mcg/min IV infusion P M M Titrated to maintain a MAP>65 mmHg or Medical Control
PEARLS:
Consider Chest Decompression with signs of shock and injury to torso. See Regional Trauma Guidelines for criteria when notifying the ED of Trauma Transport or Trauma Alert. Record "Trauma Notification" in patient record. The goal in treating patients suffering from internal non-compressible bleeding is to maintain a systolic BP of 70 mmHg. Peripheral neurovascular status should be assessed in extremity trauma. If evidence of brain herniation (blown pupil, Cushings reflex, rapid decline in GCS, or bradycardia) hyperventilate the patient to titrate ETCO2 to 30 - 35 mmHg. Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Level of consciousness and GCS trending should be document and monitored in all trauma patients .
Clinical Operating Guidelines VTRANS02012020 Regional Trauma Criterion
Patients should be transported to a System Designated Adult ( 15 yrs ) or Pediatric ( < 15 yrs ) Trauma Center with early notification of the receiving facility. Algorithm based on CDC trauma criteria. Modified for CATRAC/STRAC Specific Facilities
Measure vitals signs and level of consciousness
Glasgow Coma Scale 13 Step Systolic Blood Pressure (mmHg) <90 mmHg One Respiratory Rate <10 or >29 breaths per minute (<20 in infant aged <1 year), or need for ventilatory support Transport to a trauma center. Steps One and Two attempt to identify the most seriously No injured patients. These patients should be transported preferentially to Assess anatomy Yes the highest level of care of injury within the defined trauma system. (Dell Seton, Dell Children s, All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee South Austin, University, Step Crushed, degloved, mangled, or pulseless extremity SAMMC, Seton Hays) Amputation proximal to wrist or ankle Two Open or depressed skull fracture Paralysis Chest wall instability or deformity (e.g, flail chest) Two or more proximal long-bone fractures Pelvic fractures T
No 0 5 Assess mechanism of injury and evidence of high-energy impact
Falls Adults:>20 feet (one story is equal to 10 feet) Transport to a trauma center, Children>10 feet or two or three times the height of the child which, depending upon the High – risk auto crash defined trauma system, need Step Intrusion, including roof: >12 inches occupant site; >18 inches any site Yes not be the highest level Three Ejection (partial or complete) from automobile trauma center. Death in same passenger compartment (Dell Seton, Dell Children s, Vehicle telemetry data consistent with a high risk of injury South Austin, University, Auto vs. pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact SAMMC, Seton Hays) Motorcycle crash >20 mph
No
Assess special patient or system considerations
Older adults Risk of injury/death increases after age 55 years SBP <100 might represent shock after age 65 years Transport to a trauma center Low impact mechanisms (e.g. ground level falls) might result in severe injury or hospital capable of timely Step Children and thorough evaluation and Should be triaged preferentially to prediatric capable trauma centers Four initial management of Anticoagulants and bleeding disorders Yes potentially serious injuries. Patients with head injury are at high risk for rapid deterioration Consider consultation with Burns medical control. Without other trauma mechanism: triage to burn facility (Closest appropriate facility) With trauma mechanism: triage to trauma center Pregnancy > 20 weeks EMS provider judgement
No
Transport according to protocol
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 SMART Triage Algorithm
© TSG Associates
T 0 6
Pearls: Use the provided Pediatric Triage tape for small children and infants. All EMS providers are encouraged to use the Triage Algorithm any time there are more than 2-3 patients requiring evaluation, treatment or transport.
ClinicalClinical Operating Operating GuidelinesGuidelines VTRANS02012020 v011010 .T- 08 Obstetrical Emergency Protocols
Childbirth / Labor
History Signs & Symptoms Differential: Due date Episodic pain Abnormal presentation Time contractions started / how often Vaginal discharge or bleeding -- Buttock -- Foot Rupture of membranes Crowning or urge to push Time / amount of any vaginal bleeding -- Hand Meconium Sensation of fetal activity Prolapsed cord Past medical and delivery history Placenta previa Gravida/Para Status Abruptio placenta Medications High Risk pregnancy (known)
Universal Patient Care Protocol (U-01) Legend System No S S Obstetrical Responder Emergencies Protocol Active Labor B EMT - B B (OB-02) Yes I EMT- I I <20 Weeks P EMT- P P M Medical Control M >20 Weeks
Visually inspect perineum for crowning (No digital vaginal exam)
Monitor and reassess Priority symptoms: Document frequency Crowning 36 weeks gestation and duration Abnormal presentation of contractions Vaginal bleeding O P Consider N/S Bolus P Multiple gestation B Childbirth Procedure (CP-11) Placenta Previa Hypotension Protocol 0 PRN (M-15) 1 If prolapsed cord, place patient in knee/chest position and Expedite Transport push up on infants head
Newly Born Protocol (OB-03)
Contact Destination or M Medical Control M
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, allowing child to nurse and massaging the uterus (lower abdomen) will promote uterine contraction and help to control postpartum bleeding. Record APGAR at 1 minute and 5 minutes after birth. Post partum hemorrhage defined as blood loss > 1000mL or greater than 500mL with signs/symptoms. 500mL blood loss is commonly seen in uncomplicated vaginal deliveries without signs or symptoms.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 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 hands and face
Legend Universal Patient Care Protocol (U-01) System S S Responder B EMT - B B Active Labor? I EMT- I I P EMT- P P No Yes M Medical Control M
Hypotension Yes Vaginal bleeding? Protocol (M-15) No
If Active Seizures or BP Greater Childbirth Procedure as needed (CP-11) than 140/90 If Postpartum Hemorrhage Altered Mental Status Present O Protocol as needed (M-02) Mild Severe B Magnesium Sulfate P P 0 4 grams over 5 minutes Infant to mother s S Fundal Massage S 2 Continued active seizure activity? S breast for feeding S Midazolam 2-5 mg slow IV/IM Hypotension Protocol as needed (M-15) Fundal S Massage S
Contact Destination or M Medical Control M
Pearls: Severe headache, vision changes, edema, or RUQ pain may indicate preeclampsia. In the setting of pregnancy, hypertension is defined as a SBP greater than >140 or a DBP > 90, or relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure. 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 and fetal monitoring. Magnesium may cause hypotension and decreased respiratory drive, monitor closely. Post partum hemorrhage defined as blood loss > 1000mL or greater than 500mL with signs/symptoms. 500mL blood loss is commonly seen in uncomplicated vaginal deliveries without signs or symptoms. The perineum should be checked for bleeding from vaginal tears which may be mistaken for uterine bleeding. Bleeding should be controlled by direct pressure over the laceration. The most common cause of post partum hemorrhage is uterine atony due to prolonged labor, augmented labor or multiple gestations If > 20 weeks, consider left lateral position. Eclamptic seizures may occur up to 2 months after post partum.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Newly Born History: Signs and Symptoms: Differential: Due date and gestational age Respiratory distress Airway failure Multiple gestation (twins etc.) Peripheral cyanosis or mottling (normal) Secretions Respiratory drive Meconium Central cyanosis (abnormal) Infection Delivery difficulties Altered level of responsiveness Maternal medication effect Congenital disease Bradycardia Hypovolemia Medications (maternal) Hypoglycemia Maternal risk factors Congenital heart disease - substance abuse Hypothermia - smoking
Universal Patient Care Protocol Legend (For Mother) (U-01) System S S Responder Dry infant and keep warm. S Bulb syringe suction S B EMT - B B mouth / nose I EMT- I I P EMT- P P Stimulate infant and note Medical Control S APGAR Score S M M
Refer to Pediatric Respirations Distress Yes Airway Protocol (PR-01) No Meconium Present?
Deep suction with meconium Assess Heart Rate aspirator. Repeat until free from P meconinum. P Oral Intubation O B 0 3 HR <60 HR 60-100 HR >100
CPR / Peds Airway Protocol Pediatric Airway Protocol (PR-01) Monitor Reassess HR<60 HR >100 5 Minute APGAR Appropriate Dysrhythmia Protocol Reassess heart rate
D10 1-2 mL/kg IV, Contact Destination Monitor & reassess I Naloxone 0.1 mg/kg IV I M M NS bolus titrate to perfusion or MC Continue Oxygen
PEARLS: Recommended Exam: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro CPR in neonates is 120 compressions/minute with a 3:1 compression to ventilation ratio (Birth to 5 days) It is extremely important to keep infant warm Maternal sedation or narcotics will sedate infant (Naloxone effective but may precipitate seizures). Consider hypoglycemia in infant. Document 1 and 5 minute Apgars in PCR Shallow or slow respirations should be considered respiratory distress in neonates.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014
Pediatric Protocols: Patients < 37 Kg
Pediatric Extremity Trauma
History: Signs & Symptoms: Differential Type of injury Pain, swelling Abrasion Mechanism: crush / Deformity Contusion penetrating / amputation Altered sensation / motor function Laceration Time of injury Diminished pulse / capillary refill Sprain Open vs. closed wound / Decreased extremity temperature Dislocation fracture Fracture Wound contamination Amputation Medical history Medications
Universal Patient Care Protocol (U-01) Pediatric Pain Protocol (PM-08) If Snake Bite: Splint limb and place at level below heart. Constant crush injuries S NO ice and minimize S If indicated, immobilize extremity greater than four (4) movement. hours duration S If distal pulses are absent attempt reduction S Remove constricting P Sodium Bicarbonate P X1 followed by reassessment of PMS items 1 mEq/kg (maximum P of 100 mEq) in 1000 T mL NS wide open 0 S Wound care/ hemorrhage control S 1 Tourniquet Procedure (CP-56) Legend If amputation: System S S Do not delay transport for tissue retrieval Responder B EMT - B B S Rinse amputated part with NS S Wrap part in NS moistened gauze I EMT- I I Place tissue into plastic bag or container P EMT- P P Place bag/container on ice M Medical Control M
Pediatric Hypotension Protocol (PM-04)
M Contact Destination or M Medical Control
PEARLS: Recommended Exam: Mental Status, Extremity, Neuro Peripheral neurovascular status is important In amputations, time is critical. Transport and notify medical control immediately, so that the appropriate destination can be determined. Hip dislocations and knee and elbow fracture / dislocations have a high incidence of vascular compromise. Urgently transport any injury with vascular compromise. Blood loss may be concealed or not apparent with extremity injuries.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Head Trauma
History: Signs and Symptoms: Differential: Time of injury Pain, swelling, bleeding Skull fracture Mechanism: blunt / penetrating Altered mental status Brain injury (concussion, Loss of consciousness Unconscious contusion, hemorrhage, or laceration) Bleeding Respiratory distress / failure Epidural/subdural hematoma Medical history Vomiting Alcohol Intoxication Medications Significant mechanism of injury Subarachnoid/intracranial Allergies Pupillary abnormalities hemorrhage Evidence of multi-trauma CSF leaking from ears, nose, mouth Spinal injury Helmet use or damage to helmet Abuse
Universal Patient Care Protocol (U-01) Legend System S S Multiple Trauma Responder No Isolated Head Trauma? B EMT - B B Protocol (PT-03) Yes I EMT- I I P EMT- P P Spinal Motion Restriction Protocol (U-05) M Medical Control M Airway Obtain and Record GCS Protocol Yes S S SAO < 90 % or ETCO > 45 ? (PR-01) 2 2 No P Yes T S Hypotension SBP < 70+2 x age(years) S 0 No Yes 2 Seizure Protocol (PM-09) Seizure ?
No Altered Mentation Yes S Blood Glucose < 60 ? S Protocol (PM-02) No S Monitor and reassess patient q 5 min S
Contact Destination or M M Medical Control
Pearls: If evidence of brain herniation (blown pupil, Cushings reflex, rapid decline in GCS, or bradycardia) and in absence of capnometer, hyperventilate the patient 20 – 24 breaths per minute. If available titrate to adult ETCO2 30 - 35 mmHg. Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Hypotension may indicate injury or shock unrelated to the head injury and should be aggressively treated. Hypovolemic shock--hypotension, tachycardia, pallor, coolness, diaphoresis, decreased mentation. Spinal shock--hypotension, inappropriate bradycardia, cool and clammy above the level of the lesion, priaprism. Consider Altered Mental Status Protocol The most important item to monitor and document is a change in the level of consciousness and GCS. Consider Restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. Any documented loss of consciousness, prolonged confusion or mental status abnormality which does not return to normal within 15 minutes should be evaluated by a physician ASAP.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Multiple Trauma History: Signs & Symptoms: Differential (Life threatening): Time and mechanism of Pain, swelling Chest: Tension pneumothorax injury Deformity, lesions, bleeding Flail chest Damage to structure or Altered mental status or Pericardial tamponade Open chest wound vehicle unconscious Location in structure or Hemothorax Hypotension or shock vehicle Intra-abdominal bleeding Others injured or dead Arrest Pelvis / Femur fracture Speed and details of MVC Spine fracture / Cord injury Restraints / protective Head injury (see Head Trauma) equipment Extremity fracture / Dislocation Past medical history HEENT (Airway obstruction) Medications Hypothermia
Universal Patient Care Protocol (U-01) Legend System S S Responder Rapid trauma assessment and GCS S S B EMT - B B On Scene Time <10 minutes I EMT- I I Airway Protocol as needed (PR-01) P EMT- P P M Medical Control M Spinal Motion Restriction Protocol (U-05) S Declare Trauma Alert/Transport S
Vital signs / perfusion ? P T 0 Consider: Consider 3 Realignment of Long Bone Uncontrolled S S P P Fracture oropharyngeal bleeding: Control of External Hemorrhage 500 mg TXA (Nebulized) Tourniquet Procedure (CP-56) NS 20 ml/kg IV/IO I May reqeat 10 ml/kg maintain SBP > I Non-Compressible Hemorrhage below the 70+2 x age(years) Non-Compressible P neck: P 15 mg/kg TXA over 10 min Consider : Chest Decompression Procedure (CP-43) Head Injury Protocol (PT-02)
Spinal Shock Contact Destination Levophed 0.05-0.1 mcg/kg/min IV infusion M M P P Titrated to maintain a SBP 70+2 x or Medical Control age(years)
PEARLS: Consider Chest Decompression with signs of shock and injury to torso and evidence of tension pneumothorax. See Regional Trauma Guidelines for criteria when notifying the ED of Trauma Transport or Trauma Alert. Severe bleeding from an extremity not rapidly controlled with direct pressure may necessitate the application of a tourniquet Record "Trauma Notification" in patient record. Do not overlook the possibility of child abuse.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Airway, Pediatric
Legend Assess ABC's System Supplemental S S S S Adequate Respiratory Rate, Responder Oxygen Effort, Adequacy & B EMT - B B Pulse Oximetry I EMT- I I Unsuccessful/Inadequate Inadequate P EMT- P P M Medical Control M Basic Maneuvers First: - Open Airway B - Bag Valve Mask (BVM) B - Nasal or Oral Airway BIAD (i-Gel) - Proper Position size per packaging
B B Successful Preoxygenation with 100% All other Airway O2 Continue BVM Intervention Unsuccessful For 3-5 min until SPO2 >90% Maintain If pulse present S Pulse Ox >90% S EtCO2 >35 & <45 Oral-Tracheal Intubation Consider: Age <10 Needle Cricothyrotomy If clenched Procedure (CP-37) Consider Pediatric RSI/ P Or P Medication Assisted P P Age > 10 Intubation Protocol (2) Unsuccessful Surgical Airway Attempts Procedure (CP-53) Midazolam 0.05 mg/kg IV P PRN Sedation after placement of airway R Consider: Contact Destination or 0 Successful Gastric Tube M Medical Control M 1 Procedure (CP-26) as needed
PEARLS: Most pediatric airways are managed with basic interventions. Use only the interventions needed to deliver adequate oxygenation and ventilation. Respiratory failure is the leading cause of cardiac arrest in pediatric patients and should be addressed as soon as possible. Capnography is mandatory with all methods of intubation. Document results Continuous capnography (EtCO2) is required for the monitoring of all patients with an endotracheal tube. If an effective airway is being maintained by BVM with continuous pulse oximetry values of > 90, it is acceptable and encouraged to continue with basic airway measures instead of Intubation. For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. Ventilatory rate should maintain a EtCO2 between 35 and 45. Avoid hyperventilation. Paramedics should consider using Basic Maneuvers if oral-tracheal intubation is unsuccessful. Maintain C-spine immobilization for patients with suspected spinal injury. Do not assume hyperventilation is psychogenic – use oxygen, never a paper bag. Gastric tube placement should be considered in all intubated patients. Secure the airway device well and apply a c-collar to better maintain placement.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 RSI / Medication Assisted Intubation (< 37 kg)
Indications: Contraindications: May be utilized in conjunction with Airway Protocol Advanced airway can be achieved without RSI and Failed Airway Protocol to assist in intubation in the conscious or clenched patient requiring intubation
Legend System Referred from Airway Protocol (PR-01) S S Responder B EMT - B B I EMT- I I Prepare equipment, suction, BIAD P EMT- P P M Medical Control M S Preoxygenation with 100% O2 S For 3-5 min until SPO2 >90%
Consider Apneic Oxygenation Paralyzed patients in this protocol MUST be sedated Etomidate 0.3 mg/kg IV P P Monitor pulse, BP and respiratory or Ketamine 2 mg/kg Slow IV Push efforts for indications of sedation P R 0 Atropine 0.02 mg/kg IV min. 0.1 mg – max. 2 P 1.0 mg 2 minutes prior to intubation in P children < 2 years old
P Rocuronium 1 mg/kg IV P
If Etomidate given P Midazolam 0.1 mg/kg IV/IM P max total of 2 mg Intubation per Pediatric Airway Protocol (Max 2 attempts post rocuronium administration) P Confirm and Monitor tube placement P
Contact Destination or Pediatric Sedation Protocol (PM-05) M M Medical Control
Pearls: Continuous Pulse Ox, ETCO2 and ECG Monitor are required for sedated patients. Careful monitoring of level of consciousness, BP, and respiratory status with above interventions is essential. Etomidate should be avoided when sepsis or other infection suspected. Paralyzed patients in this protocol MUST be sedated Monitor pulse, BP and respiratory efforts for indications of sedation
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Respiratory Distress History: Signs & Symptoms: Differential: Asthma Aspiration Foreign body Infection Pneumonia Croup Epiglotitis Congenital heart disease Medication or Toxin Trauma
Universal Patient Care Protocol Legend System S S Respiratory Insufficiency? Responder Airway Obtain and record ETCO2 and Pulse Oximetry B EMT - B B Yes Protocol (PR-01) I EMT- I I No P EMT- P P Position of comfort M Medical Control M Wheezing Stridor
Consider : Albuterol 2.5 mg Neb, P P B (continuous if needed) B Epi Neb (2mg 1:1000 in 1ml NS) Albuterol 2.5 mg with I Atrovent 0.5 mg Neb x1 I P Not Improved ? R 0 3 Methylprednisolone 2 mg/kg IV P Max 125 mg P Albuterol 2.5 mg Neb P Continuous PRN P
Methylprednisolone 2 mg/kg IV P Max 125 mg P
P Magnesium Sulfate 50% 50 mg kg IV P Epinephrine 0.01 mg/kg IM Over 20 minutes Max 2 grams P Max 0.3 mg P
Contact Destination or M M Medical Control as needed
PEARLS: Patient respiratory status must be reassessed after each 2.5 mg Albuterol to determine need for additional dosing. Magnesium Sulfate may cause hypotension. Consider early fluid bolus. Determine whether the patient has sensitivity to peanuts and/or soy prior to Ipratropium Bromide use. If assisting patient with their MDI and dosing instructions are not available, give second dose at 20 minutes if needed.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Asystole/PEA
History: Signs & Symptoms: Differential: Time of arrest Unresponsive Respiratory failure Medical History Cardiac Arrest Foreign body Medications Secretions Infection (croup, epiglotitis) Possibility of foreign body Hypovolemia (dehydration) Hypothermia Congenital heart disease Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis Legend Universal Patient Care Protocol (U-01) System S S Responder CPR Procedure B EMT - B B I EMT- I I P EMT- P P Pediatric Airway Protocol (PR-01) M Medical Control M
Epinephrine 0.01 mg/kg (1:10,000 : 0.1 mL/kg) IV/IO P P Repeat every 5-8 minutes Treatment of Correctable Causes: Calcium 20 mg/kg IV max 2 grams (Hyperkalemia, CCB OD) Identify and treat P Sodium Bicarbonate 1meq/kg IV P Correctable causes (Hyperkalemia,TCA OD, Renal Failure). Glucagon 0.1 mg/kg max 1 mg IV (Beta blocker or CCB OD) P Levophed 0.05-0.1 mcg/kg/min C ROSC: Post Chest Decompression A Hypo/Hyperthermia Resuscitation Protocol 0 (PCA-03) 1
Contact Destination or M M Medical Control as needed
Pearls: - In order to be successful in pediatric arrests, a cause must be identified and corrected. - During CPR - 1) Push hard and fast (100/min) 2) Ensure full chest recoil 3) Minimize interruptions in CPR
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric V-Fib/Pulseless V-Tach
History: Signs & Symptoms: Differential: Events leading to arrest Unresponsive Respiratory failure Estimated downtime Cardiac Arrest Foreign body Past medical history Secretions Infection (croup, epiglotitis) Medications Hypovolemia (dehydration) Existence of terminal illness Congenital heart disease Hypothermia Trauma Tension pneumothorax Hypothermia Toxin or medication Hypoglycemia Acidosis
Cardiac Arrest Protocol Legend System S S Responder AED 1yr or Defibrillate @ B EMT - B B S 2 J/kg, resume CPR immediately S I EMT- I I Pediatric Airway Protocol (PR-01) P EMT- P P M Medical Control M
Epinephrine 0.01 mg/kg (1:10,000 : 0.1 mL/ P kg) IV/IO Repeat every 5-8 minutes P
Resume CPR Procedures P S AED or Defibrillate @ 4 J/kg, S resume CPR immediately C A
0 Amiodarone 5 mg/kg IV/IO ROSC: Post Resuscitation 2 P may repeat x1 q5 min if recurs or is persistent P Protocol (PCA-03) (max 2nd dose 150 mg)
Torsades de pointes: Contact Destination or Magnesium sulfate 50% 50 mg/kg slow IV/ M P IO push. May repeat same dose q- 5 P Medical Control as needed M minutes until a maximum of 2 grams.
Pearls: In order to be successful in pediatric arrests, a cause must be identified and corrected. In most cases pediatric airways can be managed by basic interventions. Respiratory arrest is a common cause of cardiac arrest. Unlike adults early ventilation intervention is critical. During CPR - 1) Push hard and fast at appropriate rate 2) Ensure full chest recoil 3) Minimize interruptions in CPR
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Post Resuscitation
History Signs & Symptoms Differential Respiratory Arrest Return of pulse Continue to address specific Cardiac Arrest differentials associated with original dysrhythemia
Repeat Primary Assessment Legend System S S Responder Declare a B EMT - B B Resuscitation Alert I EMT- I I ASAP after ROSC. P EMT- P P Continue ventilatory support - 100% oxygen M Medical Control M S - ETCO2 >20 S - Age appropriate Resp Rate DO NOT HYPERVENTILATE
Airway Protocol (PR-01)
P Cardiac Monitor & 12 Lead P
P C A Hypotensive Significant Ectopy Bradycardia 0 3
Hypotension Go to Appropriate Bradycardia Protocol (PM-04) Protocol Protocol (PC-01)
If arrest reoccurs, revert to appropriate protocol and/or initial successful treatment
Notify Destination or M M Contact Medical Control
PEARLS: Hyperventilation is a significant cause of hypotension and cardiac arrest in the post-resuscitation phase it must be avoided at all cost. Most patients immediately post resuscitation will require ventilatory assistance. The condition of post-resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. Appropriate post-resuscitation management can best be planned in consultation with medical control. Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and medication reaction to ALS drugs. Significant ectopy is defined as a dysrythmia that meets treatment criteria as part of another protocol (ie SVT, V-Tach)
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Bradycardia
History: Signs & Symptoms: Differential: Past Medical History HR <60/min with hypotension, Respiratory effort Medications acute altered LOC, chest pain, Respiratory obstruction Events Leading to Current Status CHF, Sz, syncope or shock Foreign body secondary to bradycardia Secretions Croup Altered LOC Epiglotitis Shock/Hypotension Hypovolemia Syncope Hypothermia Hypoxia Infection / Sepsis Medication or Toxin Hypoglycemia Trauma
Universal Patient Legend Care Protocol (U-01) System S S HR < 60 with poor perfusion S S Responder Pediatric Airway begin CPR B EMT - B B Protocol (PR-01) I EMT- I I Yes P 12 Lead ECG P Poor perfusion, P EMT- P P Decreased blood pressure, Normal Saline M Medical Control M Respiratory insufficiency, I 20 ml/kg bolus I unstable? (Repeat x1)
Epinephrine 0.01 mg/kg (1:10,000 : P P 0.1 mL/kg) IV/IO Repeat every 5-8 minutes
P Monitor S and S Atropine 0.02 mg/kg C (Minimum 0.1 mg reassess P 0 P Maximum 1mg) 1 May repeat once in 5 min.
Epinephrine (1:1,000) 0.1-1 mcg/kg/min as a catecholamine infusion after N/S Contact Destination or bolus M Medical Control M
Consider External P Transcutaneous Pacing P
Pediatric Sedation Protocol (PM-05)
Pearls: The use of lidocaine in heart block can worsen bradycardia and lead to asystole and death. Pharmacological treatment of Bradycardia is based upon the presence or absence of symptoms. If symptomatic, treat. If asymptomatic, monitor only. Consider treatable causes for bradycardia (Beta blocker OD, Calcium channel blocker OD, etc.) - treat appropriately (See Toxic Ingestion Protocol (PM-07)) Be sure to aggressively oxygenate the patient and support respiratory effort. The use of Atropine in Mobitz II is not recommended. If you are uncertain as to the type of bradycardia there is no contraindication to the use of atropine. Fluid Bolus and Epinephrine Infusion Titrated to maintain a SBP >70 + (age in years x2) mmHg
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Comprehensive Medical Practice Management Program v10.10.1 PC-1 Pediatric Supraventricular Tachycardia History: Signs and Symptoms: Differential: Past medical history Heart Rate: Child > 180/bpm Heart Disease (Congenital) Medications or Toxic Infant > 220/bpm Hypo/Hyperthermia Ingestion(thyroid, Digoxin, Pale or Cyanosis Hypovolemia or Anemia Electrolyte Imbalance Decongestants Diaphoresis Anxiety/Pain/Emotional Stress Drugs (nicotine, cocaine) Tachypnea Fever/Infection/Sepsis Congenital Heart Disease Vomiting Hypoxia Respiratory Distress Hypotension Hypoglycemia Syncope or Near Syncope Altered Level of Medication/Toxin/Drugs Consciousness Pulmonary Embolus Pulmonary Congestion Trauma Syncope Tension Pneumothorax
Universal Patient Care Protocol (U-01) Legend System S S Responder B EMT - B B Is patient stable or in pre-arrest I I Altered mental status, no palpable BP EMT- I P EMT- P P M Medical Control M
Yes No
Attempt vagal maneuvers Use sedation if possible, and must P (Ice Pack, Valsava...) P P not delay cardioversion P
Synchronized Cardioversion Consider 12-Lead ECG if P 0.5 -1 J/kg practical prior to and during C P P May increase to 2J/Kg if initial Adenosine treatment. 0 dose ineffective 2 Adenosine 0.2mg/kg IV; use No rapid bolus technique Converts? P (max dose 12mg) P May repeat x1 If at any time rhythm changes Go to appropriate Protocol Contact Destination or Yes M Medical Control as needed M
PEARLS: Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro Carefully evaluate the rhythm to distinguish Sinus Tachycardia, Supraventricular Tachycardia, and Ventricular Tachycardia Separating the child from the caregiver may worsen the child s clinical condition. Pediatric paddles should be used in children < 10 kg or Broselow-Luten color Purple. Monitor for respiratory depression and hypotension associated if a benzodiazepine is used. Continuous pulse oximetry is required for all SVT patients if available. Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. As a rule of thumb, the maximum sinus tachycardia rate is (220 – the patient s age in years).
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Allergic Reaction
History Signs & Symptoms Differential Medication history Edema / Voice Changes Urticaria (rash only) Onset and location Itching or hives Anaphylaxis (systemic effect) Past medical history Coughing / wheezing or respiratory Shock (vascular effect) Past history of reactions Angioedema (drug induced) distress New clothing, soap, detergent Aspiration / Airway obstruction Medication allergy / exposure Chest or throat constriction Vasovagal event Food allergy / exposure Difficulty swallowing CHF Insect sting or bite Hypotension or shock Asthma or COPD
Universal Patient Care Protocol (U-01) Legend System S S Hives/Rash only Responder Severe Respiratory Distress No Respiratory Distress B EMT - B B and/or I EMT- I I Hypotension P EMT- P P Mild to Moderate Distress MMedical Control M
Albuterol 2.5 mg Neb, P Cardiac Monitor P continuous if needed Epinephrine 0.01mg/kg IM B B B B Max single dose 0.3 mg Diphenhydramine Diphenhydramine 1-1.25 mg/kg PO x1 dose B >10kg & <20kg 1 PO tablet B >20kg & <37kg 2 PO tablets Go to >>> Diphenhydramine 1-1.25 mg/kg IV/IM x1 dose I I NS 20ml/kg P May repeat x1 M 0 Cardiac Monitor Reassess patient P P 1 Methylprednisolone 2 mg/kg IV x1 dose
Continue to reassess airway
Epinephrine 0.01mg/kg IM P Max single dose 0.3 mg P
Contact Destination or M Medical Control M
PEARLS: Recommended Exam: Mental Status, Skin, Heart, Lungs Vomiting may be a sign/symptom of an allergic reaction. These patients should receive a 12 lead ECG and should be continually monitored. Any patient with respiratory symptoms or extensive skin reaction should receive IV or IM diphenhydramine. The shorter the onset from symptoms to contact, the more severe the reaction. Fluids and Medication titrated to maintain a SBP >70 + (age in years x 2) mmHg
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Altered Mental Status History: Signs/Symptoms: Differential: Known diabetic, medic Decreased mental status Head trauma alert tag Change in baseline mental CNS (stroke, tumor, seizure, infection) Drugs, drug paraphernalia status Cardiac (MI, CHF) Report of illicit drug use or Bizarre behavior Infection toxic ingestion Hypoglycemia (cool, diaphoretic Thyroid (hyper / hypo) Past medical history skin) Shock (septic, metabolic, traumatic) Medications Hyperglycemia (warm, dry skin; Diabetes (hyper / hypoglycemia) History of trauma fruity breath; Kussmaul resps; Toxicologic Acidosis / Alkalosis signs of dehydration) Environmental exposure Pulmonary (Hypoxia) Electrolyte abnormality Psychiatric disorder
Universal Patient Care Protocol (U-01) Legend System S S Responder Consider B EMT - B B Spinal Motion Restriction Protocol (U-05) I EMT- I I P EMT- P P Blood glucose M Medical Control M Glucose < 60 Glucose > 300 and S/S of Dehydration? Oral Glucose 7.5 grams S S if Pt. able to protect Airway
If respirations depressed Normal Saline 20ml/kg IV I I P P Nalaxone 0.1 mg/kg may repeat x1 for hypotension D10W 5ml/kg or until the patient P I returns to baseline mental status. I M Consider other causes and Assess Protocols: P Cardiac Monitor P 0 Head injury (PT-02), Overdose & 12 Lead 2 (PM-07), Hypoxia (PR-01), Seizure (PM-09), If signs of hyperkalemia Glucagon P Consider Calcium 50mg/kg IV P P 0.1 mg/kg IM, if no IV P Arrhythmia & Sodium Bicarb 1 meq/kg IV (Max dose 1mg) Return to baseline ? No
Contact Destination or M M Medical Control as needed
Pearls: Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. Consider Restraints if necessary for patient's and/or personnel's protection per the restraint procedure.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Fever/Infection History: Signs & Symptoms: Differential: Age Warm, flushed, diaphoretic Infections/Sepsis Duration of fever Chills Cancer/Tumors Severity of fever Tachycardia Medication or drug Past medical history Cough reaction Medications Headache, mental status changes Connective Tissue Immunocompromised Disease Environmentals exposure Dysuria Kawasaki Disease Last dose Acetaminophen or Abdominal pain Ibuprofen Rash Environmental Exposure Meningitis
Universal Patient Care Protocol (U-01) Legend System S S Consider Appropriate PPE Responder B EMT - B B Signs of dehydration? I EMT- I I P EMT- P P M Medical Control M
If temperature is > 100.4° F B Acetaminophen 15mg/kg PO B max dose of 500mg Consider Fluid Bolus I I 20ml/kg PRN
Appropriate protocol By complaint P M 0 Contact Destination or 3 M Medical Control as needed M
PEARLS: Patients with a history of liver failure should not receive acetaminophen. If tachycardia and/or signs of poor perfusion, consider sepsis.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Hypotension (Non-Trauma)
History: Signs and Symptoms: Differential: Blood loss Restlessness, confusion, Trauma Fluid loss weakness Infection Vomiting Dizziness Dehydration Diarrhea Increased HR, rapid pulse Vomiting Fever Decreased BP Diarrhea Infection Pale, cool, clammy skin Fever Delayed capillary refill Congenital Heart Disease Medication or Toxin
Universal Legend Patient Care Protocol (U-01) System S S Responder Pediatric Altered B B Altered Mental Status? EMT - B Mental Status Protocol (PM-02) I EMT- I I P EMT- P P Normal Saline bolus 20 ml/kg I May repeat 10ml/kg x2 PRN I M Medical Control M
S Monitor and Reassess S Yes Perfusion Improved?
Consider Epinephrine 1:100,000 (IV/IO) P 1-5 mcg q 1 min P max 10 doses Titrate to SBP>70 + 2 x age(years) P M 0 Levophed 0.05 – 0.1 mcg/kg/min 4 OR P Epinephrine (IV/IO) P .05 -.1 mcg/kg/min Titrate to SBP> 70 + 2 x age(years)
Contact Destination or M Medical Control M
PEARLS: Fluids and Medication titrated to maintain a SBP >70 + (age in years x 2) mmHg Consider causes of pediatric hypotension and address per appropriate protocol. Consider Levophed in warm shock or shock of cardiogenic origin. Consider Epinephrine in cold shock, hypotensive patients with mottling or bradycardia, or other shock of non cardiogenic origin.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Sedation
History Signs & Symptoms Differential: Situational crisis Anxiety, agitation, confusion see Altered Mental Status differential Psychiatric illness/medications Affect change, hallucinations Hypoxia Alcohol Intoxication Injury to self or threats to others Delusional thoughts, bizarre Toxin / Substance abuse Medic alert tag behavior Medication effect / overdose Substance abuse / overdose Combative violent Withdrawal syndromes Diabetes Expression of suicidal/homicidal Depression thoughts Bipolar (manic-depressive) Schizophrenia, anxiety disorders, etc.
Scene Safety Legend System S S Responder B EMT - B B Consider protocol: Universal Patient Care Protocol (U-01) Overdose (PM-07) I EMT- I I P EMT- P P M Medical Control M Remove patient from stressful environment, verbal techniques (reassurance, calm, rapport)
GCS & Respiratory status on all patients Advanced Restraint Procedure as needed (CP-42) GCS>14 and Airway in maintaining own Place airway
Ketamine 2 mg/kg IV/IO Midazolam 0.1mg/kg IV May repeat q 20 minutes P (Max dose 2 mg) PRN M P - OR - P 0 OR 5 Midazolam 0.2mg/kg mg IM/IN (Max dose 5 mg) P Midazolam 0.1 mg/kg IV/IO P May repeat q 10 minutes PRN And Fentanyl 2 mcg/kg IV/IO May repeat q 10 minutes PRN
Contact Destination or M M Continuous ETCO2, Pulse OX, Medical Control Cardiac Monitor and Document
PEARLS: Fentanyl & Versed may cause hypotension. Maintain SBP> 70+2 x age(years) Be sure to consider all possible medical/trauma causes for behavior (hypoglycemia, overdose, substance abuse, hypoxia, head injury, etc.) Do not overlook the possibility of associated domestic violence or child abuse. All patients who receive chemical sedation must be continuously monitored by ALS personnel on scene. ECG, ETCO2 and Pulse Ox should be obtained q 5 min.
Clinical Operating Guidelines VTRANS02012020 Pediatric Nausea Vomiting and Diarrhea History: Signs and Symptoms: Differential: Age Pain CNS (Increased pressure, headache, Time of last meal Character of Pain ( Intermittent, stroke, CNS Lesions, trauma or Last bowel movement / emesis constant, sharp, dull, etc.) hemorrhage, vestibular) Improvement or worsening with Distension AMI food or activity Constipation Drugs (NSAIDS, Duration of problem Diarrhea antibiotics,narcotics,chemotherapy.) GI or Renal disorders Other sick contacts Anorexia Radiation Diabetic Ketoacidosis Past Medical History Gynecologic disease (Ovarian Cyst / PID) ASSOCIATED Past Surgical History Infections (pneumonia, influenza) SYMPTOMS(Helpful to localize Medications Electrolyte abnormalities source) Fever, headache, Food or Toxin induced Menstrual history / Pregnancy blurred vision, weakness, Medication or Substance abuse Travel history myalgia, cough, dysuria, mental Pregnancy Bloody Emesis or diarrhea status changes, rash Psychological
Universal Patient Care Protocol (U-01) Legend System S S Responder B EMT - B B S Signs or symptoms of Dehydration S I EMT- I I P EMT- P P M Medical Control M S Blood Glucose S
Pediatric Altered Mental Status Protocol As Needed (PM-02) P M 0 6 I Consider Fluid Bolus I 20 ml/kg PRN
Ondansetron P 0.1 mg/kg IV P Single Dose Administration Only
Contact Destination or M Medical Control M
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Overdose/ Toxic Ingestion
History: Signs and Symptoms: Differential: Ingestion or suspected ingestion Mental status changes Tricyclic antidepressants of a possibly toxic substance Hypotension/ Hypertension Acetaminophen (Tylenol) Substance ingested, route, Decreased respiratory rate Depressants quantity Tachycardia, dysrhythmias Stimulants Time of ingestion Seizures Anticholinergic Reason (suicidal, accidental, Cardiac medications criminal) Solvents, alcohols, cleaning agents Available medication in home Insecticides (organophosphates) Past medical history, medications
Legend Universal Patient Care Protocol (U-01) System S S Responder B EMT - B B Appropriate Hypotension (PM-04), Seizures (PM-09), Airway I EMT- I I Protocol (PR-01), Ventricular dysrhythmias or Mental Status Change (PM-02) P EMT- P P Suspected Opioid Ingestion Other M Medical Control M Organophosphate / Carbamates
Narcotic Overdose: I Naloxone 0.1 mg/kg IV/IM/IN I Toxic Exposure Max Dose 2mg Organophosphate/ Nerve Agent Protocol P Tricyclic Overdose: P P (TX-09) Sodium Bicarbonate1meq/kg IV M 0 Beta Blocker Overdose: 7 P Glucagon 0.1 mg/kg IM P (Max 1 mg)
Contact Destination or Calcium Channel Blocker Overdose: M M P Calcium Gluconate 50 mg/kg slow IVP P Medical Control (Max 1 gram)
Pearls: Do not rely on patient history of ingestion especially in suicide attempts. Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. Opioid: decreased HR, decreased respirations, constricted pupils. Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure. Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non-specific pupils. Stimulants: increased HR, increased BP, increased temperature, dilated pupils, seizures. Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes. Cardiac Meds: dysrhythmias and mental status changes. Solvents: Nausea, vomiting, respiratory distress, and mental status changes. Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils. Consider contacting the US/Texas Poison Control Center for guidance. 1-800-222-1222
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric Pain Management
History: Signs and Symptoms: Differential: Age Severity ( pain scale) Per the specific protocol Location Quality Musculoskeletal Duration Radiation Visceral (abdominal) Severity ( 1-10 ) Relation to movement, Cardiac Past Medical History respiration Pleural / Respiratory Medications Increased with palpation of Neurogenic Drug allergies area. Renal ( colic ) Medications taken prior to arrival
Universal Patient Care Protocol Legend System S S Responder B EMT - B B Assess Degree of Pain I EMT- I I Immobilize extremity if indicated P EMT- P P M Medical Control M
Pn 2-4 Pn 6-8 Pn 10
Acetaminophen 15mg/kg Fentanyl 1-2 mcg/kg IV/IM/IN/IO B PO B P May repeat q 10 min P Max dose 500mg to a max. dose of 400 mcg
Consider fluids if kidney If pain from muscle spasm, consider stones suspected Midazolam 0.05 mg/kg IV/IO (Max dose 2 mg) P P P - OR - Ketamine 0.5 mg/kg IM M Midazolam 0.1 mg/kg IM/IN May repeat Q 5 min x 1 0 (Max dose 5 mg) Max dose 100mg 8 P - AND/OR - P
Fentanyl 1-2 mcg/kg IV/IM/ P Continuous Monitoring P IN/IO May repeat q 10 min to a max. dose of 400 mcg Contact destination or M Medical Control as needed M
Pearls: The patient s parent/guardian should be involved in pain management decisions. Pain severity (0-10) is a vital sign to be recorded pre and post IV or IM medication delivery and at disposition. Vital signs should be obtained pre, 15 minutes post, and at disposition with all pain medications. All patient s must have drug allergies documented prior to administering pain medications. All patient's who receive IM or IV medications must be observed 15 minutes for drug interaction. Watch closely for respiratory depression with narcotics - refer to Airway Protocol if needed - keep Naloxone available Monitor patient closely for oversedation - refer to overdose protocol if needed Use Wong-Baker faces pain scale over 3 years old. Under 3 years, use FLACC scale.
Clinical Operating Guidelines VTRANS02012020 Pediatric Seizure History: Signs & Symptoms: Differential: Fever Observed Seizure Activity Fever Prior history of seizures Altered Mental Status Infection Seizure Medications Hot, dry skin or elevated body Head trauma Medication or Toxin Reported Seizure Activity temperature Hypoxia or Respiratory History of recent head trauma failure Congenital abnormality Hypoglycemia Metabolic abnormality / acidosis Tumor
Legend System Universal Patient Care Protocol (U-01) S S Responder B EMT - B B Pediatric Airway Protocol (PR-01) I EMT- I I P EMT- P P Active seizure ? M Medical Control M Yes No Midazolam 0.1 mg/kg IV/IO (Max dose 2 mg) S Monitor and Reassess S - OR - P Midazolam 0.2 mg/kg IM/IN P (Max dose 5 mg)
If temperature is > 100.4° F B Acetaminophen 15mg/kg PO, B max dose of 500mg P M Blood Glucose < 60 ? 0 9 Pediatric Altered Mental Status (PM- Consider other causes: 02)
Electrolyte Imbalance Trauma Infection Contact Destination or Toxins M Medical Control as needed M Arrhythmia
PEARLS: Avoiding hypoxemia is extremely important Status Epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergecy required rapid airway control, treatment, and transport. Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. Petit mal seizures (focal) effect only a part of the body and do not usually result in a loss of consciousness. Jacksonian seizures start as a focal seizure and become generalized. Be prepared to assist ventilations, especially if a benzodiazepine is used. If evidence or suspicion of trauma, spine should be immobilized In an infant, a seizure may be the only evidence of a closed head injury.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Special Response Protocols (Adult/Pedi)
Toxic Exposure Ammonia (Gas & Liquid)
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Scene and patient management per Core Principles IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove patient from the source of exposure. Request HazMat response as appropriate Decontaminate patient per Hazardous Materials Recommendation S Focused history and physical exam S Estimation of exposure time Develop and implement treatment plan based on assessment findings, resources, and training Flush contaminated skin/eyes. If ingested and the patient is completely alert give 8 oz. of water for dilution.
Universal Patient Care Protocol
ADULT PEDI 37 Kg < 37 Kg T X As Needed: 0 Legend Respiratory Distress Protocol Hypotension/Shock Protocol 1 System S S Responder B EMT - B B I EMT- I I Contact Destination or M M P EMT- P P Medical Control M Medical Control M
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT
Clinical Operating Guidelines VTRANS02012020 Clinical Operating Guidelines v0212014 Carbon Monoxide Exposure
History: Signs and Symptoms: Differential: Known or suspected CO exposure Altered mental status/dizziness Effects of other toxic fire by product Suspected source/duration exposure Headache, Nausea/Vomiting Acute cardiac event Age Chest Pain/Respiratory distress Acute neurological event Known or possible pregnancy Neurological impairments Flu/GI illness Reason (accidental, suicidal) Vision problems/reddened eyes Acute intoxication Measured atmospheric levels Tachycardia/tachypnea Diabetic Ketoacidosis Past medical history, medications Arrhythmias, seizures, coma Headache of non-toxic origin
Universal Patient Care Protocol Legend System S S Responder Measure COHb % (SpCO) B EMT - B B If equipment is available I EMT- I I P EMT- P P SpCO 0% to 5 % SpCO > 5 % M Medical Control M
No further medical evaluation of SpCO SpCO > 15% or SpCO < 15 and SpO2 < 90 SpO2 > 90 % required*
100% Oxygen by Symptoms of CO NRB and Yes and/or Hypoxia? transport to ED No
If cardiac/respiratory/ hypotension/neurological No treatment for CO exposure required* symptoms are also present, Recommend smokers seek smoking T go to appropriate protocol cessation treatment. X Recommend evaluation of home/work 0 environment for presence of CO 2 If monitoring responders at fire scene, proceed with Scene Rehabilitation Protocol
Pearls: *Fetal hemoglobin has a greater attraction for CO than maternal hemoglobin. Females who are known to be pregnant or who could be 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 WMD Cyanide treatment protocol The differential list for CO Toxicity is extensive. Attempt to evaluate other correctable causes when possible Chronic CO exposure is clinically significant; therefore advice on smoking cessation is important medical instruction Severe CO Toxicity may require Hyperbaric Chamber – Transport All ages to St. David s Medical Center.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Toxic Exposure Chlorine and Related Compounds
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Legend Scene and patient management per Core Principles System IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove S S Responder patient from the source of exposure. Request HazMat response as appropriate B B EMT - B Decontaminate patient per Hazardous Materials Recommendation I EMT- I I S Focused history and physical exam S Estimation of exposure time P P EMT- P Develop and implement treatment plan based on assessment findings, H HAZMAT H resources, and training Flush contaminated skin/eyes. Medical Control M M Monitor for pulmonary edema and/or shock.
Universal Patient Care Protocol
As Needed: Respiratory Distress Protocol Hypotension/Shock Protocol Seizure protocol T X FOR CHLORINE GAS 0 EXPOSURE ONLY: H H 3 Nebulize Sodium Bicarbonate
Contact Destination or M M Medical Control
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT Sodium Bicarbonate Nebulized: Place 2 ml sodium bicarbonate 8.4% (standard sodium bicarbonate) into 2 ml of sterile water administered by hand-held nebulizer. May be repeated q 20 minutes. Max dose total of 2 times. Racemic Epinephrine 0.25 – 0.75 ml of a 2.25% solution in 2.5cc sterile water via nebulization repeat every 20 minute s as needed. Max dose total of 3 times. Clinical Operating Guidelines VTRANS02012020 Clinical Operating Guidelines v0212014 Toxic Exposure Cyanide
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Legend Scene and patient management per Core Principles System IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove S S Responder patient from the source of exposure. Request HazMat response as appropriate B B EMT - B Decontaminate patient per Hazardous Materials Recommendation I EMT- I I S Focused history and physical exam S Estimation of exposure time P P EMT- P Develop and implement treatment plan based on assessment findings, H HAZMAT H resources, and training Flush contaminated skin/eyes. Medical Control M M Monitor for shock.
ADULT PEDI Universal Patient Care Protocol 37 Kg < 37 Kg
Cyanide Antidote Kit (if Cyanide Antidote Kit (if available and Provider is available and Provider is properly trained) As Needed: properly trained) Amyl nitrite pearls Respiratory Distress Protocol Amyl nitrite pearls Hypotension/Shock Protocol T by inhalation for 30 by inhalation for 30 seconds Seizure protocol seconds X 3% Sodium nitrite 3% Sodium nitrite 9 0 P 300 mg IV over 2- P P mg/kg up to 300 mg P 4 4 min utes IV over 2-4 min utes 25% Sodium 25% Sodium Thiosulfate 12.5 Thiosulfate 12.5 grams IV infusion grams IV infusion following nitrite following nitrite therapy Contact Destination or therapy M M Medical Control
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT Be alert for exposure related Acute dyspnea/tachypnea without cyanosis, Nausea/vomiting, Seizures, Hyper or hypotension Be cautious of pulse oximetry readings
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Toxic Exposure—Fumigants: Methyl Bromide, Sulfuryl Fluoride, Chloropicrin, & Phosphides
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Legend Scene and patient management per Core Principles System S S IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove Responder patient from the source of exposure. B EMT - B B Request HazMat response as appropriate Decontaminate patient per Hazardous Materials Recommendation I I EMT- I S Focused history and physical exam S P EMT- P P Estimation of exposure time Develop and implement treatment plan based on assessment findings, H HAZMAT H resources, and training M Medical Control M Flush contaminated skin/eyes. Monitor for pulmonary edema and/or shock.
Universal Patient Care Protocol
As Needed: Respiratory Distress Protocol Hypotension/Shock Protocol Seizure protocol T X 0 Proparacaine hydrochloride one (1) 5 H or two (2) drops per eye to assist H with eye irrigation.
Contact Destination or M M Medical Control
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT Be alert for exposure related Acute dyspnea/tachypnea without cyanosis, Nausea/vomiting, Seizures, Hyper or hypotension
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Toxic Exposure - Hydrazines
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Legend Scene and patient management per Core Principles System S S IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove Responder patient from the source of exposure. B EMT - B B Request HazMat response as appropriate Decontaminate patient per Hazardous Materials Recommendation I I EMT- I S Focused history and physical exam S P EMT- P P Estimation of exposure time Develop and implement treatment plan based on assessment findings, H HAZMAT H resources, and training M Medical Control M Flush contaminated skin/eyes. Monitor for pulmonary edema and/or shock.
Universal Patient Care Protocol
As Needed: Respiratory Distress Protocol Hypotension/Shock Protocol Seizure protocol T X 0 Proparacaine hydrochloride one (1) or Pyridoxine 25 mg/kg IV, over 5 H H 6 H two (2) drops per eye to assist with eye H minutes. As needed. irrigation. As needed.
Contact Destination or M M Medical Control
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT Be alert for exposure related Acute dyspnea/tachypnea without cyanosis, Nausea/vomiting, Seizures, Hypotension
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Toxic Exposure – Hydrofluoric Acid
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Scene and patient management per Core Principles IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove patient from the source of exposure. Request HazMat response as appropriate Decontaminate patient per Hazardous Materials Recommendation Develop and implement treatment plan based on assessment findings, resources, and training Skin Exposure Immediate irrigation. Clothing, jewelry etc., is removed as irrigation is taking place. S S Adult & Pedi Soak burned skin in magnesium hydroxide antacid preparations (milk of magnesia, Mylanta, Maalox). Eye Exposure Dermal exposure Continuous rinsing for a minimum of 15 minutes or until a calcium ocular Topical solution solution is available. Mix 10 mL calcium Ingestion – Conscious/Alert Patient Only gluconate 10% with 30 If patient is able to swallow, administer high amounts of any calcium or gms of water-soluble gel magnesium based antacid (milk of magnesia, Mylanta, Maalox). In the Dermal exposure with absence of these products, have patient drink approximately 8-16 oz. of persistent pain after 30 water minutes of calcium gluconate gel application 0.5 ml/cm(2) burn of 10% calcium gluconate by SQ T infiltration Universal Patient Care Protocol X H Ocular Exposure H 0 Mix 10 mL calcium Legend 7 gluconate 10% with 1000 System S S mL of NS Responder Irrigate affected eye(s) B EMT - B B with 500 mL of solution I EMT- I I Inhalation exposure with Contact Destination or P EMT- P P M M pulmonary edema Medical Control H HAZMAT H Mix 1 mL calcium M Medical Control M gluconate 10% with 3mL sterile water and nebulize solution
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Toxic Exposure Hydrogen Sulfide, Sulfides, & Mercaptans
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Scene and patient management per Core Principles Legend IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove System patient from the source of exposure. S S Responder Request HazMat response as appropriate Decontaminate patient per Hazardous Materials Recommendation B B EMT - B Due to chemical characteristics consider hypothermia/frostbite. I EMT- I I S If symptoms are mild, including eye and throat irritation, headache, nausea S or dizziness, supportive care will suffice. P P EMT- P Focused history and physical exam H HAZMAT H Estimation of exposure time Develop and implement treatment plan based on assessment findings, M Medical Control M resources, and training Flush contaminated skin/eyes.
Universal Patient Care Protocol
As Needed: ADULT Hypotension/Shock Protocol PEDI 37 Kg Hypothermia Protocol < 37 Kg Seizure Protocol
T Proparacaine hydrochloride one (1) or X H two (2) drops per eye to assist with eye H irrigation. As needed. 0 8 ANTIDOTE ADMINISTRATION Amyl Nitrite - should be broken and held, one at a time in front of the patient's nose. They should be left in place for 15- H seconds and followed with a 15- second rest and a new H Amyl Nitrite aspirol should be used each minute or 4 cycles until sodium nitrite can be administered. Sodium nitrite (3% IV Sodium nitrite (3% IV H solution): 300 mg IV solution): 9 mg/kg up to H H over 2-4 minutes Contact Destination or 300 mg IV over 2-4 M M Medical Control minutes
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT Repeat antidote at 50% of initial dose if symptoms persist after 20 minutes. If symptoms worsen after treatment consider the possibility of NITRITE TOXICITY causing METHEMOGLOBINEMIA greater than 25%. Contact Medical Control
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 TOXIC EXPOSURE ORGANOPHOSPHATES/NERVE AGENTS
ECA/All Providers : Scene and patient management per Core Principles If properly trained and equipped, safely and rapidly remove patient from the Credentialing Exception and source of exposure Exclusion for (Hot Zone) treat- Request HazMat response as appropriate ments: Focused history and physical exam If properly equipped, trained and Be alert for S.L.U.D.G.E. presentation in Level A Hazmat protection, S alivation treat severe exposures with IM L acrimation auto injectors only. Urination D efecation G astrointestinal cramping Emesis Develop and implement treatment plan based on assessment findings, ADD DEADLY B S resources, and training BRONCOHRREA Immediate irrigation. BRONCHOCONS Clothing, jewelry etc., is removed as irrigation is taking place Consider the use of a Nerve Agent Response Kit (s) for self preservation TRIOCN if you are exposed and become symptomatic. BRADYCARDIA
Contamination Reduction (Warm Zone) Mild to severe exposures
ECA/EMT- B: ABCs & O 2 & (Monitor ECG & ETCO2 if Equipment is available)
ILS/ALS: Advanced airway, vascular access and fluid therapy per Resuscitation and Per- fusion Core PrincipleTitrate SBP 100
Mild Exposure Moderate Exposure Severe Exposure
ALS: Atropine: ALS: Atropine: ALS: Atropine: 2 mg atropine IV/IO (IM 1: 1,000). 4 mg atropine IV/IO (IM 1:1,000). May 6mg atropine IV/IO (IM 1:1,000). May May repeat every 3 to 5 mins until repeat 2 mg every 3 to 5 mins until symp- repeat: 2 mg IV/IO (IM 1:1,000) every 3 symptoms improve OR 1 Atropine toms improve OR 2 Atropine Autoinjec- to 5 mins until symptoms improve OR 3 Autoinjector. tors. Atropine Autoinjectors.
T X ALS: 2PAM ALS: 2PAM 0 If symptoms don't improve in 5 mins, administer one (1) 2PAM autoinjector ALS: 2PAM 9 administer one (1) 2PAM (600 mg) IM. May repeat x 1 in 5 to 10 administer three (3) 2PAM autoinjectors autoinjector (600 mg) IM. One time mins if symptoms don't improve. (1800 mg) IM . only.
Seizure Activity ALS Only OR Midazolam 5 mg IM, or intra nasal Seizures refractory to Diazepam and titrated to effect for seizure activity when unable to establish IV/ IO Diazepam 5- 20 mg (5 mg incre- SBP 100 mmHg or peripheral pulses ments) IV/IO or adult autoinjector present May repeat X 1 dose for active seizures with SBP 100 Midazolam 2.5–10 mg (2.5 mg increments) mmHg IV/IO (preferred)
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Toxic Exposure Sodium Hydroxide
History: Signs and Symptoms: Differential: Suspected source/duration exposure Altered mental status/dizziness Acute cardiac event Age Headache, Nausea/Vomiting Acute neurological event Known or possible pregnancy Chest Pain/Respiratory distress Acute intoxication Reason (accidental, suicidal) Neurological impairments Past medical history, medications Vision problems/reddened eyes Tachycardia/tachypnea Arrhythmias, seizures, coma
Scene and patient management per Core Principles IF PROPERLY TRAINED AND EQUIPPED, safely and rapidly remove patient from the source of exposure. Request HazMat response as appropriate Decontaminate patient per Hazardous Materials Recommendation Do not attempt to neutralize with an acid because of exothermic chemical reaction. S S Focused history and physical exam Estimation of exposure time Develop and implement treatment plan based on assessment findings, resources, and training Dilute ingestions orally with water or milk in alert patient. Remove clothing for liquid dermal exposure - rapid body wash and flush eyes with water.
Legend System Universal Patient Care Protocol S S Responder Adult & Pedi B EMT - B B As Needed: I EMT- I I Hypotension/Shock Protocol T Pain/Anxiety Mgt. Protocol X P EMT- P P 0 H HAZMAT H Proparacaine hydrochloride one (1) 1 M Medical Control M 0 H or two (2) drops per eye to assist H with eye irrigation. As needed.
Contact Destination or M M Medical Control
Pearls DO NOT BEGIN TRANSPORT UNTIL ALL CONTAMINATED CLOTHING HAS BEEN REMOVED AND PATIENT HAS BEEN PROPERLY AND THOROUGHLY DECONTAMINATED AND CLEARED BY HAZMAT FOR TRANSPORT
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Scene Rehabilitation Protocol Adult 37 Kg
Encourage removal of all PPE, Legend including bunker pants being pushed System S S down on boots. Rest, active/passive Responders cooling, and oral rehydration. PROCEED AFTER 10 MINUTES B EMT - B B Have person stand for 2 minutes and I EMT- I I observe for symptoms. Perform Pulse P EMT- P P Yes orthostatic vitals. > 85 percent maximum for age Does pulse increase > 20 or Systolic M Medical Control M BP drop >20? No No Yes IV rehydration up to 2 liters until pulse Blood Pressure is = to or < 100 and systolic is > 110. SBP >200 or DBP >110? Yes I If pulse remains elevated or BP low, I transport to ED. If pulse/BP OK, do No not return to scene activities. Respirations < 8 per minute or >40 per minute Yes IV/IO Protocol as time and patient No condition requires or allows Temperature > 101 tympanic or oral Yes after 2 minutes without fluids? No
Pulse Oximetry Yes < 90%? Mandatory rest, rehydration and No re-evaluation in 10 minutes. Transport to ED if no improvement in Return to full duty total rehab time of 30 minutes
Pearls: This protocol may be applied to adult patients on fire scenes and any gathering approved by Medical Director Exam: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro When used for firefighter rehab, firefighters should report to rehab for evaluation after 45 minutes (2 thirty minute or 1 sixty minute cylinder), or earlier if the firefighter or incident commander desires. Any person complaining of shortness of breath, confusion, combativeness or headache will be treated with high flow oxygen and be transported to the hospital. Automatic Transport Criteria: Chest Pain Shortness of breath unresolved by 10 minutes on high flow oxygen. Heart rhythm other than NSR or sinus tach A syncopal episode, disorientation, or confusion R Vital signs that have not returned to normal after 30 minutes of rest E Inability to hold fluids down or an episode of vomiting H Request for transport for any reason Cooling Techniques A Expose by full gear removal B Immerse forearms in water in rehab chairs when available (most effective technique) Do not apply wet towels to neck or head of firefighters- risk of steam burns is increased Cooling fans, ambient evaporative cooling Medical Control contact is not required to discontinue IV therapy to adult Emergency Services personnel treated under this protocol. For other approved gatherings, contact requirements are determined at approval.
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 CPR Procedure
Person in Position 6 (P6) always just outside the Person in Position 3 (P3) always at patients Head Triangle of CPR 1. Assembles/apply BVM 1. Assist other providers as 2. Opens/clears Airway needed 3. Provides ventilations (1 breath every 6 seconds) 2. Interface with family 4. Connect to O2 & Uses 2 handed mask seal when additional provider available to bag 5. Inserts/secures BIAD & ETCO2 Person in Position 1 (P1) always on patients Right side Person in Position 2 (P2) always on 1. Initial patient assessment patients Left side 2. Initiates 100 compressions 1.Turns on monitor and metronome 3. After P2 performs 100 2. Places LUCAS Backboard under patient compressions, attaches LUCAS after P1 performs initial 100 compressions. device to backboard and 3. Alternates appropriate compressions initiates mechanical CPR. with P1 4. Assist with BVM or BIAD 4. Assist with BVM or BIAD Preparation if Preparation in off cycle needed
Advanced Provider in Position 4 (P4) always at an area outside the CPR Triangle near a lower leg and Operates the Monitor 1. Code Commander Advanced Provider in Position 5 2. Communicates/Interfaces with (P5) always at an extremity Team Leader outside the CPR Triangle 3. Makes all Patient treatment 1. Initiates IV/IO access decisions 2. Administers Medications requested by Code Commander
C P R
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Pediatric CPR Procedure
Person in Position 6 (P6) always just outside the Person in Position 3 (P3) always at patients Head Triangle of CPR 1. Assembles/apply BVM 1. Assist other providers as 2. Opens/clears Airway needed 3. Provides ventilations (1 Breath every 3-5 seconds) 2. Interface with family 4. Connect to O2 & Uses 2 handed mask seal when additional provider available to bag 5. Inserts/secures BIAD & ETCO2 after 4 rounds of Compressions
Person in Position 1 (P1) always on patients Right side Person in Position 2 (P2) always on 1. Initial patient assessment patients Left side 2. Initiates appropriate 1.Turns on monitor and metronome compressions 2. Alternates appropriate compressions 3. Ventilates in off cycle with P1 4. Assist with BVM or BIAD 3. Ventilates in off cycle Preparation in off cycle 4. Assist with BVM or BIAD Preparation if needed
Advanced Provider in Position 4 (P4) always at an area outside the CPR Triangle near a lower leg and Operates the Monitor 1. Code Commander Advanced Provider in Position 5 2. Communicates/Interfaces with (P5) always at an extremity Team Leader outside the CPR Triangle 3. Makes all Patient treatment 1. Initiates IV/IO access decisions 2. Administers Medications requested by Code Commander
P e d i
C P R
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014 Defibrillation Procedure
CPR Procedure
Provider in P2 P2 Brings and operates the AED Apply Pads to patients bare chest Connects pads to AED
Witnessed Arrest ?
NO/Uncertain Yes
Turns on AED Immediately After 200 turns on AED compressions
Follow prompt to shock and/or P6 Immediately resumes CPR Procedure
Provider in P6 (Code Commander) Brings and operates the Monitor Turns on Monitor Connects to AED Pads Selects PADDLES mode Evaluates rhythm for defibrillation every 2 minutes. Set Defibrillator to 360j for all shocks. Minimizes evaluation time
D E Delivers shock and/or F Immediately resumes I CPR Procedure B
ClinicalClinical OperatingClinical Operating GuidelinesOperating Guidelines Guidelines VTRANS02012020 v0212014 v011010 . Restraint Procedure
Restraint/Transport Against Patient Will
An EMS System has an obligation to treat and transport certain patients who may be suffering from an illness or injury that i mpairs their ability to make an informed decision. These patients will often refuse treatment or transport to a medical facility. In circumstances where an acute illness or injury impairs a patient s ability to make an informed decision AND the patient is in need of medical treatment or evaluation to prevent further significant illness or injury, the patient shall be transported to an ED for further evaluation. There are certain circumstances where a patient s condition or behavior pose an immediate threat to the health and safety of themselves or others around them. In these circumstances, the patient should be safely and humanely restrained and continuously monitored during restraint. Patient restraint and transport against their will should never be taken lightly. Every individual has a legal and moral right to refuse medical treatment, even if that refusal results in potential harm. It is our responsibility to make sure the patient is making an informed decision and that the patient causes no harm to themselves or others as a resu lt of their behavior. Determine scene safety. Attempts to physically restrain a patient should be made (when possible) with law enforcement assistance. Determine that a potentially harmful condition exists (if the condition is immediately life-threatening, the patient should be treated and transported as soon as safely possible). Determine patients competency to make an informed decision using the following:
Is the patient alert? Oriented times three (person, place, time)?
Does the patient understand his / her illness or injury and the potential for adverse outcome?
Can the patient describe his / her condition to you?
Does patient understand consequences (including death) of not treating his/her illness or injury?
Does the patient understand the alternatives to immediate care by EMS?
Does the patient have any physical findings suggestive of impaired physiology that could effect decision making? hypotension, hypothermia, hypoxia, head injury, alcohol / drug intoxication, evidence of CVA, symptoms of psychiatric decompensation If, based on Provider assessment, the patient is not capable of making an informed decision (because of abnormalities defined above) AND the patient has a potentially harmful illness or injury, the patient should be extensively counseled regarding the need for medical care. If the patient STILL refuses further care/evaluation, or is a harm to (him/her) self or others, the patient should be physically restrained by EMS personnel (with law enforcement assistance, if available). PHYSICAL RESTRAINTS should be safe & humane. At NO TIME should a patient be struck or managed in such a way as to impose pain. Restrain in a position of comfort and safety. Commercially engineered and available devices should be used (Posey limb restraints). Unless absolutely necessary, improvised physical restraint devices should be avoided. Thoroughly document (on the PCR) the reason for restraint, the mental status exam, options attempted, and method of restraint (no exceptions). CHEMICAL RESTRAINT should be used for patients that are unable to be safely managed by Physical Restraints only. Refer to the Behavioral/Anxiety or Excited Delirium Protocol for medications. Patients should be monitored every 5-10 minutes during either type restraint. Findings should be documented on PCR. Never leave a patient alone after any form of restraint. R E S T R A I N T
ClinicalClinical Operating Operating Guidelines Guidelines VTRANS02012020 v0212014
Special Populations Protocols (Adult/Pedi)
Adrenal Insufficiency
S History: Signs & Symptoms: SPECIAL NOTE: P Diagnosed Adrenal Severe Illness Confirm Adrenal Insufficiency diagnosis 0 Insufficiency Unconsciousness with family or school staff who will Trauma provide SoluCortef on scene. 1
Patients with Arenal Insufficiency in below situations Legend may require Stress Dose of cortisol. System S S Severe Illness Responder Unconsciousness B B Trauma EMT - B Bone Fx I EMT- I I Sudden or unusual tiredness an weakness P P Dizziness when standing up EMT- P M Medical Control M
Universal Patient Care Protocol (U-01)
Solu-Cortef See dosing chart to right. All known P cases in Hays County are over 12 years P of age.
Transport to hospital designated by School or Parents
Contact Destination or M M Medical Control
Pearls: Adrenal insufficiency can be a life-threatening condition. Those with adrenal insufficiency require daily replacement of cortisol. In patients with adrenal insufficiency, their dose of cortisol MUST be increased to manage stress. Oral cortisol is preferred unless the patient is unable to swallow pill or is vomiting.
Clinical Operating Guidelines VTRANS02012020 Caleb Luddy < 37 Kg S P History: Signs & Symptoms: Address: 0 Medium-chain acyl-GoA N & V 2 dehydrongenase defect Hypotension Home: 530 Manchester Lane, Austin, (MCADD) Hypoketotic Hypoglycemia TX 78737 (Belterra Subdivision) DOB 07/12/12 Acute and Chronic Brain Injury Coma School: Rooster Elementary or future Seizures DSISD schools
Pediatric Universal Patient Care Legend Manage patient s presenting s/s Airway Protocol as needed System S S S S High flow Oxygen via NRB Responder Blood Glucose assessment B EMT - B B Vital Signs as patient condition allows I EMT- I I Oral Glucose or P EMT- P P Pedialyte with M Medical Control M added sugar, or YES Able to tolerate PO Rice Milk, or (when age appropraite) full strength juice. NO
YES BLS < 60 mg/dl NO
D10W IV at maintenance 4-2-1 Dextrose 1g/kg (max 25g) with D10W P calc. method. Must P premix in 250mL bag. use IV Burette P Titrate to patient s response. Must use P volume control device (IV Burette)
Transport to Dell Children s Medical Center
1. Dr. James Gibson 512-323-5465 M 2. Dell Children s M 3. Medical Director
Pearls: Patients with MCADD are at risk of developing hypoglycemia during periods of metabolic stress where they may have increased glucose needs or poor PO intake due to illness. MCADD patients who develop hypoglycemia may suffer acute or chronic injury to the central nervous system with subsequent seizures or coma. These complications can be avoided by preventing or aggressively treating episodes of hypoglycemia. If Caleb is unable to tolerate PO, a maintenance drip of D10W should be initiated for transport in order to prevent an episode of hypoglycemia. If treated for hypoglycemia Caleb should be closely monitored for symptoms with repeat blood glucose measurement as needed. When calling Dr. Gibson at 512-323-5465 you will be connected to MedLink. Advise the operator that you are caring for Dr. Gibson s patient, that you have an emergent consult, and need to be called immediately. During business hours you may call Dr. Gibson s office at 512-628-1840. Follow the prompts for physicians. Clinical Operating Guidelines VTRANS02012020 Danae Luddy < 37 Kg S History: Signs & Symptoms: Address: P Medium-chain acyl-GoA N & V 0 dehydrongenase defect Hypotension Home: 530 Manchester Lane, Austin, (MCADD) Hypoketotic Hypoglycemia TX 78737 (Belterra Subdivision) 3 DOB 06/14/14 Acute and Chronic Brain Injury Coma School: Rooster Elementary or future Seizures DSISD schools
Pediatric Universal Patient Care Legend Manage patient s presenting s/s Airway Protocol as needed System S S S S High flow Oxygen via NRB Responder Blood Glucose assessment B EMT - B B Vital Signs as patient condition allows I EMT- I I Oral Glucose or P EMT- P P Pedialyte with M Medical Control M added sugar, or YES Able to tolerate PO Rice Milk, or (when age appropraite) full strength juice. NO
YES BLS < 60 mg/dl NO
D10W IV at maintenance 4-2-1 Dextrose 1g/kg (max 25g) with D10W P calc. method. Must P premix in 250mL bag. use IV Burette P Titrate to patient s response. Must use P volume control device (IV Burette)
Transport to Dell Children s Medical Center
1. Dr. James Gibson 512-323-5465 M 2. Dell Children s M 3. Medical Director
Pearls: Patients with MCADD are at risk of developing hypoglycemia during periods of metabolic stress where they may have increased glucose needs or poor PO intake due to illness. MCADD patients who develop hypoglycemia may suffer acute or chronic injury to the central nervous system with subsequent seizures or coma. These complications can be avoided by preventing or aggressively treating episodes of hypoglycemia. If Danae is unable to tolerate PO, a maintenance drip of D10W should be initiated for transport in order to prevent an episode of hypoglycemia. If treated for hypoglycemia Caleb should be closely monitored for symptoms with repeat blood glucose measurement as needed. When calling Dr. Gibson at 512-323-5465 you will be connected to MedLink. Advise the operator that you are caring for Dr. Gibson s patient, that you have an emergent consult, and need to be called immediately. During business hours you may call Dr. Gibson s office at 512-628-1840. Follow the prompts for physicians. Clinical Operating Guidelines VTRANS02012020 Ventricular Assist Devices
Legend S All patients are on Universal Patient Care Protocol (U-01) blood thinners System P S S 0 Responder 4 B EMT - B B ON ALL VAD VAD Functioning? PATIENTS Auscultate left upper abdominal quadrant. I EMT- I I Continuous Humming sound = pump IS working P EMT- P P Contact VAD B B Coordinator – Attention: Non-pulsatile pump function. M Medical Control M 512-747-4260 Patient may not have palpable pulse or measurable BP Keep patient s or SPO2 readings even if pump is working properly. companion with the patient. No Yes Reconnect white Patient Stable/ Patient Unstable/ Pump connected to No B driveline to B Conscious Unconscious controller? controller Doppler pressure Yes 60-90 Controller connected to Check Capillary power? Refill for adequate Green power light perfusion Restore power to on? No B B controller Batteries depleted? PBU/PM plugged into working outlet?
Yes Treat per medical P P protocol Controller Alarming Assess for other Place on EKG monitor (red broken heart general medical P Obtain IV/IO Access P P problems P symbol illuminated) (Bleeding, Stroke, PE, Infection) Change Treat per ACLS protocol controller (only if Defibrillate if indicated instructed) Treat per standard With compressions B B P P P P Check white protocols NO EXTERNAL driveline for COMPRESSION damage Transport to Seton DEVICE Medical Center Austin th Contact MCS Coordinator or 1201 W. 38 Street M M Medical Control
Pearls: Due to the location of the MCS and tubing connecting the MCS to the heart, there may be risks associated with performing external chest compressions (CPR) on MCS patients during cardia arrest. CPR may dislodge tubing resulting in fatal bleeding. Decisions on the use of CPR and other treatments rest with the MCS surgeon, based on his or her clinical judgement and experience. Adapted from Seton Heart Specialty Care and Transplant Center HeartMate II LVAS Patient Assessment Protocol VAD Coordinator on call 24/7 – 512-797-4260
Clinical Operating Guidelines VTRANS02012020 K-9 Protocols
Canine (K-9) Emergencies – Trained Responders and Law Enforcement only
CANINE (K-9) EMERGENCIES
The care and safety of a police dog is a number one priority with handlers. The animal is normally a valued member of the officer's family and is loved and cared for like a child, but is owned and maintained by governmental agency. When not on duty, the canine lives with the handler. And in fact, it is common that the animal can often be found sleeping at the foot of a bed occupied by the handler. An extremely special bond is developed during training and throughout the work environment. The tactical medic must know how to provide emergency medical care to a canine and be able to carry the appropriate medical supplies in the event the animal itself becomes injured or ill during a mission. These protocols were designed with the primary focus being on providing advanced canine emergency of injured police dogs while in the line of duty. Only system medics of the San Marcos/Hays County EMS Tactical Medic Division shall utilize these advanced care protocols. The application of any advanced protocols by other system providers in a non-tactical or non-police dog emergency is prohibited.
K-9 Protocol Qualifications
Tactical medics are required to complete an initial training clinical as well as refresher clinical on an annual basis. The initial clinical for new provider will require that the provider attend 30 hours of surgical/vet rotations prior to clearance to practice. The provider will then be required to complete 8 hours of surgical/vet rotation per calendar year (2 hours quarterly). Provider is required to maintain documentation for clinical and must be signed by veterinarian. All clinicals are to be conducted at Williams/Sebby Vet Clinic unless approved by Dr. Williams or Dr. Sebby.
Ambulance Transport of Police Dogs
As Police dogs are sworn officers they should be afforded the same care and transport options as their human counterparts when available. The ambulance transport of an injured or ill police dog to an emergency animal center is left to the discretion of the senior tactical medic present on the scene who must take into account on-going scene stability, animal to ambulance location, other transport options available (PD vehicle specifically designed for police dogs), and provision of care for police officers still present on scene. As a general rule, transport is reserved for humans first, canines second, but both carried by EMS.
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Emergency Transport Locations
Depending on your location the following Vet Hospitals offer 24 hours emergency/surgical services:
North South
Emergency Animal Hospital Emergency Pet Center 4434 Frontier Trail 8503 Broadway, Suite 105 Austin, Texas San Antonio, Texas (512) 899-0955 (210) 822-2873
Normal Values for Dogs at Rest
Rectal temperature 100-102 F Heart rate 100-130 bpm, at rest rate is commonly around 90 and an irregular heart rate is normal. Respirations 10-30 per minute, normal is 22, rates above 60 indicates a serious problem. Remember, panting is normal for a dog and a rate in excess of 100 bpm can occur. Accessory muscle (abdominal) breathing indicates a severe problem Daily fluid intake 15-30 mL/kg: - Average German shepherd requires a minimum of 35 ounces per day. - Greater than 100 mL/kg/day (translates to 110 ounces in average German Shepherd) in the absence of intense heat or work is abnormal and the cause for it should be explored.
General Care (Applies to all protocols unless otherwise stated)
Have communications notify nearest emergency veterinarian of injury or illness Assess the overall situation and remain calm, the animal will respond to your anxiety If the dog is conscious, have the dog’s handler or another handler restrain the dog and apply a muzzle. Be firm, but gentle when evaluating Assess the heart rate and perform a focused assessment; - The heartbeat is felt on the flank, just behind the elbow - The femoral pulse is felt on the inner thigh, between the two large muscle groups Assess for signs and symptoms of shock or aberration in vital signs. Basic airway management and remove or suction secretions, blood or foreign objects as needed. Endotracheal intubation if indicated. Proceed to the appropriate section based on injuries or illness. Rapidly transport to the nearest open animal emergency center for further care. Cardiac monitoring when life-threatening condition, unconscious, or cardiac arrest is present.
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Determination of Hypoperfusion or Shock
Disturbance of circulation can follow any serious injury and the dog may present with any of the following; - Mental alertness can best be determined by the dog’s handler - White to pale or white to gray mucous membranes (gums). - Capillary refill time prolonged or absent (press finger against upper lip, should return in 1-2 secs). - Lethargy or unconsciousness. - Weak, rapid and/or thready pulses. - Shallow respirations. - Grunting, head held out to breathe, dyspnea. - Weakness and collapse
Capillary refill assessment Airway Management (unconscious)
Intubation of an animal in many ways is easier than a human. The technique is similar with a few exceptions. Remember that animals often have proportionally larger trachea. The only tube approved is the endotracheal; others (combitube, LMA) are not recommended. Open the mouth; grasp the tongue and pull forward to visualize the cords. Make sure that the neck is reasonably straight; try to bring the head in-line with the neck. Do not hyperextend in cases where neck trauma exists Using a long Miller laryngoscope blade, pull the epiglottis back against the anterior throat, insert a 9- 10 ETT through the cords and inflate the cuff as normal. Wrap a foot long (25cm) piece of roller bandage around the tube in the mouth and tie in a bow over the top or bottom jaw or behind the dog’s ears. This will hold the tube in place. Remember to check tube placement after any movement. Ventilate at 20 breathes per minute using an adult sized BVM.
Emergency Muzzling
In any emergency situation, muzzling a dog is of the utmost importance. Dogs quickly revert to instinctual behavior in situations of extreme stress and/or pain and bite when approached.
Take the material and tie it into a simple knot, keeping a loop about 5 inches high. Approach the dog slowly, deliberately, and calmly. Sudden movement may startle the dog or push him "over the edge"; if you are anxious he will sense it and may become even more panicked himself (It may help if you stand behind the dog to do this; it may be less threatening to the dog). Slowly drape the open loop over his muzzle. Slowly tighten the loop snugly, but not tight (the muzzle should be tight enough to not slip off). Finish the loop with a bow, just as you would tie off a shoelace. If the dog successfully pulls the muzzle off with his paw, reapply the muzzle but
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consider tying the loop behind the ears.
©2001 M. Nelson, www.vetref.net Artificial Respiration (mouth to nose)
Open mouth and clear away secretions. Check for a foreign body and if found, remove if possible. If impossible to reach or remove, consider performing abdominal thrusts to help clear the obstruction. Clean mouth of vomitus or foreign material, suction if needed. Pull the tongue forward and clamp mouth closed. Exhale into dog’s nose for a full 3 seconds at 20 breaths per minute. If unresponsive without an intact gag or bite reflex, or if apnea and/or cardiac arrest ensues, intubate trachea, as per airway management, and ventilate at 20 bpm using an adult sized BVM. Naloxone 0.8 mg IM or 0.4 mg IV (when IV is available) prior to intubation when respiratory depression is possibly due to a narcotic ingestion. Repeat as needed until 10 mgs is reached or improvement in respirations occurs. Consider cardiac monitoring when available and able to do so. Proceed to appropriate algorithm if cardiac arrest or drug-induced arrhythmias are present.
Abdominal Thrusts
During this first aid procedure the dog cannot be muzzled. Attempting this procedure while the dog is muzzled will cause further injury. However, the dog may still attempt to bite you. Place the animal between your legs with your head over his rump. Your knees should be slightly flexed and bracing the dog's shoulders, preventing his passing though between your legs. Place your hands in the hand over-fist position on the dog's abdomen and slide them towards your knees (towards the dog's head) until you feel the bottom of the rib cage. This is where the diaphragm is located. With short, sharp thrusts bring your hands up towards you and release. The idea is not to lift the dog off his feet, but to provide enough force to help his lungs dislodge the object. Repeat every two or three seconds until he is able to breathe. If unconscious: Place the animal on its side with his back towards you. His back should be braced against your knee. Place your hands in the hand over-fist position on his chest and push down quickly. This expels the air, and hopefully the foreign body, from his throat. Repeat until the object is expelled.
Chest Compressions Lay animal on their right side on a flat hard surface (backboard). Kneel at head, below jaw and close to front legs. Hold muzzle closed with one hand and begin artificial respirations as above. Place heel of other hand on chest wall behind the shoulder to apply cardiac massage at a depth of 1-2 inches. Compress chest at 60-80 times per minute and ventilate once every 4-5 compressions (if 2 person CPR use every 5-6th compression). Note: animals do not have palpable carotid pulses. You can only obtain a
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femoral pulse in the inguinal crease.
ECG Monitoring / Defibrillation
ECG monitoring is the same as in humans, except that common electrodes will not work effectively. Small double alligator clips are used in place of the adhesive pads and in conjunction with conductive gel (one side attached to the dog and the other clipped to the lead). Proper placement is with the animal in right lateral recumbent position, with the alligator clips placed on the elbows and knees. Make sure that you use plenty of conductive gel. Arrhythmias and ECG waveforms are the same as ECGs in humans (identification is the same). Place hands-free defibrillation therapy pads to both sides of the chest wall, behind the shoulder, in the similar region chest compressions are performed. Note: you must remove or trim hair from the area to ensure good contact with the skin. Defibrillation energy is typically 2-4 J/kg. In the absence of a manual defibrillator, an automated external defibrillator may be applied (if available) and utilized as needed for cardiac arrest.
External Hemorrhage
Leg wounds can bleed severely and should be dealt with swiftly. Apply firm continuous pressure with gauze or trauma dressings. Apply Quick Clot gauze to help promote hemostasis. Apply a pressure bandage using gauze wrapped with an elastic bandage. Use caution in occluding distal circulation; consider restoring distal circulation every 10-15 minutes for up to 1 minute. A tourniquet can be applied as a last resort when uncontrollable hemorrhage (arterial) is present. May consider a temporary tourniquet in order to apply the Quick Clot gauze and pressure bandage and then slowly release tourniquet and assess for hemorrhage control. If profuse hemorrhage continues keep tourniquet in place but loosen every 10-15 minutes for up to 1 minute.
Pain Management Continuum
Mild pain – 325mg Aspirin, PO (Maximum of 325mg per 24 hour period) Moderate pain – Fentanyl Citrate 2 mcg/kg, IV or IM o May repeat dose every 10 minutes, up to 10 mcg/kg, with no hypoperfusion present Severe pain – 0.1 cc (0.5 mg) Diazepam with 0.2 cc (10 mg) Ketamine – this causes sedation o May repeat as needed for sedation
Internal Hemorrhage or Penetrating Wounds
Apply high flow blow by oxygen. Keep head at heart level. Apply muzzle to prevent reflexive biting (do not to occlude airway). Protect airway with endotracheal intubation if needed.
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Application of a circumferential bandage (Vet-Wrap) around the abdomen may be helpful for a short period of time if bleeding is intra abdominal (be careful not to restrict respirations). Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Use extreme caution when handling the abdomen and do not lift under the belly (use a backboard to lift and move) after trauma as this may destabilize clots that have formed. Keep warm and prevent heat loss (unless already hyperthermic) Do not remove any penetrating objects unless they directly interfere with airway stabilization. If in chest or abdomen, stabilize object with layered gauze and bandaging material (kerlex, kling etc.)
Chest Trauma
Apply high flow blow by oxygen. Keep head at heart level. Consider muzzling to prevent reflexive biting (do not to occlude airway). Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Do not place constricting bandages around the chest wall. Doing so will impede chest wall excursion and may cause respiratory arrest. Keep warm and prevent heat loss (unless already hyperthermic). Use Vaseline gauze or an occlusive dressing for penetrating wounds. Carefully observe for signs of a tension pneumothorax. Do not remove any penetrating objects unless they directly interfere with airway stabilization. If in chest, stabilize object with layered gauze and bandaging material (kerlex, kling etc.)
Foreign Body Airway Obstruction (FBAO)
If actively choking, but there is still air movement allow dog to try and remove object on their own first. If total obstruction is evident you will have to assist in the FB removal. Note use extreme caution when attempting to remove a foreign object from the airway as the dog will be very anxious and will bite (do not muzzle as this will interfere with attempts to remove the FBAO). Attempt abdominal thrusts as outlined. Multiple attempts are indicated until the obstruction is relieved. If unable to dislodge the obstruction by use of abdominal thrusts and the dog become unresponsive, attempt direct visualization of the airway using a laryngoscope and Magill forceps to remove the FB (direct visualization is not recommended if animal is still conscious as they will bite!). If you still cannot remove or dislodge the obstruction and total airway obstruction is evident, immediately perform a surgical cricothyrotomy to provide an emergent airway. Pain Management – follow continuum
Pneumothorax
A closed chest pneumothorax is often tolerated better by animals than by humans. However, severe intrathoracic pressures can cause other problems. The technique for reducing a tension pneumothorax is
Lay the animal lateral with the pneumothorax up Find the 8th intercostal space Using a pre-made needle decompression kit (14 gauge 1.25” catheter and flutter valve), insert the needle on the inferior margin of the 8th intercostal space at the dorsal third of the chest wall. VERSION 02012020 CLINICAL OPERATING GUIDELINES CANINE (K-9) EMERGENCIES UPDATED 02-01-2020 PAGE 6 OF 15 K9
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Once decompression has occurred, completely withdraw the needle from the chest, leaving only the catheter in place and attach the flutter valve. Frequently reassess lung sounds as catheters can become occluded with blood and other fluids, necessitating clearing the catheter or re-inserting another if the tension pneumothorax recurs.
Fracture Management
Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock, spinal, or multiple fractures are present, otherwise run at KVO. Pain Management – follow continuum
Lower leg fractures: - Immobilize the joints above and below the break with a padded splint. Upper leg fractures: - Do not splint. This could cause additional damage to the tissues around the fracture site. - If able, tape leg to body for stability. - Allow the dog to protect the injury himself. Neck/Back/Spinal fractures: - Stabilize neck with blankets, towels, and or tape when cervical fractures are suspected. - Immobilize dog on its side on a long spine board.
Burns
Administer high flow oxygen if critical burn or smoke inhalation associated with burn. Look for singed hair, redness, blistering or charring, swelling and pain often present. Clip hair gently around wound (assess carefully as liquids often run under coat and burns are not evident). Minor thermal burns: no major involvement, superficial injuries only. - Treat with cool water. Use wet sterile dressings for burns < 10% BSA. - Do not apply any form of ointment. - Have animal evaluated later by veterinarian for further care Critical thermal / major electrical burns: large 2nd or 3rd degree burns to paws, face or airway or significant electrical shock or electrical injury. - Burns > 10 % BSA use sterile dry dressings or burn sheet. - Consider intubation if airway compromise is present. - Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus for critical burns or shock. - Pain Management – follow continuum - Cardiac monitoring, observing for arrhythmias (Lidocaine 2% 1 mg/kg IV for ventricular arrhythmias). Chemical burns: often involve mouth, lips, face or pads, occasionally ingested. - Flush chemical with cold/cool water. - Consider intubation if airway compromise is present. - Acid burns – may apply baking soda paste to burns site. - Alkali burns –rinse with lemon juice or vinegar/water mixture (if available).
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- Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus for critical burns or shock. - Pain Management – follow continuum
Heat Emergencies (Often occurs if dog is in a confined space, warm, humid weather)
Heavy breathing, panting, vomiting, collapse, red mucous membranes, tongue engorged. Apply high flow blow by oxygen if heat stroke. Keep head at heart level. Obtain a rectal temperature (normal is 100-102 F, 104 F. is dangerous, 106 F is life-threatening) Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Cool dog by applying cold packs to major vessels (groin). When temperature reached 103-104 F, dry dog off.
Dental Injury (Tooth fracture, tooth avulsion)
Check with veterinarian within 12 hours to prevent loss of tooth. Partial pulpotomy may be curative. Avulsed Tooth: Can often re-implant tooth and save it. Collect tooth and keep moistened by using a sterile or clean saline solution, or place in milk and transport ASAP. Pulpal hemorrhage: notify vet as soon as possible. Dog should not be worked until checked.
IV Access Veterinary medicine has a much more aggressive approach to IV access and any case which is considered critical should receive IV access, the preferred fluid being Normal Saline (NS) unless otherwise stated. Cannulation of the vein is identical to humans except site preparation is much different.
Shave a 1-2 inch band approximately 2-4 inches proximal to the capus (wrist) circumferentially around the leg. Clean the site with alcohol. Have one person firmly grasp the arm slightly distal to the elbow, the medic inserting the catheter should grasp the distal arm and pull it straight with moderate tension. Roll the thumb lateral, twisting the flesh of the arm to roll the cephalic vein into position as well as act as the tourniquet. Cannulate the cephalic vein the same as for a human (veins of a dog are much tougher and superficial than a human's). Large dogs (over 22Kg) commonly use a 20-18 gauge catheter. Circumferentially tape the catheter in, making sure that the tape also goes proximal to the catheter to adhere to the leg (unlike humans this doesn't cut off venous supply). An alternative vein is the saphenous vein at the joint of the hind leg on the outer aspect of the leg.
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Insect Envenomation (Severe allergic reaction, anaphylaxis) Assess for signs and symptoms of shock or aberration in vital signs. Apply high flow blow by oxygen if obvious respiratory distress. Keep head at heart level. If anaphylaxis is suspected, administer epinephrine (1:1000) 0.5 mg IM. Repeat in 10 minutes if no response. Administer diphenhydramine 1 mg/kg slow IV or IM (IV preferred). Establish at least 1 large bore IV of Normal Saline (NS) and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Protect airway with endotracheal intubation if needed. Ventilate with BVM as previously outlined, if indicated.
Snake Bite
Snakebites are classified as a “wet” (with envenomation) or “dry” (without envenomation) bite. Venomous snakes, indigenous to the Southwest, include Coral Snakes and Pit Vipers. These include the Copperhead, various species of Rattlesnakes and the Cotton Mouth (aka: Water Moccasin). The venom of pit vipers is hemolytic in nature and will cause tissue destruction, systemically. Swelling can be expected as well as compartment syndrome, if not treated. In late stages, tissue necrosis will occur and surgical amputation may result from the injury. Coral Snakes inject a neurotoxic venom that will cause smooth muscle paralysis. Expect respiratory difficulty and possible arrest. No treatment, in the field, is available for Coral Snake envenomation beyond supportive care (ie. Maintaining airway and supporting perfusion. In the event of a snake bite, inquire if the canine has been given any snake bite vaccine, typically a rattlesnake vaccine, and when it was given.
Muzzle canine for safety Apply cold pack to affected area (DO NOT USE CONSTRICTING BANDS!!) Establish IV of Normal Saline (NS) and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Pain Management if transport is greater than 15 minutes o Pain Management – follow continuum
Monitor canine for changes in condition, such as hypoperfusion, and be prepared to take control of airway should compromise occur.
Seizures
Protect airway with endotracheal intubation if needed. Diazepam 5 mg slow IV, at 2 mg/minute until seizures stop or 20 mg has been reached. VERSION 02012020 CLINICAL OPERATING GUIDELINES CANINE (K-9) EMERGENCIES UPDATED 02-01-2020 PAGE 9 OF 15 K9
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If unable to establish IV access, midazolam 5 mg IM may be administered and repeated in 10 minutes if still needed.
Accidental Poisoning
Accidental ingestion of illegal substances during searches may induce toxic syndromes requiring immediate care to prevent death. It is worth noting that dogs often vomit after chewing on plants and this probably does not represent "poisoning" has occurred. Sporadic vomiting without accompanying significant signs of toxicity (agitation, tachycardia, dyspnea, altered mentation, ataxia, etc.) is commonly not a cause for worry, but each animal should be evaluated by a veterinarian for a check-up.
Absorbed Poisons (Organophosphate insecticides – same presentation as in humans) If the dog is conscious, have the dog’s handler or another handler restrain the dog and apply a muzzle (avoid interfering with airway). Rapidly decontaminate dog with soap and water and protect yourself from exposure. Basic airway management and remove or suction secretions as needed. Atropine 0.05 mg/kg IV doubled every 3-5 minutes until secretions dry up or; Atropine 2 mg IM if no vascular access, repeat IM dose every 5-10 minutes until secretions dry up Diazepam 5-20 mg IV for control of active seizures.
Ingested Poisons (Ethylene glycol, illegal substances, plants, acids, alkalis, etc.)
Initial care same as for absorbed poisons with possible exception of external decontamination. Do not induce vomiting if substance is unknown, corrosive (acid), or petroleum product. Induce vomiting if known poison, non-corrosive or is not a petroleum product and if within 1-2 hours. Acids - Do not induce vomiting; rinse mouth and any other areas that came in contact with the acid; give milk of magnesia - 1 tbsp per 3 lb PO. Follow with 1 tsp / 3 lb of cooking or mineral oil via G Tube only. Alkalis (Laundry detergents, ammonia, paint removers) - Do not induce vomiting; rinse mouth and any other areas which came in contact with the acid; give dilute vinegar with lemon juice (equal amounts at 1 tbsp per 3 Lb.) or give orange juice 1 tbsp per 3 lb. Follow with 1 tbsp / 3 lb of cooking or mineral oil via G Tube only. Petroleum distillates (Gasoline, paint thinner, charcoal lighter) - Do not induce vomiting; rinse mouth and any other areas which came in contact with the acid; give 1 tbsp/3 lb of cooking or mineral oil via G Tube only. Stinging nettles (Bull nettles, nettle spurge, etc.) - Do not induce vomiting; rinse mouth and any other areas that came in contact with the acid; give 1-2 tablespoons of cooking or mineral oil. Note: may exhibit slow and irregular pulse.
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Ethylene Glycol Ingestion (Antifreeze)
The toxic agent in commercial antifreeze is ethylene glycol, a colorless, odorless liquid that makes up 95 percent of antifreeze solution. After ingestion, the poison is rapidly absorbed and If not treated immediately, the dog will experience severe kidney damage, could lapse into a coma, and may die, all within 24 hours of ingestion. Symptoms are similar to alcohol intoxication and include ataxia, excessive thirst, excessive urination, nausea, vomiting, and seizures. Even if only a suspicion of ingestion, since treating the animal once signs are present is often too late. Rapid removal and treatment is necessary to prevent the formation of toxic metabolites. Immediately induce vomiting when ingestion is within 2 hours unless contraindicated by presentation. Vomiting may be induced using 3% hydrogen peroxide administered at a dose of 1 teaspoon / 5 kg of weight Initiate an IV of Normal Saline and administer fluids at 10-20 mL/kg IV as an initial bolus, then at 250 mL/hour to promote diuresis. After vomiting has occurred administer activate charcoal at 10 mL/kg PO (as is, or mixed with a small amount of cold water to reduce viscosity and improve flow). Administration may require forced ingestion or insertion of a lavage tube. Severe metabolic acidosis commonly occurs in toxic ingestions; consider the administration of 8.4% Sodium Bicarbonate 1-2 mEq/kg IV over 5 minutes.
Cocaine / Stimulant Ingestion
The ingestion/sniffing of cocaine by a K9 dog team is quite serious, as the quantities ingested may be quite large. Rapid treatment is necessary to stave off death due to cardiac arrhythmias and seizures.
Immediately induce vomiting by using 3% hydrogen peroxide administered at a dose of 1 teaspoon / 5 kg of weight After vomiting has occurred administer activated charcoal at 10 mL/kg PO (as is, or mixed with a small amount of cold water to reduce viscosity and improve flow). Administration may require forced ingestion or insertion of a lavage tube. Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Diazepam 5 mg IV when evidence of a hypersympathetic state is present (tachycardia, agitation, delirium etc.) Repeat every 5 minutes as needed until 20 mg has been reached.
Opiate/Narcotic Ingestion
Naloxone 0.8 mg IM or 0.4 mg IV (when IV is available) prior to intubation when respiratory depression is possibly due to a narcotic ingestion. Repeat as needed until 10 mgs is reached or improvement in respirations occurs. Immediately induce vomiting by using 3% hydrogen peroxide administered at a dose of 1 teaspoon / 5 kg of weight
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After vomiting has occurred administer activated charcoal at 10 mL/kg PO (as is, or mixed with a small amount of cold water to reduce viscosity and improve flow). Administration may require forced ingestion or insertion of a lavage tube. Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate.
Theobromine poisoning (chocolate ingestion)
Even small amounts of Theobromine (a methyl xanthene derivative found in chocolate) can cause vomiting and restlessness in dogs and large doses can be fatal. The lethal dose of Theobromine depends on the size of the dog and the type of chocolate. Ounce for ounce, baking chocolate has six to nine times as much of the substance as milk chocolate (2 - 4½ pounds of milk chocolate or 4 - 8 oz. of baking chocolate for large dogs, including German shepherds and labs).
Immediately induce vomiting by using 3% hydrogen peroxide administered at a dose of 1 teaspoon / 5 kg of weight. After vomiting has occurred administer activated charcoal at 10 mL/kg PO (as is, or mixed with a small amount of cold water to reduce viscosity and improve flow). Administration may require forced ingestion or insertion of a lavage tube. Establish at least 1 large bore IV of Normal Saline (NS) in an unaffected extremity and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Diazepam 5 mg IV when evidence of a hypersympathetic state is present (tachycardia, agitation, delirium etc.) Repeat every 5 minutes as needed until 20 mg has been reached.
Hypoglycemia
It is unlikely that a K9 dog team or rescue dog will present with hypoglycemia; however, some accidental ingestion can cause an aberration in blood glucose. Treat hypoglycemia (< 50 mg/dL) when confirmed by a glucometer.
Establish IV of Normal Saline (NS) and administer a 10-20 mL/kg IV bolus when shock is present, otherwise run at keep open rate. Administer Dextrose 50% 2-4 mL/kg slow IV. Repeat glucose reading and repeat if needed.
Cardiac Arrest Algorithms
Cardiopulmonary arrest in humans is usually the result of a cardiac dysrhythmia or cardiac pump failure. This arrest may be the result of primary cardiac disease or diseases that affect other organs. In animals, arrest most frequently occurs with diseases of the respiratory system (pneumonia, laryngeal paralysis, neoplasia, thoracic effusions, and aspiration pneumonitis), as a result of severe multisystem disease, trauma, and following cardiac dysrhythmias
VERSION 02012016 CLINICAL OPERATING GUIDELINES CANINE (K-9) EMERGENCIES UPDATED 02-01-2016 PAGE 12 OF 15 K9
Canine (K-9) Emergencies – Trained Responders and Law Enforcement only
Asystole Intubation, IV access, CPR Epinephrine (1:1000) 1 mg IV or 2 mg ET, repeat q 3-5 minutes Atropine 1 mg IV push, may repeat once in 3-5 minutes If no response, consider terminating resuscitation
Pulseless Electrical Activity Intubation, IV access, CPR Epinephrine (1:1000) 1mg IV or 2 mg ET and repeat q 3-5 minutes IV NS @ 10-20 mL/kg fluid bolus Pleural decompression if chest trauma and difficult to ventilate If rate is < 60 bpm, consider atropine 0.5-1.0 mg IV or 1-2 mg ET If heart rate > 200 bpm and rhythm is supraventricular (possible stimulant drug ingestion), synchronized cardioversion at 2 J/kg, 4 J/kg. 4 J/kg should be attempted. If no response, consider terminating resuscitation
VF/pulseless VT Defibrillate x 3 at 2 J/kg, 4 J/kg, 4 J/kg or use of AED at standard settings is allowed. Intubation, IV access, CPR (begin CPR first if defibrillation is delayed) Epinephrine (1:1000) 1 mg IV or 2 mg ET and repeat q 3-5 minutes Defibrillate at 4 J/kg between each drug Consider Lidocaine 1 mg/kg IV or 2 mg/kg ET If no response, consider terminating resuscitation
Also consider the following during any non-traumatic sudden arrest:
• Foreign airway obstruction – abdominal thrusts, intubation, if unable to clear, perform cricothyrotomy • Narcotic ingestion (drug ingestion / poisoning) – Naloxone 0.4 mg IV up to 10 mg • Hypoglycemia (drug ingestion / poisoning etc.) – Dextrose 50% 2-4 mL/kg • Organophosphate poisoning (absorbed by walking through liquids) – Atropine 0.05 mg/kg doubled every 3-5 minutes until response is observed • Ingestion of antifreeze (ethylene glycol) – Sodium bicarbonate 2 mEq/kg IV • Amphetamine, cocaine, PCP induced arrest - Sodium bicarbonate 2 mEq/kg IV, Lidocaine 1 mg/kg
VERSION 02012016 CLINICAL OPERATING GUIDELINES CANINE (K-9) EMERGENCIES UPDATED 02-01-2016 PAGE 13 OF 15 K9
Canine (K-9) Emergencies – Trained Responders and Law Enforcement only
K-9 Bag Stocking List
1 Muzzle 4 Vaseline Gauze
4 4” rolled Kling 2 1cc syringe with needle
2 Abdominal trauma pads 2 3cc syringe with needle
2 Combat Gauze 2 10cc syringe
1 Wound Stapler 1 60cc syringe
1 SAM Splint 3 ea Needles (22, 20, 18, 16, 14 gauges)
30 Sterile 4x4’s 1 BVM Adult
2 Vet Wrap (4”) 1 ASA (81mg or 325mg)
2 TK4 Tourniquets 1 Lidocaine 2%
4 Cold Packs 1 Benadryl (IV)
1 Electric Razor 2 Eye Wash
1 Thumb Forceps with teeth (tweezers) 1 Hydrogen Peroxide
1 Trauma Shears 1 Iodine
1 Thumb Forceps without teeth (tweezers) 1 Activated Charcoal
1 Blanket 1 Milk of Magnesium
1 Pedi Pads (AED) 1 Distilled Vinegar (8oz)
2 Double Alligator Clips 1 Limon Juice (8oz)
VERSION 02012016 CLINICAL OPERATING GUIDELINES CANINE (K-9) EMERGENCIES UPDATED 02-01-2016 PAGE 14 OF 15 K9
Canine (K-9) Emergencies – Trained Responders and Law Enforcement only
1 Conducting Gel 1 Mineral Oil (8oz)
1 Horse catheter (G tube) 1 Narcan
1 Digital Thermometer 1 Diazepam
1 Surgical Cric Kit 1 Ketamine
2 Scalpel (#10/#11) 1 Fentanyl
2 Normal Saline (Liter) 1 Epi 1:1
2 10/15 drop set 1 Atropine (multi-dose)
2 Saline Lock Kit 1 Sodium Bicarbonate 8.4%
2 ETT 9 or 10 1 D-50
VERSION 02012016 CLINICAL OPERATING GUIDELINES CANINE (K-9) EMERGENCIES UPDATED 02-01-2016 PAGE 15 OF 15 K9
Clinical Reference
Table of Contents
Clinical Reference ...... Page
Adult Drug Infusion Rates ...... CR-1 Adult Epinephrine Infustion …………………………………………………………………………………………………………….CR-2 Adult Levophed Infusion Rates ...... CR-3 APGAR Scoring ...... CR-4 GCS ...... CR-5 Mass Casualty Incident Levels ...... CR-6 Oxygen Duration Chart……………………………………………………………………………………………………………………..CR-7 Pediatric Amiodarone Infusion ...... CR-8 Pediatric Calcium Gluconate Infusion ...... CR-9 Pediatric Epinephrine Infusion ...... CR-10 Pediatric IV Maintenance Fluids ...... CR-11 Pediatric Levophed Infusion Rates ...... CR-12 Pediatric Magnesium Sulfate Infusion ...... CR-13 Regional Trauma System Adult / Pediatric Trauma Criteria ...... CR-14 Rule of Nines ...... CR-15 SMHC EMS Fibrinolytic Checklist…………………………………………………………………………………..………………..CR-16
Adult Drug Infusion Rates
For all below medications, drip rate is based on injecting (Needed quantity of medication + NS) = 10 ml into a 50cc NS bag. This will always give you 60cc that need to be infused over the given time.
Drug Protocol Dose Required Drip Set Rate
Amiodarone CA-03 & C-05 150mg IV over 10 Min 15 gtts set 1.5 gtts/sec
Magnesium Sulfate C-05 2G IV over 5 Min 15 gtts set 3 gtts/sec
R-04 2G IV over 20 Min 60 gtts set 3 gtts/sec
OB-02 4G IV over 5 Min 15 gtts set 3 gtts/sec
Transexmic Acid (TXA) T-06 1G over 10 Min 15 gtts set 1.5 gtts/sec
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 1
Adult Epinephrine Infusion Range of Infusion 2-10 mcg/min
Step 1 Determine concentration Mix 1 mg Epinephrine in NS (must use 60 drop set)
Step 2 Determine Rate
Dose (mcg/min) 2 4 6 8 10 50 ml 6 12 18 24 30 Doses are in gtts/min
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 2
Adult Levophed Infusion Range of Infusion 3-15 mcg/min
Step 1 Determine concentration Mix 4 mg Levophed in NS (must use 60 drop set)
Step 2 Determine Rate
Dose (mcg/min) 3 5 8 10 12 15 50 ml 2.25 3.75 6 7.5 9 11.25 Volume of Bag 250 ml 11.25 18.75 30 37.5 45 56.25
Doses are in gtts/min 500 ml 22.5 37.5 60 75 90 112.5 1000 ml 45 75 120 150 180 225
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 3 APGAR Scoring The Agar score is tool used to evaluate and document a newborn's physical condition. It is generally performed at 1 minute, and again at 5 minutes after birth.
APGAR scores 10 Infant is in best possible condition 7-9 Infant is slightly depressed but near normal 4-6 Infant is moderately depressed 0-3 Infant is severely depressed Thorough assessment, not APGAR scoring, should determine if, and what type of resuscitation efforts may be required for a newborn
APGAR
0=Absent 1=Weak 2=Strong
1 Minute 5 Minutes
______A Appearance ______P Pulse ______G Grimace ______A Activity ______R Respiratory ______
______
______
Total______Total______
Sign 0 Points 1 Point 2 Points
A Appearance Blue-gray, pale all over Pink except for Pink over entire body (Skin Color) extremities
P Pulse Absent <100/min >100/min
G Grimace No response to stimuli Grimaces in response to Sneezes, coughs, pulls (Reflex Irritability) stimuli away
A Activity Absent, flaccid Arms and legs flexed Active movement (Muscle Tone)
R Respiration Absent Slow, irregular Good, crying
APGAR scores should be assessed at 1 minute and again at 5 minutes after birth
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 4 GCS Eyes Open Spontaneous (4) To Voice (3) To pain (2) None (1) Best Verbal Oriented (5) Confused (4) Inappropriate (3) Garbled (2) None (1) Best Motor Obeys (6) Pain-Local (5) Pain withdrawal (4) Pain-Flexion (3) Pain-Extended (2) None (1)
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 5 Mass Casualty Incident Levels
Patient categorization is based on the MEDIC system
• Minimal Green • Expectant Black • Delayed Yellow • Immediate Red • Contaminated Not tagged
Exceptions to the triage criteria “Immediate” category: • To reduce stress on associates, rescue workers that sustain severe injuries should be tagged IMMEDIATE and removed from the scene as quickly as possible • Immediately contact Command Liaison to notify the appropriate department when an injured rescue worker is removed from the scene • Emotionally uncontrollable patients should be tagged “Immediate” and removed from the scene to avoid "accelerated emotional" crisis. Triage tag should be affixed to the patient in the following location by order of preference: • Right wrist/arm • Left wrist/arm • Right leg • Left leg MCI Operational Levels Designation of Appropriate MCI Operational levels will be announced by SMHCEMS Communications based on patient information relayed from the scene in combination with the availability of on-duty EMS System capabilities LEVEL 1 – Limited Multi-Casualty Incident The number of casualties does not exceed on-duty EMS system resources. • Operational terminology: “LEVEL 1 MCI” • Designed for • Single-site incident • Patient count • Non-ambulatory 5-10 and/or • Ambulatory >10 LEVEL 2 – Multi-Casualty Incident The number of casualties may exceed on-duty EMS system capabilities, requiring support from City/County first responders, off-duty EMS resources, out-of-county EMS systems, and private ambulance providers. • Operational terminology: “LEVEL 2 MCI” • Designed for • Single and multiple-site incidents with casualties, related to a common event, (i.e., tornado, flood, explosion, wildfire, etc.) • Patient count • Non-ambulatory 11-40
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 3 CR –6 Mass Casualty Incident Levels
LEVEL 3 – Mass Casualty Incident: The number of casualties exceeds on-duty EMS system capabilities, requiring support from City/County first responders, off-duty EMS resources, out-of-county EMS systems, and private ambulance providers. • Operational terminology: “LEVEL 3 MCI” • Designed for • Single and multiple-site, incidents with casualties, related to a common event, (i.e., tornado, flood, explosion, wildfire, etc.) • Patient count Non-ambulatory >4 Procedure: 1. Rapid scene size-up 2. Notification to SMHCEMS Communications 3. Activation or confirmation of MCI and appropriate level • LEVEL 1 – Limited >10 Ambulatory and/or 5-10 non-ambulatory • LEVEL 2 – Multi 11-40 Non-ambulatory • LEVEL 3 – Mass >40 Non-ambulatory 4. Approximate number of patients by MEDIC designation 5. Information important to incoming units 6. Scene access (best approach) 7. Hazards 8. Location of initial Command Post 9. Location of potential staging area 10. Entry • Contaminated patients are not tagged • Ambulatory patients • Tag “Minimal” (Green) • Directed to Treatment/Secondary Triage area 11. Assessment • Respiratory status • Respirations <30/min (estimate) • Assess perfusion • Respirations >30/min (estimate) • Tag “Immediate” (Red) 12. Apneic • Attempt to open airway • Remains apneic following airway maneuver • Tag “Expectant” (Black) 13. Respirations resume following airway maneuver • Assess for neuro deficit • Neuro deficit • Blown pupil / Decorticate/decerebrate posturing / Exposed brain tissue • Tag “Expectant” (black) • No obvious neuro deficit • Tag “Immediate” (Red) 14. Circulatory status • Capillary refill >2 sec • Tag “Immediate” (Red) • Capillary refill cannot be assessed
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 2 of 3 CR –6 Mass Casualty Incident Levels
• Check radial pulse • Absent • Tag “Immediate” (Red) 15. Only other treatment at this stage is control of life-threatening bleeding, including positioning • Capillary refill <2 sec • Radial pulse is present • Assess LOC 16. Only patients not yet categorized • Level of Consciousness • Patient can follow simple commands (e.g., "Squeeze my hand") • Tag “Delayed” (Yellow) • If patient cannot follow simple commands (e.g., "Squeeze my hand") • Tag “Immediate” (Red)
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 3 of 3 CR –6 Oxygen Duration Chart D Oxygen Tank Duration in Minutes Pressure (Tank PSI) Flow L/min 2000 1800 1500 1000 500 5 64 58 48 32 16 10 32 29 24 16 8 15 21 19 16 11 5 20 16 14 12 8 4 25 13 12 10 6 3 30 11 10 8 5 3 Calculated H/K Cylinder volume is 352 liters at tank pressure of 2200 psi E Oxygen Tank Duration in Minutes Pressure (Tank PSI) Flow L/min 2000 1800 1500 1000 500 5 112 101 84 56 28 10 56 50 42 28 14 15 37 34 28 19 9 20 28 25 21 14 7 25 22 20 17 11 6 30 19 17 14 9 5 Calculated M Cylinder volume is 616 liters at tank pressure of 2200 psi Pressure (Tank PSI) Flow L/min 2000 1800 1500 1000 500 5 1256 1130 942 628 314 10 628 565 471 314 157 15 419 377 314 209 105 20 314 283 236 157 79 25 251 226 188 126 63 30 209 188 157 105 52 Calculated H/K Cylinder volume is 6908 liters at tank pressure of 2200 psi M Oxygen Tank Duration in Minutes Pressure (Tank PSI) Flow L/min 2000 1800 1500 1000 500 5 624 562 468 312 156 10 312 281 234 156 78 15 208 187 156 104 52 20 156 140 117 78 39 25 125 112 94 62 31 30 104 94 78 52 26 Calculated M Cylinder volume is 3432 liters at tank pressure of 2200 psi
Version 02202020 Clinical Reference Updated 02-01-2020 CR-7
Pediatric Amiodarone Infusion (for VT or WCT of unknown origin with pulses) Dose 5mg/kg over 20 minutes Max dose 150 mg
Step 1 Determine Concentration Concentration: mg amiodarone in 50 mL NS (must use 60 drop set)
Pt Weight 3kg 5kg 7kg 9kg 11kg 13kg 15kg 17kg mg amiodarone 15 25 35 45 55 65 75 85 mL amiodarone 0.3mL 0.5mL 0.7mL 0.9mL 1.1mL 1.3mL 1.5mL 1.7mL
Pt Weight 19kg 21kg 23kg 25kg 27kg 30kg 33kg 36kg mg amiodarone 95 105 115 125 135 150 150 150 mL amiodarone 1.9mL 2.1mL 2.3mL 2.5mL 2.7mL 3mL 3mL 3mL
Step 2 Determine Rate Dose in mL/minute
50 ml / 20 min
150 Drops/ minute
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 8
Pediatric Calcium Gluconate Infusion Dose 20 mg/kg over 5 minutes Max dose 2 grams
Step 1 Determine Concentration Concentration: __mg Calcium Gluconate in 50 mL NS (must use 10 drop set)
Pt Weight 3kg 5kg 7kg 9kg 11kg 13kg 15kg 17kg mg Calcium 60 100 140 180 220 260 300 340 mL Calcium 0.6mL 1mL 1.4mL 1.8mL 2.2mL 2.6mL 3mL 3.4mL
mL Calcium using 1 gram/10 mL packaging Pt Weight 19kg 21kg 23kg 25kg 27kg 30kg 33kg 36kg mg Calcium 380 420 460 500 540 600 660 720 mL Calcium 3.8mL 4.2mL 4.6mL 5mL 5.4mL 6mL 6.6mL 7.2mL
Dose in mL/min
50 mL / 5 min 100 Drops/minute
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 9
Pediatric Epinephrine Infusion
Range of infusion 0.1-1.0 mcg/kg/min
Step 1 Determine Concentration Concentration: mg Epi 1:1000 in 250 mL NS must use 60 drop set
Pt Weight 3 KG 5 KG 7 KG 9 KG 11 KG 13 KG 15 KG 17 KG mg Epi 0.2 0.4 0.6 0.7 0.9 1 1.2 1.4
Pt Weight 19 KG 21 KG 23 KG 25 KG 27 KG 30 KG 33 KG 35 KG mg Epi 1.5 1.7 1.8 2 2.2 2.4 2.6 2.8 Place in 250 mL NS Step 2 Determine Rate Dose in mcg/kg/min
0.1 0.2 0.3 0.5 0.7 0.8 0.9 1 Drops/minute 19 38 56 94 131 150 169 188 Concentration based on (Pt weight in kg x 0.08) = mg Epi in 250 mL NS
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Pediatric IV Maintenance Fluids
Patient Weight 3kg 5kg 7kg 9kg 11kg 13kg 15kg 17kg Maintenance in mL/hr 12 20 28 36 42 46 50 54 gtts/min with 60 gtt set 12 20 28 36 42 46 50 54 1.5 x Maintenance 18 30 42 54 63 69 75 81 gtts/min with 60 gtt set 18 30 42 54 63 69 75 81
Patient Weight 19kg 21kg 23kg 25kg 27kg 30kg 33kg 35kg Maintenance in mL/hr 58 61 63 65 67 70 73 75 gtts/min with 60 gtt/set 58 61 63 65 67 70 73 75 1.5 X Maintenance 87 92 95 98 101 105 110 113 gtts/min with 60 gtt/set 87 92 95 98 101 105 110 113
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 11
Pediatric Levophed Infusion Range of Infusion 0.05-0.1 mcg/kg/min
Step 1 Mix 4 mg Levophed in 1000 ml NS (must use 60 drop Determine concentration set)
Step 2 Determine Rate
Patient’s Weight in KG 3 5 7 10 12 15 18 24 32 Volume of Bag 0.05 2.25 3.75 5.25 7.50 9.00 11.25 13.50 18.00 24.00 0.08 3.60 6.00 8.40 12.00 14.40 18.00 21.60 28.80 38.40 Doses are in gtts/min 0.10 4.50 7.50 10.50 15.00 18.30 22.50 27.00 36.00 48.00
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 12
Pediatric Magnesium Sulfate Infusion Range of Infusion 50 mg/kg over 20 min Max dose 2 grams Step 1 Concentration: __mg Magnesium Sulfate in 50 mL NS (must use 60 drop set) Determine Concentration
Pt Weight 3 kg 5 kg 7 kg 9 kg 11 kg 13 kg 15 kg 17 kg mg MgSO4 150 250 350 450 550 650 750 800 mL MgSO4 0.3mL 0.5mL 0.7mL 0.9mL 1.1mL 1.3mL 1.5mL 1.7mL mL MgSO4 using 1 gram/2mL packaging
Pt Weight 19 kg 21 kg 23 kg 25 kg 27 kg 30 kg 33 kg 36 kg mg MgSO4 950 1050 1150 1250 1350 1500 1650 1800 mL MgSO4 1.9mL 2.1mL 2.3mL 2.5mL 2.7mL 3mL 3.3mL 3.6mL Place in 50 mL NS Step 2 Determine Rate Dose in mL/min
50 mL / 20 min 150 Drops/ minute
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 13 Adult/Pediatric Trauma Criteria
Regional Trauma System Criteria
Patients should be transported to a System Designated Adult ( ≥ 15 yrs ) or Pediatric ( < 15 yrs ) Trauma Center as rapidly as possible and with early notification of the receiving facility.
EMS TRAUMA ALERT Traumatic injury with signs of shock Any airway or respiratory compromise secondary to trauma, obstruction or inhalation or need for intubation. Penetrating injuries to the head, neck, torso or extremities proximal to the elbow or knee. Traumatic injury with GCS ≤ 8without sedation. Suspected spinal cord injury with neurologic findings. Amputation proximal to wrist or ankle Depressed or open skull fracture Flail Chest Potential pelvic fracture Two or more proximal long bone fractures Burns with associated inhalation injury or 2nd or 3rd degree burns greater than 20% of body surface area.
EMS TRAUMA TRANSPORT Traumatic injuries with a GCS 9 -14 Falls greater than 10 feet Motorized Vehicle Crashes with reported history of: Ejection of the patient from the vehicle Prolonged extrication > 20 minutes Auto rollover collision > 90 degrees Death or Trauma Alert or Trauma Transport designation of any occupant in same vehicle Automobile impact speed ≥ 40 MPH Motorcycle or watercraft crashes > 20 MPH Auto vs. pedestrian or Auto vs. bicycle collisions > 10 MPH 2nd or 3rd degree burns between 5% - 20% BSA Blunt trauma patients with co-existing conditions: Immunosuppression Coagulopathy Pregnancy Hanging or strangling mechanism 3 or more long bone fractures Crush injuries proximal to the wrist or ankle
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 14 Rule of Nines
The Rule of Nines is commonly used in the prehospital setting to provide a rough estimate of burn injury size. If the burned areas are irregular in shape or widely distributed, an alternate method of estimating the burn area is to visualize the patient’s palm as being equal to 1% of body surface area. This is referred to as the “Rule of Palm.”
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL REFERENCE UPDATED 02-01-2020 PAGE 1 of 1 CR – 15 San Marcos Hays County EMS Fibrinolytic Exclusion Checklist For use in ALL patients with 12-Lead ACS Changes
Patient's Name: Date: / /
Has patient experienced chest discomfort for greater than 15 minutes, but less than 6 hours? Yes = Continue with Checklist No = NOT a Fibrinolytic Candidate Does 12-Lead ECG show STEMI or new or presumably new LBBB? Yes = Continue with Checklist No = NOT a Fibrinolytic Candidate Are there any contraindications to fibrinolysis? Yes No Criteria Active internal bleeding Major trauma, surgery (including laser eye surgery), GI or urinary tract bleeding in the previous 6 weeks Any intracranial surgery, serious head/facial trauma, or previous stroke within the past 3 months Recent arterial puncture at a non-compressible site History of intracranial hemorrhage, arteriovenous malformation, or aneurysm Lumbar puncture within the past 7 days Bleeding or clotting problems or on blood thinners Pregnancy CPR greater than 10 minutes Serious Systemic Disease (e.g., Advanced terminal cancer, severe liver or kidney diseas) > 75 years old
Is patiet at high risk? Yes No Criteria HR greater than 100 BPM AND BP less than 100 mm/Hg systolic Pulmonary edema (crackles/rales) Signs of shock Contraindications to fibrinolytic therapy
All answers "No" - Transport to closest appropriate facility Any answers "Yes" - Explain risks/benefits to patient of bypassing Yes No Questions Pt understood findings and how it relates to their treatment? Pt agreed to bypass after explanations?
Document all findings (Yes or No) and explanations in patient care report narrative.
Clinical Procedures
Table of Contents
Clinical Procedures ...... Pages
12 Lead ECG ...... CP-1 AED ...... CP-2 Airway Obstruction ...... CP-3 Alternative Venous Access ...... CP-4 Assessment - Adult ...... CP-5 Assessment - Pediatric ...... CP-6 Auto-injector Delivered Medication ...... CP-7 Blood Glucose Assessment ...... CP-8 Cardiac Pacing ...... CP-9 Cardioversion ...... CP-10 Childbirth ...... CP-11 Clinical Event Reporting ...... CP-12 Contact Precautions ...... CP-13 CPAP ...... CP-14 CPR – Pit Crew ...... CP-15 CPR (BLS) ...... CP-16 Cricoid Pressure ...... CP-17 Decontamination ...... CP-18 Determination of Capacity ...... CP-19 Endotracheal Medication Administration ...... CP-20 End – Tidal CO2 Monitoring Wave Form ...... CP-21 External Jugular Access ...... CP-22 Extremity IV Intravenous Fluid Therapy ...... CP-23 Eye Irrigation BLS Only ...... CP-24 Flex Guide ETT Introducer (Bougie) ...... CP-25 Gastric Tube Insertion ...... CP-26 Hemostatic Agent ...... CP-27 i-gel O2 Airway Device (BIAD) ...... CP-28 Intramuscular Injections ...... CP-29 Insulin Pump ...... CP-30 Intraosseous Infusion EZ - IO ...... CP-31 Kendrick Traction Device ...... CP-32 LUCAS ...... CP-33 Manual Defibrillation ...... CP-34 Nasal Drug Delivery Device ...... CP-35 Nebulized Medication ...... CP-36 Needle Cricothyrotomy ...... CP-37 Orotracheal Intubation ...... CP-38 Orthostatic Blood Pressure Measurement ...... CP-39 Pediatric Immobilization Board (Pedi-Board)………………………………………………………………………………….CP-40 Pelvic Binder (SAM Sling®) ...... CP-41 Physical Restraints ...... CP-42 Pleural Decompression ...... CP-43 Pain Assessment and Documentation ...... CP-44 Pressure Infusion Bag ...... CP-45 Pulse Oximetry ...... CP-46 Respiratory Precautions ...... CP-47 Safe Injection Practices ...... CP-48 Spinal Motion Restriction ...... CP-49 Splinting ...... CP-50 Standard Precautions ...... CP-51 Stroke Screens ...... CP-52 Surgical Cricothyrotomy ...... CP-53 Suctioning-Advanced ...... CP-54 Taser® Probe Removal ...... CP-55 Tourniquet ...... CP-56 Transport Ventilator……………………………………………………………………………………………………………………….CP-57 Vagus Nerve Stimulator………………………………………………………………………………………………………………....CP-58 Wound Care ...... CP-59
12 Lead ECG Legend Clinical Indications: System S S Any patient > 20 years old with the following: Responders B EMT - B B • Suspected cardiac patient I EMT- I I o Includes pain between navel and jaw o Pressure, discomfort, tightness or heartburn P EMT- P P o “Heart racing”, “palpitations,”or “heart too slow” o CHF • Electrical injuries • Syncope • Weakness • New onset stroke symptoms • Difficulty breathing • Suspected overdose Procedure:
Any provider: 1. Assess patient. 2. Administer oxygen as patient condition warrants. 3. Expose chest and prep as necessary. Modesty of the patient should be respected. 4. 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 Paramedic: 5. Prepare ECG monitor and connect patient cable with electrodes. 6. Instruct patient to remain still. 7. Press the appropriate button to acquire the 12 Lead ECG. 8. For patients with cardiac complaint, keep all leads connected at all times practical to allow automatic ST-segment monitoring to proceed. 9. Monitor the patient while continuing with the treatment protocol. 10. Document the procedure, time, and results on/with the patient care report (PCR).
If signs of Inferior involvement • V4R -5th intercostal space at midclavicular line
If signs of Posterior involvement • V7, V8, V9 -Move V4, V5, & V6 to patient’s back in same positions.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 1 AED Legend Clinical Indications: System S S • Patients in cardiac arrest (pulseless, non-breathing) Responders B EMT - B B Contraindications: I EMT- I I • None P EMT- P P Notes/Precautions: • Age < 8 years, use Pediatric Pads, if available, or if device has “energy attenuating” key, be sure to activate key • If AED Pads touch due to patient size, use an Anterior-Posterior pad placement 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. Use alternate placement when implanted devices (pacemakers, AICDs) occupy preferred pad positions. 3. Remove any medication patches on the chest and wipe off any residue. 4. Turn on AED and follow prompts. 5. Keep interruption in CPR as brief as possible. 6. If shock advised, Assertively state “CLEAR” and visualize that no one, including yourself, is in contact with the patient then press the shock button 7. Immediately return to chest compressions. 8. If no shock advised, immediately return to chest compressions. 9. Allow AED to analyze when prompted (approximately 2 minutes). Perform pulse check at this time. 10. Repeat steps 6 through 8. 11. Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation If pulse returns: See post resuscitation protocol
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 2 Foreign Body Airway Obstruction Legend Clinical Indications: System S S • Sudden onset of respiratory distress often with coughing, Responders wheezing, gagging, or stridor due to a foreign-body obstruction B EMT - B B of the upper airway I EMT- I I • Respiratory arrest where ventilation cannot be accomplished P after repositioning of airway EMT- P P 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 may clutch his/her neck in the universal choking sign 2. For an infant, deliver five (5) back blows followed by five (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 or the victim becomes unresponsive • If abdominal thrusts are ineffective, chest thrusts should be used. Chest thrusts should be used primarily in morbidly obese patients and in 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, Paramedic and Intermediate level providers should visualize the posterior pharynx with a laryngoscope to potentially identify and remove the foreign- body using Magill forceps. 8. Document the methods used and result of these procedures in the Patient Care Report (PCR).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP –3 Alternative Venous Access
P EMT-P P Clinical Indications: • Venous access when traditional means are unsuccessful • Only in those patients with life-threatening situations such as cardiac arrest, lethal arrhythmias, or in-extremis from a readily treatable cause (i.e., CHF) Contraindications: • Patients where traditional IV access is available Notes/Precautions: • Venous access devices can be complicated. Consider contact with OLMC for guidance • Alternate access devices provide a direct line into patient circulation; therefore, the introduction of air can be extremely hazardous • Do not remove injection cap from catheter or allow IV fluids to run dry Procedure: Broviac / Hickman / Groshong and other double and triple lumen catheters 1. Silicone tube inserted into the distal superior vena cava or right atrium, usually via the cephalic vein. The catheter enters the skin through an incision in the chest. Most lines are kept heparinized and protected via an injectable cap. 2. Select appropriate port for access. If two are available, access the blue or brown port. 3. Thoroughly cleanse injectable port cap with chlorohexadine. • Insert an 18-gauge needle attached to a 12 cc syringe into injectable port cap and aspirate 10 mL of blood from catheter (this prevents an inadvertent anticoagulant bolus from occurring). Dispose of aspirated blood • If ports are needleless, use appropriate needleless adapter 4. If at any time you are unable to aspirate blood or infuse fluids, do not use line as clotting may have occurred. 5. Attach IV line (attached to an 18-20 gauge needle) into injection port. Begin IV fluid flow and adjust appropriately. 6. Medications are injected through the IV lifeline. PICC Line (Peripherally Inserted Central Catheter) 1. Usually inserted into the right atrium via the antecubital vein. 2. Select a port on one of the catheters. When two sizes are available, select the larger. Cleanse port with chlorohexadine. 3. Attach a needle to a 10 cc syringe and draw up 5 cc of normal saline (NS). Insert needle into port and attempt to inject NS. If resistance is met, withdraw needle and attempt same procedure on different port. Do this until you find catheter that does not present with resistance to administration of NS. If resistance continues, do not use either port. 4. When no resistance is met, inject contents of syringe into catheter and then draw back to achieve blood flash, indicating successful access. 5. Remove syringe, attach IV tubing, and proceed as normal, opening line and insuring patency.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 2 CP – 4 Alternative Venous Access
Internal Subcutaneous Infusion Ports (portacath) 1. Unless patient is in cardiac arrest, access should not be attempted without specialized Huber needle. 2. Patients with a pulse: Inquire if patient has Huber needles available. If so, proceed as outlined. If no Huber angle needles are available, DO NOT ACCESS PORT WITH REGULAR NEEDLES. 3. Patients in cardiac arrest: Access may be obtained using a regular 18 gauge needle when Huber needles are not available. Do not use unless absolutely necessary as a regular needle may destroy the self- sealing core, rendering the port useless. 4. Locate the sight by visualization and palpation. These ports are generally found in the upper chest and present as a dome shaped protrusion. 5. Prepare sight as if starting an IV. 6. Using a non-coring Huber angle needle attached to a syringe, insert into the sight at a 90-degree angle until resistance is met. 7. Inject saline into port and aspirate blood (withdraw 10 ml of blood and waste) If resistance is met or blood cannot be aspirated, withdraw needle and do not attempt further access at this sight. 8. With successful attempt, remove syringe, attach IV tubing, and proceed as normal, opening line and insuring patency. Hemodialysis AV-FISTULAS / AV-GRAFTS 1. A tube that diverts blood flow from an artery to a vein. Typically seen in renal failure patients. 2. Prior to access, check site for bruit and thrills, if none are present do not use. 3. Access fistula on venous side (side with weaker thrill in patient with a pulse) using 18 to 16 gauge angiocath in the same manner as intravenous access. 4. Remove catheter, and use only the needle if accessing an AV-Graft to avoid tearing synthetic material. 5. If patient does not have a pulse, either side may be accessed. 6. Inflate BP cuff around IV bag to maintain flow of IV fluids. 7. If unsuccessful in accessing site (no obvious blood return or flow of fluids), hold direct pressure over site for 5-8 minutes for a fistula and 8-15 minutes for a graft to prevent hemorrhaging. Do not continue attempting to access.
Multi-lumen Catheter Internal PICC Line Hemodialysis Subcuntaneous Port Fistula/Graft
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CP – 4 Adult Assessment Legend Clinical Indications: System S S • Any patient requesting a medical evaluation that is too large to Responders be measured with a Broselow-Luten Resuscitation Tape or B EMT - B B >37 Kg I EMT- I I Procedure: P EMT- P P 1. Scene size-up, including appropriate PPE, scene safety, environmental hazards assessment, need for additional resources, by-stander safety, and patient/caregiver interaction. 2. Initial assessment includes a general impression as well as rapid evaluation of the status of a patient’s airway, breathing, and circulation, mental status (e.g., AVPU, GCS) and disability (e.g.motor/neuro deficits, pupil response). 3. Assess the need for and complete any critical interventions. Manage additional system resources as appropriate.(request additional units or where appropriate downgrade or cancel responding units). 4. Perform a focused history and physical based on patient’s chief complaint making efforts to protect patient privacy and modesty. Complete secondary exam to include a baseline set of vital signs as directed by patient complaint or protocol. 5. Maintain an on-going assessment throughout transport; to include patient response to/possible complications of interventions, need for additional interventions, and assessment of evolving patient complaints/conditions. 6. Document all findings and information associated with the assessment, performed procedures, and any administration of medications on the PCR.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 5 Pediatric Assessment
Legend Clinical Indications: System S S • Any child that can be measured with the Broselow-Luten Responders Resuscitation Tape or < 37 Kg B EMT - B B Procedure: I EMT- I I 1. Scene size-up, including appropriate PPE, scene safety, P EMT- P P environmental hazards assessment, need for additional resources, by-stander safety, and patient/caregiver interaction. Take reasonable steps to protect patient privacy and modesty. 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. Assess disability (motor function, sensory function, pupils). 4. Determine responsiveness appropriate for age (AVPU, GCS, etc.). 5. Perform spinal motion restriction, if suspicion of spinal injury. 6. Color code using Broselow-Luten tape. 7. Perform a focused history and physical exam. Pediatric patients unable to verbalize their own complaint should be fully exposed for assessment. 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: • Ideally the use of infant or child/pediatrc BP cuff sizes when appropriate and available 50th percentile BP estimate = (age in years x 2) + 90 mm Hg Hypotension when BP ≤ (age in years x 2) + 70 mm Hg • To assess perfusion when obtaining a BP is not possible: Age appropriate heart rate Tachycardia is usually the most common sign of compensated shock in children, BP doesn't drop until about 30% of circulating blood volume is lost Mottled extremities Decreased peripheral pulses compared to central, cool extremities 9. Include Immunizations, Allergies, Medications, Past Medical History, last meal, and events leading up to injury or illness where appropriate. 10. Treat chief complaint as per protocol.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 6 Auto-injector Delivered Medication B EMT - B B I EMT- I I Clinical Indications: P EMT- P P • When protocol indicates medication delivery via auto-injector • When other administration routes are unsuccessful or unavailable Contraindications: • None Notes/Precautions: • Appropriate equipment • Chlorohexadine wipe and Band-aids • Appropriate injection sites • Do NOT place thumb over either end of the auto-injector at any time. Procedure: 1. Prepare equipment. 2. Check label, date, and appearance of medication. 3. Locate appropriate injection site. • Vastus lateralis located on the lateral aspect of the thigh • Injection is given into the mid thigh 4. When time permits expose target site and prep with chlorohexadine/alcohol wipe. (not required as injectors are designed to work through clothing.). 5. Remove the auto-injector from its storage container. 6. Form a fist around the auto-injector with black tip facing down. Do NOT place thumb over either end of the auto-injector. 7. Remove the gray safety cap with your other hand. 8. At a 90 degree angle jab the black cap sharply against the desired injection site listening for an audible “click.” 9. Hold auto-injector in place for 10 seconds to allow complete delivery of medication. 10. Remove auto-injector and dispose of the sharp in an appropriate container. 11. Massage the injection site for 10 seconds to speed delivery of the medication. 12. Observe patient for response to medication. 13. All patients receiving auto-injector medications should be transported to the hospital for further evaluation and observation.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 7 Blood Glucose Assessment Legend Clinical Indications: System S S • Any patient with an altered mental status Responders • Patients with metabolic or endocrine disorders, and B EMT - B B presenting with non-specific complaints I EMT- I I • Bradycardia or hypothermia in infants P EMT-P P
Procedure: 1. Gather and prepare equipment. 2. Blood samples for performing glucose analysis should be obtained through a finger-stick. Venous blood samples may produce artificially high blood glucose values and should be avoided. 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 as recommended by the manufacturer and document. If any clinically suspicious readings are noted perform quality assurance test immediately after the call and notify a supervisor as appropriate.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 8 Cardiac Pacing
P EMT-P P Clinical Indications: • Adult patient with unstable bradycardia (HR <60 and signs of hypoperfusion such as SBP <90 mm Hg, change in mental status, chest pain, CHF) • Pediatric patients with unstable bradycardia unresponsive to treatable causes (PEDI, SBP < 70 + (age in years x 2) mmHg). Unresponsive to aggressive Oxygenation and Ventilation attempts Contraindications: • Hypothermia with a temperature <86 degrees F Procedure: 1. Attach standard four lead monitor. 2. Apply defibrillation/pacing pads assuring clean dry contact surface (shave/dry): • One pad to anterior left mid chest next to sternum. (medial/inferior to pectoral muscle) • One pad to posterior left mid chest next to spine. (medial/inferior to scapula) 3. For pediatric patients use correct size and type pads for pacing and patient weight. 4. Select pacing mode on the monitor. 5. Adjust heart rate to 60 BPM (adult) or 100 BPM (child). 6. Note presence of pacer spikes. 7. Increase output until electrical capture of the rhythm on the monitor. 8. If unable to capture at maximum output discontinue pacing immediately. 9. If capture observed, check for corresponding pulse and assess vital signs. 10. Consider the use of sedation or analgesia. 11. Document the procedure, time of intervention and response in the patient care report.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 9 Cardioversion P EMT-P P Clinical Indications: • Unstable tachydysrhythmia with a pulse (ventricular tachycardia, torsade de pointe, SVT, A-fib/Flutter with RVR, etc.) in accordance with the appropriate tachydysrhythmia protocol Contraindications; • Repetitive, self-terminating, short-lived tachycardias (i.e., runs of non-sustained VT)
Procedure: 1. Confirm that the rhythm on the monitor coincides with a patient in an unstable condition 2. Set to synchronized cardioversion mode watching for R wave markers on each QRS complex. 3. If the R wave markers do not appear, or appear elsewhere on the ECG, adjust the ECG size or gain up or down until they appear on each R-wave. . If markers still do not appear, select another lead or reposition the ECG electrodes . If these methods are ineffective unsynchronized cardioversion may be required 4. Apply self-adhesive pads in the anterior/posterior position, ensuring firm contact with patient’s skin. 5. Consider the use of pain/sedating medications. 6. Charge device to appropriate energy level and clear all personnel from direct patient contact. 7. Depress and hold discharge buttons until electrical charge is delivered.(There may be substantial delay between pressing the button and the actual discharge of energy). 8. Reassess the patient. If rhythm deteriorates into VF/pulseless VT, switch to asynchronous mode and immediately defibrillate per Patient Care protocols. 9. Repeat steps 2 to 7 above using escalating energy settings until maximum setting or until efforts succeed. Consider discussion with medical control if cardioversion is unsuccessful after 2 attempts. 10. Document the procedure, time performed and patient response in the patient care report.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 10 Childbirth Legend Clinical Indications: System S S • Imminent delivery with crowning Responders B B Procedure: EMT - B I EMT- I I 1. Delivery should be controlled so as to allow a slow, controlled delivery of the infant. This will prevent injury to the mother and P EMT-P P infant. 2. Consider additional resources as there will be two potential patients. 3. Support the infants head as it delivers. 4. If the umbilical cord is around the neck, slip it over the head. If unable to free cord from the neck, double clamp the cord and cut between the clamps. 5. Suction the airway with a bulb syringe. 6. While continuing to support the head, gently lower the head to encourage delivery of the anterior shoulder. 7. Once the anterior shoulder delivers gently lift the head and anterior shoulder to allow delivery of the posterior shoulder. 8. Be prepared to support the infant while delivering the remainder of the body. 9. Clamp the cord 6 inches and place second clamp 9 inches from the abdomen and cut the cord between the clamps. 10. Record APGAR scores at 1 and 5 minutes. 11. Follow the Newly Born Protocol for further treatment. 12. The placenta will deliver spontaneously, usually within 5-25 minutes of the infant. Do not force the placenta to deliver or pull on the umbilical cord. 13. Massage the uterus and/or initiate breast feeding (as infant and/or maternal condition allows) to stimulate uterine contractions, decrease bleeding and initiate delivery of the placenta. If the placenta delivers it should be retained for inspection. For post-partum hemorrhage refer to the OB Emergencies protocol.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 11 Clinical Event Reporting Legend Clinical Indication: System S S The primary objective of a standardized clinical event review process is Responders to identify individual and system improvement to clinical care. This B EMT - B B procedure defines the mechanisms for reporting clinical events and I EMT- I I triggering the clinical event review process P EMT- P P Procedure 1. Each System Transport Provider and First Responder Organization will establish a process by which their staff will report clinical events and concerns to the Organization’s Performance Improvement staff. 2. Credentialed providers will use their Organization’s process to report clinical concerns and events. • When reporting to the Performance Improvement staff is not possible, the Organization’s first level supervisor should receive the report and forward it to the Performance Improvement staff as soon as possible • Providers who wish to do so may report the concern or event directly to the on-call Medical Director 3. Reports of clinical concerns or events should include, at a minimum, the following information related to the event/concern: • Date and approximate time • Incident number • Brief description of the clinical event/concern • Name of reporting person (optional) 4. Examples of potential events and concerns that must be reported include but are not limited to: • Unrecognized esophageal intubation • Medication error with or without apparent patient harm • ED physician complaint or conflict • High profile emergency medical events • Device failure causing inability to provide a critical intervention • Surgical Airway • Absolute deviation from a EMD protocol with a clinical impact • Transport to an inappropriate receiving facility • Any potential decredentialing issue 5. To maintain confidentiality, reports should not include details related to the substantiation, cause or outcome of the reported concern/event. 6. Credentialed providers are expected to fully participate in the clinical event reporting and review processes.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 12 Contact Precautions Legend Clinical Indications: System S S • Used when the organism is transmitted by direct contact with Responders patient or environmental surfaces B EMT - B B • Patients with large infected ulcers and drainage that is not I EMT- I I contained by dressing • Any drug resistant organism, Clostridium difficile, Scabies, E. P EMT- P P coli O157:H7 Contraindications: Not Applicable Notes/Precautions: Not Applicable Procedure: 1. Explain the need for Contact Precautions to the patient. 2. Everyone involved in direct patient care should wear clean gloves and gowns. 3. Gloves and gowns should be removed and hands washed with soap and water prior to leaving the treatment area or upon completion of patient transfer. 4. Additional protection (e.g. masks, face protection, goggles) should be added per Standard Precautions depending on the procedures done. (e.g. wear masks and eye protection for suctioning, intubation, or nebulized medication).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 13 CPAP Continuous Positive Airway Pressure Ventilation
Clinical Indications: B EMT - B B • Congestive Heart Failure/Pulmonary Edema I EMT- I I • Submersion / Drowning P EMT- P P • Chronic Obstructive Pulmonary Disease • Acute Respiratory Distress Contraindications: • Respiratory arrest • Agonal respirations • Unconsciousness • Shock associated with cardiac insufficiency • Pneumothorax • Facial trauma, burns • Hypotension Notes/Precautions: Possible complications include • Gastric distention • Reduced cardiac output • Hypoventilation • Pulmonary barotrauma Procedure: 1. Ensure all necessary equipment is available and assembled. 2. Select initial appropriate PEEP for condition (5 cm H2O or 10 cm H2O). 3. Fully explain procedure to patient. 4. Have patient hold mask to face and instruct him/her to breathe slowly and deeply. 5. Once patient is comfortable with mask, securely attach headpiece and tighten to fit. 6. The adjunctive delivery of an albuterol Neb with the CPAP device is an approved procedure and treatment modality. Patient presentation and distress level should dictate the timing or use of this procedure. The addition of Albuterol in this fashion should not create delays in the use of CPAP and; only providers who are trained and appropriately equipped should use this.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 14 CPR – Pit Crew
Legend Clinical Indications: System S S • Patient in cardiac arrest Responders B EMT - B B Contraindications: I EMT- I I • < 1 year or patient size prohibits access P EMT- P P Notes/Precautions: • Focus is on: Minimally interrupted compressions Appropriate depth and quality of compressions Consider compressor fatigue and change compressors every 2 minutes Team approach • Infants and small children may require modification of the procedure due to size • This procedure is based on a 3-person crew of providers (if a 4th person is available, they should assist with setting up BIAD and rotate into a Compressor position • If LUCAS device is available, Position 1 becomes the operator of LUCAS • If there is only a 2-person crew, go to CPR Procedure Procedure: 1. First arriving providers: 2. Establish prior to arriving at patient’s side, the following responsibilities: • Position 1 (patient’s right side) assesses responsiveness/pulses initiates chest compressions immediately if needed checks & pre-assembles BIAD (ventilates BVM when not performing compressions) alternates chest compressions ventilates BVM when not performing chest compressions assembles, applies & operates LUCAS • Position 2 (patient’s left side) applies AED pads immediately operates AED after each 2 minute cycle of compressions alternates chest compressions with Position 1 ventilates BVM when not performing chest compressions may assist with BIAD • Position 3 (patient’s head) assembles and appropriately applies all equipment for airway and ventilations (OPA, BVM, ITD, Suction, O2, BIAD, BIAD securing device, ETCO2) opens/clears airway inserts OPA assembles and applies BVM & ITD turns on timing light on ITD maintains two-hand BVM mask seal inserts & secures BIAD at appropriate time (after 400 chest compressions during 2nd AED rhythm analysis or when able) • Position 4 (if available) rotates and assists wherever needed may function as a “team leader”
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 2 CP – 15 CPR – Pit Crew
3. ALS Integration: 4. Establish prior to arriving at patient’s side, the following responsibilities: • Code Commander (Paramedic in control of monitor) communicates/interfaces with providers performing CPR sets up & operates monitor/defibrillator makes all patient treatment decisions • Intervention Paramedic (positioned at feet when possible) initiates IV/IO access administers medications at the direction of the code commander anticipates needs of code commander Below is graphical representation of the Pit Crew CPR Procedure:
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CP – 15 CPR (BLS) Legend Clinical Indications: System S S • Basic Life Support for the patient in cardiac arrest Responders Contraindications; B EMT - B B • None I EMT- I I Notes/Precautions: P EMT- P P • Focus is on: Minimally interrupted compressions Appropriate depth and quality of compressions Consider compressor fatigue and change often • Witnessed Arrest: Go Immediately to AED Procedure Procedure: 1. Assess the patient’s level of responsiveness (shake and shout). 2. If no response, open the patient’s airway with the head-tilt, chin-lift and look, listen, and feel for respiratory effort. If the patient may have sustained C-spine trauma, use the modified jaw thrust while maintaining immobilization of the C-spine. For infants, positioning the head in the sniffing position is the most effective method for opening the airway. 3. Go to AED Procedure. 4. Check for pulse (carotid for adults and older children, brachial for infants) for no more than 10 seconds. If no pulse begins chest compressions as directed below: Age Location Depth Rate Infant Over sternum, 0.5 to 1 inch At least 100/minute between nipples (1/3 the anterior- (inter-mammary posterior chest line), 2-3 fingers dimension) Allow Full Chest Recoil. Child Over sternum, just 1 to 1.5 inches (1/3 100/minute above the xyphoid the anterior- (3 compressions process, heel of one posterior chest every 2 seconds) hand dimension) Allow Full Chest Recoil. Adult Over sternum, just 1.5 to 2 inches (1/3 100 minute above the xyphoid the anterior- (3 compressions process, hands with posterior chest every 2 seconds) interlocked fingers dimension). Allow Full Chest Recoil. 5. Go to Cardiac Arrest Protocol. Begin ventilations. 6. Provide age appropriate ventilations. 7. Chest compressions should be provided in an uninterrupted manner. Only interrupt at 2 minute intervals for rhythm analysis, defibrillation, and performance of procedures. No interruption should last more than 10 seconds. 8. Document the time and procedure in the Patient Care Report (PCR).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 16 Cricoid Pressure
• The routine use of cricoid pressure is no longer supported by the American Heart Association
Clinical Indications: Legend System • S S Patients in need of airway protection due to gastric Responders insufflation and/or vomitus entering airway B B • As needed during advanced airway procedures to enhance EMT - B Intubation attempts in patients with difficult airways/anatomy I EMT- I I Contraindications: P EMT- P P • Cricoid pressure should not be applied to children less than 1 year of age Notes/Precautions: • Caution should be exercised when utilizing this technique on children of any age. The cricoid cartilage is not as firm in children as it is in adults. As a result, less pressure is needed to achieve the same effect • Evidence has shown that the routine use of cricoid pressure may actually prevent the insertion of an advanced airway. Use only to assist with difficult airway insertion (i.e. Short neck, anterior anatomy). Procedure: 1. Locate the cricoid cartilage by: . Palpating the protuberant midline portion of the thyroid cartilage (“Adams apple”) . Move the fingertip inferiorly until it rests in the soft, flat depression between the thyroid cartilage and the cricoid cartilage 2. Using the thumb and forefinger of one hand, apply downward pressure (approximately 5-6 lbs. of pressure) on the cricoid cartilage. 3. When using to assist intubation the provider performing the intubation may place their fingers over those of the provider giving cricoid pressure to direct the movement of the larynx backward, upward, rightward pressure (BURP)to allow visualization. 4. Once visualized the intubating provider may remove their hand and introduce the endotracheal tube.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 17 Decontamination
Legend Clinical Indications: System S S • Any patient who may have been exposed to significant Responders hazardous materials, including chemical, biological, or B EMT - B B radiological weapons I EMT- I I Procedure: P EMT- P P 1. HazMat Command will establish hot, warm and cold zones of operation. 2. Ensure that personnel assigned to operate within each zone have proper personal protective equipment and training. 3. In coordination with other public safety personnel, assure that 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. 7. Monitor all patients for environmental illness. 8. Transport patients per protocol.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 18 Determination of Capacity Legend Clinical Indication: System S S • To determine if a patient has present mental capacity to Responders make an informed decision to accept or refuse care. All B EMT - B B refusals should be conducted in accordance with the Refusal I EMT- I I of Treatment/Transport Standard and the Definition of a Patient Standard P EMT- P P Procedure: 1. Determine scene safety. 2. If the patient is suicidal or homicidal contact police immediately. 3. In order to have decision making capacity the patient must be 18 years of age or if a minor, be emancipated, must not be suicidal or homicidal or have had their decision making capacity removed by determination of a court of law. 4. If the above criteria in #3 have been met the patient must be assessed for their ability to demonstrate the following: • Does the patient understand their illness or injury and the benefits of treatment and/or evaluation AND • Does patient understand consequences (including death) of not seeking treatment and/or evaluation for their illness or injury AND • Does the patient understand the alternatives to immediate care by EMS AND • Can the patient describe, in his own words, the above components and provide and defend a reason for their decision not to submit to treatment or transportation? 5. Utilize the Determination of Capacity checklist. If there is any uncertainty about the patients present mental capacity contact On-Line Medical Control. 6. Every individual who has demonstrated present mental capacity has a legal right to refuse medical treatment, even if that refusal is contrary to the beliefs of the provider or may result in potential harm to the patient. It is a healthcare provider’s responsibility to provide the patient with information about the risks of refusal and the benefits of treatment and/or evaluation so that their decision is informed. 7. If it is determined that a patient who wishes to refuse care lacks the present mental capacity to do so contact medical control and a supervisor to assist with the process. 8. Document any allowed history and exam, the absence of suicidal or homicidal ideation, the components of the capacity assessment and contact with medical control.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 19 Endotracheal Medication Administration P EMT-P P Clinical Indication: • Intubated patients requiring any of the identified medications when intravenous or intraosseous access is not obtainable Contraindications: • Administration of medications not identified • Instilling into or through ITD • Instilling into or through King LTS-D Airway Notes/Precautions: • The following medications (LANE) may be administered via the endotracheal route: o Lidocaine o Atropine o Narcan o Epinephrine • Medications administered via this route should be double the age/weight appropriate dose
Procedure: 1. Oxygenate the patient with 100% oxygen. 2. If CPR is in progress, do not stop chest compressions during administration of medications. 3. Disconnect BVM from the endotracheal tube and instill medication via the endotracheal tube: • Adults—No more than 10 milliliters at one time. • Pediatric—Flush dose with 5 milliliters normal saline 4. Reconnect Bag-Valve device and ventilate patient with 5 full breaths prior to administering any remaining amount of medication.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 20 End – Tidal CO2 Monitoring Wave Form
B EMT - B B Clinical Indications: I EMT- I I • All patients with a potential, or actual, change in metabolism, P EMT- P P circulation, and/or respiratory function • Hypoventilation states • Shock states • Shortness of breath/Bronchospastic disease • Chest pain with respiratory distress • Congestive Heart Failure • All patients with advanced airways or receiving CPR • Patients experiencing altered mental status • Any patient receiving/having received sedating medications or magnesium Contraindications: • None Notes/Precautions:
• A patient with normal cardiac and pulmonary function will have an ETCO2 level between 35-45 mmHg • When no CO2 is detected, 3 factors must be quickly evaluated for the cause: • Loss of airway function- Improper tube placement, apnea • Loss of circulatory function- Massive PE, cardiac arrest, exsanguination • Equipment malfunction- Tube dislodgement or obstruction • All advanced airway patients will have capnography (when available) applied and a printed copy of the post intubation readings attached to the Patient Care Record (PCR). A copy of the waveform will also be left with hospital staff • If used with ITD in Cardiac Arrest, the ITD must be attached to advanced airway Procedure: 1. Turn on monitor and adjust contrast as needed. 2. Verify ETCO2 display is on and functioning in Channel 3. 3. Open tubing connector door and connect ETCO2 Filterline tubing by turning clockwise. Tubing should be connected to monitor before being connected to patient’s airway. 4. Connect tubing to patient airway. 5. To record waveform: • Press “PRINT”- This will print real time capture • Press “EVENT” then highlight and press “GENERIC”- This will capture 3 seconds prior to and 5 seconds after event selection 6. For patients meeting the indications for capnography the capnometer shall remain in place and be monitored throughout prehospital care and transport. 7. Continuous capnometry should be monitored as airway procedures are performed to aid in verification or correction of an airway problem. 8. Any loss of CO2 detection or waveform should be immediately evaluated for loss of airway or circulatory compromise and should be documented. 9. In all patients with a pulse an ETCO2 reading > 20 is expected. In the post resuscitation patient no effort should be made to lower ETCO2 by modification of the ventilatory rate. 10. In the pulseless patient an ETCO2 waveform with an ETCO2 value > 10 may be utilized to confirm the adequacy of an airway to include BVM and advanced devices when SpO2 will not register.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 21 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 require intravenous access for fluid or medication administration and in whom an extremity vein or intraosseous access is not obtainable • External jugular cannulation can be attempted initially in life threatening events where no obvious peripheral site is noted and intraosseous access is contraindicated or undesirable Procedure: 1. Place the patient in a supine head down position where possible to distend the neck veins. 2. Turn the patient’s head toward the 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. “Tourniqueting” 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. Avoid using cervical collars with external jugular venous access. If needed, other methods of cervical motion restriction should be used. 8. Document the procedure, time, and result (success) on/with the Patient Care Report (PCR).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 22 Extremity Intravenous Fluid Therapy I EMT- I I Clinical Indications: P EMT- P P • Any patient where intravenous access is indicated (significant trauma or mechanism, emergent or potentially emergent medical condition) • Patients requiring intravenous fluids or medications • Patients in which a potential for hemodynamic compromise or vascular system instability exists Contraindications: • None Procedure: Saline locks may be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the ALS provider. EMT-I and Paramedics can use intraosseous access where threat to life exists as provided for in the Venous Access- Intraosseous Procedure. 1. Locate suitable venipuncture site and place a venous constricting band above the chosen site. 2. Select a vein and an appropriate gauge catheter for the vein and the patient’s condition. Suitable venipuncture sites include: • Back of the hand • Forearm • Antecubital fossa • Leg • Scalp vein (infants only) 3. Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles. 4. Connect the 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. 5. Prep the skin with Chlorohexadine. 6. Insert the needle with the bevel up into the skin in a steady, deliberate motion until a “pop” is felt and a blood flashback is visualized in the catheter. 7. Advance the catheter into the vein. Never reinsert the needle through the catheter. Dispose of the needle into the proper container without recapping. 8. Remove the venous constricting band and connect the IV tubing or saline lock. 9. Open the IV to assure patent access and free flow of the fluid and then adjust to a keep vein open (KVO) rate or as clinically indicated. 10. Cover the site with a sterile dressing and secure IV line. 11. Label the IV with date, time, catheter gauge, and name/ID of the person starting the IV 12. Document the procedure, time and result on the patient care report (PCR). Saline Lock: 1. Prepare equipment. 2. Flush air from “saline lock” with 1 to 3 mL of fluid. 3. Follow steps 1 through 8 as above for venipuncture. 4. Remove protective cap on the Luer lock device and carefully twist it onto the IV hub. Confirm that firm contact has been established and no fluid leaks exist. 5. Flush saline lock with 3 mL of normal saline looking for infiltration. 6. Tape or secure as previously noted.
VERSION 10012017 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 10-01-2017 PAGE 1 of 1 CP – 23 Eye Irrigation BLS Only Legend Clinical Indications: System S S • Irrigation of eye after chemical exposure/burn Responders • Assist with removal of foreign material from eye B EMT - B B Contraindications: I EMT- I I P P • Impaled object in eye EMT- P • Trauma to globe of eye Notes/Precautions: • None Procedure: 1. Remove contact lenses (if present). 2. Initiate irrigation and direct the tip of the IV tubing at the medial canthus (corner of the eye nearest the nose) and allow to flow laterally. Do not allow irrigation fluid to come in contact with unaffected eye. 3. Continue irrigation throughout transport. All patients should receive transport to the ED to evaluate for corneal injury.
VERSION 10012017 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 10-01-2017 PAGE 1 of 1 CP – 24 Flex Guide ETT Introducer (Gum-elastic Bougie)
Clinical Indications: P EMT-P P • Any patient who meets clinical indication for orotracheal intubation • Initial attempt unsuccessful • Predicted difficult intubation • Digital intubation Contraindications: • Use of ET tube <6.0 mm Notes/Precautions: • Soft tissue damage or bronchial rupture may occur: o During blind intubation o Positioning past the carina o If undue pressure is applied o If ET tube is passed over introducer without the use of a laryngoscope • This is a single-use device. Do not attempt to clean or sterilize • For optimal use, store flat in the same shape as packaged. Do not fold or roll up to save space Procedure: 1. Prepare and perform an optimal direct laryngoscopy in accordance with the orotracheal intubation procedure. 2. Begin insertion of introducer. • Tactile confirmation of tracheal clicking will be felt as the distal tip of the introducer bumps against the tracheal rings • If tracheal clicking cannot be felt, continue to gently advance the introducer until “hold up” is felt • Tracheal “clicking” and “hold up” are positive signs that the introducer has entered the trachea 3. Lack of tracheal clicking or hold-up is indicative of esophageal placement. 4. While holding the introducer securely, and without removing laryngoscope, advance endotracheal tube over the proximal tip of the introducer. 5. As the tip of the endotracheal tube passes beyond the teeth, rotate the tube 90 degrees counter clockwise (1/4 turn to the left) so tube bevel does not catch on the arytenoid cartilage. 6. Advance endotracheal tube to the proper depth. 7. Holding endotracheal tube securely, remove introducer. 8. Verify correct placement of ET tube in accordance with the orotracheal intubation procedure.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 25 Gastric Tube Insertion I EMT- I I Clinical Indications: P EMT- P P • Adult and pediatric cardiac arrest following placement of advanced airway • When requested by On-Line Medical Control Contraindications: • Actual or suspected laceration or perforation of the esophagus • Suspected fractures of the cribiform plate as evidenced by severe maxillofacial trauma (Nasal gastric tube placement only) • Ingestion of a caustic substance • Anticoagulant use (e.g., coumadin, warfarin) or disorders of coagulopathy (hemophilia) is a relative contraindication Procedure: 1. Select appropriate sized tube according to patient size and measure the correct length for insertion. • To measure length: While holding the distal end of the tube, measure the distance from the patient’s earlobe to the bridge of his/her nose, and from there to a point just below the xiphoid process • Mark this length with a piece of tape to serve as a future guide point 2. Have patient sit upright and lean slightly forward with his/her neck slightly flexed unless otherwise contraindicated. 3. In the unconscious or arrested patient with an advanced airway in place the orogastric route of insertion may be preferred. The gastric tube may also be inserted through the gastric lumen of the King-LT airway. 4. Lubricate distal 3 to 6 inches of the tube (preferably with Lidocaine jelly) and select the most widely patent nostril. 5. Support the back of the patient’s head and gently advance tube straight back along the floor of the nasal cavity (in an anterior-to-posterior direction, not cephalad). If resistance is felt, rotate tube slightly to help advance it into position. 6. As tube reaches the posterior nasopharynx the patient is likely to gag. At this point, if the patient is able to do so, and it is not contraindicated, have the patient swallow a small amount of water. 7. Continue to insert the tube past the glottic opening into the esophagus. Continue to insert the tube into the nose until the pre-measured mark reaches the front edge of the nostril. 8. After reaching the predetermined mark confirm that the tube has not curled up into the oropharynx or pharynx. While listening over the epigastrium, inject 20-30 mL of air into the tube and listen for “gurgling” to indicate proper placement. Aspirate and observe for gastric contents (may not always be present). 9. If no sounds are heard over the epigastrium, and you notice fogging or misting in the tube, or patient cannot cough or speak, immediately withdraw the tube and oxygenate the patient. 10. If tube placement has been confirmed, securely tape the proximal end where it enters the nostril to the bridge of the nose. 11. After tube is firmly secured, connect the proximal end to suction device and suction as needed.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 26 Hemostatic Agent – Combat Gauze
Clinical Indications: Legend • Serious hemorrhage that can not be controlled by other means B EMT - B B and in areas where a tourniquet cannot be applied such as the groin, axilla, neck, or clavicle area. I EMT- I I P EMT- P P Contraindications: • Wounds involving open thoracic or abdominal cavities Procedure: 1. Expose the injury. 2. If possible, remove excess blood from the wound while preserving any clots that may have formed. 3. Locate the source of the most active bleeding. 4. Remove Combat Gauze from packaging and pack it tightly into the wound directly over the site of the most active bleeding. 5. More than one gauze may be required to control the hemorrhage. 6. Combat Gauze may be re-packed or adjusted in the wound to ensure proper placement. 7. Apply direct pressure quickly with enough force to stop the bleeding. 8. Hold direct pressure for 3 minutes. 9. Reassess for bleeding control. 10. Combat Gauze may be repacked as necessary to stop any continued bleeding. 11. Leave the gauze in place. 12. Secure in place with a pressure dressing. 13. Transport.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 27 i-gel O2 Airway Device (BIAD) B EMT - B B Clinical Indications: I EMT- I I • Cardiac arrest after assuring continuous compressions, defibrillation and BLS airway management has been P EMT- P P completed • Non-cardiac arrest patient without a gag reflex. (PARAMEDIC and INTERMEDIATE ONLY) • Intubation is difficult/impossible due to patient access or airway anatomy (PARAMEDIC ONLY) Contraindications: • Patients who are conscious or who have an intact gag reflex • Patients under/over weight for tube size used • Patients with known esophageal disease (varices, alcoholism, cirrhosis etc.) or ingestion of caustic substances • Deforming facial trauma that prevents proper seating of the airway Size selection:
• Select appropriate size i-gel O2 by assessing on the patients anatomy/weight.
Pre-use checks: 1. Inspect the packaging and ensure it is not damaged prior to opening. 2. Inspect the device carefully, check that the airway is patent and confirm there are no foreign bodies or a bolus of lubricant obstructing the distal opening of the airway or gastric channel. 3. Carefully inspect inside the bowl of the device ensuring surfaces are smooth and intact and also that the gastric channel is patent. 4. Discard the device if the airway tube or the body of the device looks abnormal or deformed.
Pre-insertion preparation: 1. Use appropriate PPE.
2. Open the i-gel 02 package, and on a flat surface remove the inner tray containing the airway support strap and sachet of lubricant and place to one side (Figure 1). 3. In the final minute of pre-oxygenation, remove the i-gel o2 open the sachet of supplied lubricant and place a small bolus of the lubricant on the base of the inner side of the main shell of the packaging (Figure 2).\ 4. Grasp the i-gel O2 along the integral bite block and lubricate the back sides and front of the cuff with a thin layer of lubricant. This process may be repeated if lubrication is not adequate, but after lubrication has been completed. Check that no BOLUS of lubricant remains in the bowl of the cuff or elsewhere on the device. Avoid touching the cuff of the device with your hands. (Figures 3, 4, and 5).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 3 CP – 28 i-gel O2 Airway Device (BIAD)
5. Ensure the supplementary oxygen port is firmly dosed with the integral cap until it is required for use. 6. Place the i-gel back into the main shell of the packaging in preparation for insertion. (Figure 6). Recommended insertion technique: WARNING: REMOVE DENTURES OR REMOVABLE PLATES FROM THE MOUTH BEFORE ATTEMPTING INSERTION OF THE DEVICE. DO NOT APPLY EXCESIVE FORCE DURING INSERTION. IT IS NOT NECESSARY TO INSERT FINGERS OR THUMBS INTO THE PATIENT'S MOUTH DURING THE PROCESS OF INSERTING THE DEVICE. 1. Grasp the lubricated i-gel 02 firmly along the integral bite block. Position the device so that the i-gel O2 cuff outlet is facing towards the chin of the patient ( Figure 7). 2. The patient should be in the 'sniffing the morning air' position (Figure 7) with head extended and neck flexed. The chin should be gently pressed down by an assistant before proceeding to insert the i-gel O2 . 3. Introduce the leading soft tip into the mouth of the patient in a direction towards the hard palate. 4. Glide the device downwards and backwards along the hard palate with a continuous but gentle push until a definitive resistance is felt. 5. At this point the tip of the airway should be located into the upper esophageal opening (Figure 8a) and the cuff should be located against the laryngeal framework (Figure 8b). The incisors should be resting on the integral bite-block (Figure 8c) 6. i-gel 02 should be taped down from maxilla to maxilla AND secured with the airway support strap provided (Figures 9,10,11 and 12). 7. Apply CO2 detection device (or capnography if available). 8. Confirm proper position by auscultation, chest movement and verification of CO2 by capnography/ capnometry after 6 breaths. 9. Once proper position in confirmed by auscultation and/or chest rise; the provider must continue to stabilize the i-gel with their free hand. (Figure 13). 10. Providers may use backboards to assist in patient movement as needed.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 3 CP – 28 i-gel O2 Airway Device (BIAD)
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 3 of 3 CP – 28 Intramuscular Injections Clinical Indications: I EMT- I I • When the rate of absorption needs to be slower and/or P EMT- P P prolonged in action • When other administration routes are unsuccessful, unavailable or indicated by protocol Contraindications: • None Notes/Precautions: • Appropriate equipment • Needles size and length 5/8 to 1 inch for deltoid, 1 to1.5 inch for larger muscles 25 gauge for aqueous medications, 21 gauge for oily or thicker medications • 3 or 5 ml syringe • Chlorohexadine wipe and Band-aids • Appropriate injection sites Posterior deltoid for injections of 1 mL or less in adults Vastus Lateralis for injections of 2 mL or less in children and adults Ventrogluteal site for injections of 2 to 5 mL in adults or 2 mL or less in children Procedure: 1. Prepare equipment. 2. Check label, date, and appearance of medication. 3. Five “R’s” : Right patient / Right drug / Right dose / Right route / Right time. 4. Locate appropriate injection site. 5. Deltoid: • Identify the bony portion of the shoulder where the clavicle and scapula meet [the acromioclavicular joint (AC)] • Measure 3 to 4 fingers-width down the arm from AC joint • Slide one to two fingers-width posteriorly on the arm 6. Vastus lateralis sites: • Located on the anterior and lateral aspects of the thigh • Divide the area into thirds between the greater trochanter of the femur and the lateral femoral condyle • Injection is given into the middle third 7. Ventrogluteal site: • Place heel of palm on patient’s greater trochanter of the femur • Place index finger on the anterior superior iliac spine and spread other fingers posteriorly • Injection is given in the V formed between the index finger and the second finger ---A diagram of approved injection sites can be found on the following page--- 8. Using a circular motion from selected site outward, cleanse site with Chlorohexadine. 9. With one hand, stretch or flatten the skin overlying the selected site. This will allow for smoother entry of the needle. 10. In the other hand, hold syringe like a dart and quickly thrust the needle into the tissue and muscle at a 90-degree angle. 11. Slowly inject medication. 12. After all medication is injected. 13. Quickly withdraw syringe and dispose of in an approved container. 14. Gently massage over the injection site to increase absorption and medication distribution. 15. Apply firm pressure and place band-aid over site.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 Page 1 of 2 CP – 29 Intramuscular Injections Injection Sites
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 Page 2 of 2 CP – 29 Insulin Pump Legend Clinical Indications System S S • Patient that is hypoglycemic with altered mentation and an Responders insulin pump in place B EMT - B B Contraindications I EMT- I I • None P EMT- P P Notes/Precautions: • Care is directed at treating hypoglycemia first, then stopping administration of insulin Procedure 1. Refer to appropriate PPE procedure. 2. Turn off insulin pump, if possible. 3. If no one familiar with the device is available to assist, disconnect pump from patient by: • Using quick-release where tubing enters dressing on patient’s skin -or- • Completely removing the dressing, thereby removing the subcutaneous needle and catheter from under patient’s skin 4. Transport patient to hospital. 5. If patient is refusing transport against medical advice (AMA): • Encourage the patient to eat, • Ensure the patient is with a competent person to observe the patient and assure they eat, • Instruct them to follow-up with their physician • Instruct them to call back if symptoms return.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 30 Intraosseous Infusion - EZ - IO I EMT- I I Clinical Indications: P EMT- P P • As the initial means of circulatory access in cardiac arrest • Patient where rapid vascular access is unavailable by other means in the following conditions: o Multisystem trauma with severe hypovolemia o Severe dehydration with vascular collapse and/or loss of consciousness o Respiratory failure or respiratory arrest o After 2 unsuccessful attempts & patient is unstable (PARAMEDIC Only) Contraindications: • Fracture proximal to proposed intraosseous site • History of Osteogenesis Imperfecta • Current or recent infection at proposed Intraosseous site • Previous Intraosseous insertion or joint replacement at or above the selected site Procedure: 1. Prepare EZ-IO assuring that complete needle set with trochar and needle is present. . Examine needle set to insure that seal is intact and needle is sterile, unused 2. Landmark for insertion as follows: . Humeral head: Place the patient palm on the umbilicus with the elbow on the ground or stretcher. Use your thumb to identify the humeral shaft. Slide thumb towards humeral head with firm pressure. Locate the tubercle by the prominent bulge. Use the opposite hand to pinch anterior and posterior humerus to assure midline position on the humerous . Proximal Tibia: Identify anteromedial aspect of the proximal tibia palpated just below the inferior border of the patella. Insertion site is 1-2 cm (2 finger breadths) below this on the flat surface of the tibia . Distal Tibia: (reserved for > 12 years of age) Identify the anteriormedial aspect of the distal tibia (2 cm proximal to the medial malleolus) . Distal Femur: Identify the patella. Insertion site is 1-2 cm (2 finger breadths) proximal to the patella. 3. Prep the selected insertion site with Betadine. 4. Hold the Intraosseous needle at 60-90 degree angle aimed away from the nearest joint. Power the driver until a “pop” or “give” is felt indicating a loss of resistance. Do not advance the needle further. 5. Remove the stylette and place in approved sharps container. 6. Attach a syringe filled with at least 5 mL of NS and aspirate to confirm placement. Inject 5 mL of NS to clear the needle while observing for infiltration. 7. Attach IV tubing and adjust flow rate as desired. A pressure bag may be used to enhance flow where appropriate. 8. Stabilize and secure the needle. 9. If the patient experiences pain with infusion or medication administration lidocaine may be instilled in the IO catheter line. Discontinue fluid/medication administration prior to administering lidocaine and wait 15 seconds prior to restarting. Lidocaine dosing as follows may be repeated once if pain persists: . Adult: 40 mg (2 mL of 2% solution) . Pediatric: 0.5mg/kg (0.025mL/Kg of 2% solution) 10. When administering medications via the IO route delivery should be followed with a 10mL flush of NS. 11. Document the procedure, time and result on the patient care report and apply wrist band.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 31 Kendrick Traction Device Legend Clinical Indications: System S S • Open or closed mid-shaft femur fracture Responders B B Contraindications: EMT - B I EMT- I I • Injuries immediately proximal, or involving the knee joint • Injury to the pelvis P EMT- P P • Partial amputation • Lower leg or ankle injuries • If use would delay transport of a patient with a life-threatening condition Notes/Precautions: • Isolated proximal femur fractures in the elderly are usually best managed with anatomical splinting utilizing a scoop stretcher. Traction splints are not appropriate for proximal femur fractures Procedure: 1. Patient should be supine. 2. Check distal circulation, sensation, and motion. 3. Apply the ankle hitch tightly, slightly above the ankle bone. 4. Tighten stirrup by pulling the GREEN tabbed strap until the hitch fits snugly under the heel. 5. Apply upper thigh system by sliding male buckle under the leg at the patella, and using a “see-saw” motion, slide the strap upward until positioned in the groin. 6. Engage the buckle and cinch the strap until the traction pole receptacle is positioned at the belt-line or pelvic crest. Assure that genitalia is clear of strap. 7. Snap out traction pole making sure that each joint of the pole is securely seated. 8. Place traction pole alongside the leg so that one section (8”) extends beyond the bottom of the foot. 9. Adjust pole length as required (i.e., pediatric vs. adult). Insert pole end, or ends, into the traction pole receptacle. 10. Secure elastic strap around knee. 11. Place YELLOW tab over pointed (dart) end of traction pole and apply traction by pulling RED tab. 12. Patient comfort will be the primary objective. Traction should be applied smoothly by grasping the strap on each side of the buckle and simultaneously feeding and pulling with equal pressure. 13. Finish packaging by applying upper (thigh) and lower (ankle) elastic straps. 14. Reassess distal circulation, sensation, and motion. 15. Secure to long spine board, scoop, etc.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 32 LUCAS Legend Clinical Indications: System S S • Adult patient in cardiac arrest Responders B EMT - B B Contraindications: I EMT- I I • Device does not fit patients P EMT- P P Notes/Precautions: • Must perform 4 minutes of chest compressions while minimizing pauses prior to Lucas compressions. • Should not interrupt chest compressions to place device. • Must be appropriately trained • Should follow CPR Procedure protocol (CPR) Procedure: 1. Remove from bag. 2. Pause chest compressions at 2 minute pause (Pit-crew model). 3. Place back plate under patient on backboard below armpits. Shall take less than 10 seconds. 4. Perform 2 minutes of chest compressions. 5. During step 4, a team member should make sure Lucas is operational. 6. Attach LUCAS device to back plate. 7. Position suction cup. • Lower edge immediately above end of sternum • Pressure pad centered over middle of sternum • Lower suction cup & pressure pad to the point where it just comes into contact with the patient’s chest 8. If pad does not fit, return to manual chest compressions immediately. 9. Push play button. 10. Check device for proper position. 11. Attach stabilization straps. 12. LUCAS device should never be left unattended or with an untrained provider. 13. To stop LUCAS, press pause. • Should only be done: • If device improperly placed • If injury to the patient is occurring • to check for pulse
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 33 Manual Defibrillation P EMT-P P Clinical Indications: • Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia Contraindications: • None Procedure: 1. Ensure that chest compressions are adequate and interrupted only at two minute pause (Pit-crew model). 2. Apply hands-free defibrillation pads on the patient’s chest per the manufacturers instructions. 3. Clinically confirm the patients condition is consistent with the rhythm and the need for defibrillation exists. This is a SHOCK/NO SHOCK interpretation ONLY. 4. Select energy level to be delivered per protocol and charge defibrillator to the desired energy level. (this may be performed 15 seconds in advance of an anticipated break in CPR). Assure chest compressions continue while the device is charging. 5. Discontinue compressions, assertively state, “CLEAR” and visualize from the patients head to toe to assure no one is touching the patient. 6. Deliver shock by depressing shock button. 7. Immediately resume chest compressions. After 2 minutes of continuous CPR, pause briefly (< 10 sec) to perform pulse check and analyze rhythm. 8. Repeat the procedure every two minutes as indicated by the patient’s response and rhythm.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 34 Nasal Drug Delivery Device
I EMT- I I Clinical Indications: P EMT- P P • Patients requiring rapid medication administration in accordance with protocol and other route(s) of administration are not immediately available • Medications currently System approved for this route: o Midazolam (Versed) various, see individual Protocol for application (Adult and Pedi) o Fentanyl (Sublimaze) for Pain/Anxiety management (Adult and Pedi) o Naloxone (Narcan) for opiate overdoses (Adult and Pedi) Procedure: 1. Airborne PPE (N95 and eye protection) should be worn when administering medication via this route. 2. Dose appropriate medications should be drawn up unto Syringe. 3. Attach MAD 300 device to syringe. 4. Administer medications by aerosolizing medication in patient nostril (limit of 1.0 mL per nostril). 5. Due to fluid contamination dispose of in an approved sharps container.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 35 Nebulized Medication
B EMT - B B Clinical Indications: I EMT- I I • Patients requiring medication administration via nebulized P EMT- P P route in accordance with the appropriate protocol Contraindications: • Hypersensitivity to medication • Medications not approved for nebulized delivery Procedure: 1. Ensure all required pieces are available. • T-piece • 6” tubes X 2 • Mouthpiece and/or face mask • Medication chamber • Oxygen tubing 2. Assemble nebulizer. 3. Attach larger female port of T-piece firmly to male adapter on medication chamber. 4. If face mask is being used, the female fitting on the bottom of the mask is connected directly to the male adapter on the medication chamber. 5. Attach 6” tubes to each of the male ports on the T-piece. 6. Firmly attach threaded portion of mouthpiece to either 6” tube. 7. If patient is intubated, attach 90-degree endotracheal tube adapter to endotracheal tube and other end to the 6” tube. 8. Attach oxygen supply tubing to oxygen port located on bottom of medication chamber. 9. Unscrew top of medication chamber, add total amount of medication to be nebulized, and replace top. 10. Set oxygen flow rate based on equipment specifications. 11. Ensure that medication is flowing prior to giving mouthpiece to patient or placing face mask on patient. 12. Place mouthpiece in patient’s mouth or position face mask on patient, instructing him/her to inhale as deeply as possible and hold as long as possible prior to exhaling. 13. If patient is intubated. • Attach non-rebreathing patient valve of bag-valve-mask to free 6” tube • Ensure suctioning port on 90-degree adapter is closed • Begin ventilating patient 14. Nebulized medications may be used with CPAP device. Refer to CPAP device instructions for appropriate assembly and administration. 15. Treatment should be provided until medication is depleted. 16. Monitor patient for medication effects including reassessment of vital signs and breath sounds. 17. Document the medication administration including dose and time as well as any observed patient response in the patient care record.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 36 Needle Cricothyrotomy
P EMT-P P Indications: • Patients <10 years of age • With obstructed airway or in whom all conventional methods of oxygenation have failed Contraindications: • Anytime a less invasive maneuver would allow oxygenation of the patient • Tracheal transection Notes/Precautions: • Cricothyroid membrane is located by: • Palpating the protuberant midline portion of the thyroid cartilage (“Adams apple”) • Move the fingertip inferiorly until it rests in the soft, flat depression between the thyroid cartilage and the cricoid cartilage • In order to minimize the risk of dislodgement: • The individual completing the procedure should direct any/all patient movement • BVM is to be disconnected from the ET tube adapter any patient movement • The catheter is to be reassessed following any patient movement • Appropriate size angiocath is generally 14-18 gauge, depending on size of the child Procedure: 1. Position patient supine with head slightly extended unless contraindicated due to suspected cervical spine injury. 2. Prepare anterior surface of the neck with Chlorohexadine. 3. Locate the cricothyroid membrane. 4. Place thumb and index finger of non-dominant hand on either side of the tracheal cartilage to stabilize the trachea and anchor and stretch the skin slightly. 5. Connect appropriate sized angiocath to a 12 cc syringe. 6. Pierce the skin and cricothyroid membrane at a 45-degree angle, directing the catheter tip inferiorly while pulling suction on the syringe until air is aspirated freely. 7. Advance the catheter to the skin and withdraw needle. 8. Connect catheter to 3.0 mm pediatric ET tube adapter. 9. With a BVM attached to 100% oxygen begin ventilating and confirm proper placement. 10. With hub of catheter snug against the neck, tape catheter firmly in place. • Catheter and ET tube adapter are to be secured at all times by hand • Catheter should secured with tape and benzoin to prevent slipping 11. Apply an appropriately sized cervical collar immediately following successful placement and securing of the catheter. If a C-collar will not fit, manual inline stabilization should be utilized and blankets, towels and tape should be used appropriately to restrict cervical spinal motion. 12. Transported patients should be secured to a backboard unless the patient is awake and will not tolerate a supine position.
VERSION 10012017 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 10-01-2017 PAGE 1 of 1 CP – 37 Orotracheal Intubation
Clinical Indications: Legend System S S • Inability to adequately ventilate a patient with a Bag Valve Responders Mask or prolonged EMS transport requires a more advanced B EMT - B B airway • An unconscious patient without a gag reflex who is apneic or I EMT- I I is demonstrating inadequate respiratory effort P EMT- P P • Risk to benefit ratio of oral tracheal intubation to BIAD insertion favors oral tracheal intubation • Inability to adequately oxygenate/ventilate a patient after attempted BIAD insertion • Patient suspected having suffered inhalation injuries with impending airway compromise Contraindications: • None in the presence of the need for definitive airway management Procedure: 1. Prepare, position and oxygenate the patient using appropriate BLS maneuvers and 100% oxygen. 2. Select proper ET tube size and have all equipment ready(including suction). 3. Using laryngoscope visualize vocal cords using cricoid pressure/BURP maneuver as needed. 4. Limit each intubation attempt to less than 30 seconds. Utilize BVM between attempts. 5. If unable to visualize the cords change patient position, or blade size/type. If able to visualize the vocal cords but unable to advance tube consider using smaller tube or using additional lubricant. 6. Visualize tube passing through vocal cords. Remove stylet where used and inflate ETT cuff with 3-10 mL of air. 7. Auscultate for absence of breath sounds over epigastrum and presence of bilateral breath sounds. If unilateral or unequal breath sounds adjust tube position and/or consider causes for this finding. If unsure of placement at any time remove the ETT and resume ventilations with BVM. 8. Apply ETCO2 monitor. After 3 ventilations ETCO2 should be > 10 or comparable to pre- intubation values. If < 10 check for adequate circulation, equipment failure and ventilatory rate. If no cause can be found remove the ETT and resume BVM ventilation. 9. Record initial, ongoing and final ETCO2 values in the PCR. 10. Secure the ETT using commercial device whenever possible. 11. Document ETT size, depth of insertion, time of successful intubation and number of attempts. Document confirmation of the ETT by presence of breath sounds, absence of sounds over the epigastrum, end tidal CO2 and/or capnography and any/all additional methods of confirmation. Reconfirm correct placement after each patient movement. 12. Consider gastric distention and place an NG/OG tube after airway is secured with ETT. 13. Complete airway verification form on arrival at destination.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 38 Orthostatic Blood Pressure Measurement Legend Clinical Indications: System S S • Patient situations with suspected blood, fluid loss, or dehydration Responders with no indication for spinal immobilization B EMT - B B • Patients ≥ 8 years of age, or patients larger than the Broselow- I EMT- I I Luten tape P EMT-P P 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 20 mmHg or pulse increases more than 20 beats per minute or the patient develops symptoms such as lightheadedness, weakness or presyncopal symptoms the patient is considered to be orthostatic. 6. If no symptoms or significant change in vital signs have the patient stand. Repeat steps #4 and #5 above. 7. If a patient is symptomatic while sitting, lying or is obviously dehydrated based on history or physical exam, formal orthostatic examination should be omitted and fluid resuscitation initiated.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 39 Pediatric Immobilization Board (Pedi-Board) Legend Clinical Indications: System S S • Pediatric patients requiring immobilization where a Long Spine Responders Board (LSB) is not appropriate or to large. B EMT - B B I EMT- I I • Infants to children approximately 75 pounds. P EMT-P P
Procedure: 1. Position the board next to the victim 2. Open the harness system 3. Align the child’s shoulders (under all circumstances) with the stitching of the shoulder straps 4. Proper shoulder alignment is essential to provide “vertical” and “horizontal” immobilization of the child’s spine. 5. After the patient has been properly positioned on the board, place the chest strap and secure. 6. Position and secure the shoulder straps based on anatomical considerations and the condition of the child’s chest. *Avoid over tightening the shoulder or chest straps since they could restrict chest expansion. 7. Hold the head harness by the hook and loop fasteners at the bottom. 8. Position the center of the foam rubber section against the top of the victims head while Its bottom rests on the surface of the board. 9. While applying counter pressure to one side of the head, gently press the opposite side of the foam section against the patient’s head and secure the hook and loop flap to the underside of the board. Repeat the procedure on the other side. 10. Firmly adjust the forehead strap while applying counter pressure to the left side of the patient’s head by using an arching motion over the child’s eyebrows so the head does not move. When properly positioned, the forehead strap should connect to both outer sides of the head harness at the same angle. 11. Adjust the chin strap snugly, allowing the mouth to open if necessary. 12. Adjust the abdominal or lower torso strap. The size of the child will determine. 13. Adjust arm straps (if necessary) 14. Adjust leg straps. A small child or infant may not require the use of these straps.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 40 Pelvic Binder (SAM Sling®) Legend System S S Clinical Indications: Responders B B • Potential unstable pelvic fracture EMT - B I EMT- I I Contraindications: P EMT- P P • Provided the patient is of appropriate size for the size of SAM Sling® available, there are no contraindications for it’s use in the presence of appropriate assessment findings Notes/Precautions: • Anytime application of the SAM Sling® is a consideration, application of the Spinal Restriction Algorithm should be considered as well • The SAM Sling® is a force-controlled device that won’t allow the belt to be over tightened • “Autostop” buckle has spring-loaded prongs that lock the buckle in place when the right amount of force is applied • Except for two small metal springs in the buckle, the SAM Sling® is transparent to X- rays • Once properly applied, the Sling is to be removed only under the supervision of a physician • If necessary to remove the Sling • Do not cut to remove • Release orange pull handle in order to remove Procedure: 1. Unfold Sling with white surface facing up. 2. Place white side of Sling beneath patient at level of buttocks along a line drawn between greater trochanters and the symphysis pubis. 3. Firmly close Sling by placing black Velcro side of flap down on blue surface of Sling. 4. Fold back material as needed. 5. Try to place buckle close to midline. 6. Grab orange handle on outer surface of flap and release from flap by pulling upward. 7. With or without assistance pull both orange handles in opposite directions to tighten Sling. 8. Keep pulling until the buckle “clicks” and the free handle stops. 9. Maintain tension and firmly press orange handle against the blue surface of the Sling.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 41 Restraints
Legend Clinical Indications: System S S • Any patient who may harm himself, or others may be gently Responders restrained to prevent injury to the patient or crew. Physical or B EMT - B B chemical restraint must be humane and used only as a last I EMT- I I resort. Other means to prevent injury to the patient or crew must be attempted first. These efforts could include reality P EMT- P P orientation, distraction techniques, or other less restrictive therapeutic means 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 placed on top of the patient. The patient will never be restrained in the prone position. 5. The restrained patient must be under constant observation by a credentialed provider 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 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. If the above actions are unsuccessful, or if the patient is resisting the restraints, chemical restraint should be utilized in accordance with the Behavioral Protocol. (Chemical restraint may be considered earlier.). 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 or be immediately available.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 42 Pleural Decompression P EMT-P P Clinical Indications: • Patients with suspected tension pneumothorax as evidenced by: • Hypotension (SBP<90), clinical signs of shock and at least one of the following: o Jugular vein distention o Absent or decreased breath sounds on the affected side o Hyper-resonance to percussion on the affected side o Increased resistance when ventilating a patient o Tracheal deviation away from the side of injury (a late sign) • Patient in traumatic arrest with chest or abdominal trauma in whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above Contraindications: • Bilateral decompression should not be performed without positive pressure ventilations Procedure: 1. Administer high flow oxygen. 2. Prepare equipment and don appropriate PPE. 3. Identify and prep the site: . Locate the second intercostal space in the midclavicular line (preferred) . As a last resort lateral placement at the fourth intercostal space in the mid- axillary line may be used. 4. Prepare the site with Chlorohexadine. 5. Insert the appropriate catheter perpendicular to the chest wall over the top of the inferior rib. 6. Advance the needle-catheter assembly through the parietal pleura until a “pop” is felt and air or blood exits the catheter. Advance only the catheter until the hub is in contact with the chest wall. 7. Remove the needle leaving the plastic catheter in place. 8. Secure the catheter hub to the chest wall. 9. Consider placing one-way valve or creating a flutter valve from the finger of an exam glove. This should not delay the pleural decompression procedure.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 43 Patient Assessment and Documentation Clinical Indications: Legend System • S S Any patient Responders Definitions: B EMT - B B • Pain is an unpleasant sensory and emotional experience I EMT- I I associated with actual or potential tissue damage. P EMT- P P • Pain is subjective (whatever the patient says it is) Procedure: 1. Initial and ongoing assessment of pain intensity and character is accomplished through the patients self report. 2. Pain should be assessed and documented in the PCR during initial assessment, before starting pain control treatment, with each set of vitals after a pharmaceutical pain management intervention, and with vital signs until transfer of care. 3. Three pain scales are available: the 0 – 10 Scale, 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. . 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).
Categories Scoring 0 1 2 Face No particular expression or Occasional grimace or Frequent to constant smile frown, withdrawn, quivering chin, clenched disinterested jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity Lying quietly, normal Squirming, shifting back Arched, rigid or jerking position moves easily and forth, tense Cry No cry, (awake or asleep) Moans or whimpers; Crying steadily, screams or occasional complaint sobs, frequent complaints Consolability Content and relaxed Reassured by occasional Difficulty to console comfort touching hugging or being talked to, distractible
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 44 Pressure Infusion Bag
I EMT- I I Clinical Indications: P EMT- P P • Inadequate gravity flow of IV fluid Contraindications: • Controlled drip rates required for fluid or medication administration • IV/IO where patency of line is in question Procedure: 1. Purge the air from the IV bag. 2. Spike the bag as usual. 3. Invert the bag and squeeze to expel all of the air from the IV bag, drip chamber, and tubing. 4. Establish IO/IV and assure patency. 5. Place IV bag into the net pocket of the pressure infusion bag and inflate infusion bag until the desired amount of pressure has been applied. 6. Once patient has been delivered to receiving facility, deflate infusion bag and remove the IV fluid bag. 7. If the bag is grossly contaminated, dispose of it. 8. If the bag is not grossly contaminated, decontaminate it in the same fashion as a blood pressure cuff.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 45 Pulse Oximetry Legend Clinical Indications: System S S • As an adjunct to patient assessment Responders • Any patient who receives a narcotic, sedative, or paralytic B EMT - B B medication I EMT- I I • Before, during, and after advanced airway, CPAP or other airway intervention P EMT- P P Contraindications: • None Notes/Precautions: Specific circumstances that may result in inaccurate pulse oximetry readings: • States of decreased peripheral perfusion (hypotension, hypothermia) • Carbon monoxide poisoning, methemoglobinemia, cyanide poisoning • Excessive ambient light (sunlight, florescent lights) on the pulse oximeter probe Procedure: 1. Apply probe to finger or other site as recommended by the device manufacturer. 2. Allow device to register initial saturation level and record the time and result on the patient care report. Initial readings should be on room air when possible and patient condition allows. 3. Correlate patient pulse with oximeter pulse and waveform. 4. Monitor critical patients continuously throughout pre-hospital care. 5. In general a “normal” pulse oximetry reading is 97-100%. 6. Remember to treat the patient not the pulse oximeter reading. The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 46 Respiratory Precautions Legend Clinical Indications: System S S In cases where infectious agents transmitted by an airborne route are Responders prevalent in the community or have reached pandemic status a provider B EMT - B B pre-alert system may be implemented in the communications center. In I EMT- I I these cases providers will be advised of the potential need for increased precautions at the time of dispatch. P EMT-P P In the absence of pre-arrival notification respiratory protection should be considered when confronted by any patient presenting with an acute febrile respiratory illness, which may include fever plus one or more of the following: • nasal congestion/ rhinorrhea, • sore throat • or cough Contraindications: Not Applicable Notes/Precautions: • EMS providers should be aware of the signs and symptoms of infectious respiratory diseases and the procedures necessary for protecting themselves. Not all respiratory infections are transmitted in the same way. Transmission can occur from direct or indirect contact, large droplets, or small droplet nuclei. The mode of transmission will depend on the etiological agent. Providers must be familiar with PPE application (donning) and removal (doffing) procedures.
• Certain procedures can also impact transmission of infectious agents by producing aerosols. These are deemed "high risk respiratory procedures" and include intubation, extubation, deep tracheal suctioning, and nebulized respiratory treatments. Fitted N95 mask is recommended for any “high risk respiratory procedures” in the setting of suspected acute febrile respiratory illness.
• More often in the field of emergency medicine, the etiologic agents of infections are unknown. Procedure: Droplet Precautions: Droplet precautions should be employed for patients with febrile respiratory illness as defined above. (Examples include influenza, meningitis and pertussis as well as common respiratory viruses such as adenovirus and rhinovirus). 1. Utilize the incident information provided by Communications that alerts providers to a possibly symptomatic patient.(when applicable). 2. Provide surgical masks to all patients with symptoms of a respiratory illness who can tolerate its placement. 3. For patients who cannot wear a surgical mask in addition to any medical treatment being provided, consider application of oxygen via non-rebreather face mask to limit dissemination of airborne particles. 4. Providers should wear a surgical mask and adhere to the Standard Precautions Procedure - the use of gown, gloves and eye protection if contact with bodily secretions or a contaminated environment is anticipated. 5. High risk respiratory procedures which include intubation, extubation, deep tracheal suctioning, and nebulized respiratory treatments, require the highest level of respiratory
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 2 CS – 47 Respiratory Precautions protection which is a fitted N95 respirator mask. Perform a "fit check" by molding the mask to the face and checking for air leaks after donning N95 respirators. 6. Continue to use droplet precautions to manage patients with respiratory symptoms until it is determined that the cause of symptoms is not an infectious agent that requires precautions beyond standard precautions. 7. Be attentive to minimizing the transfer of any potentially infectious materials acquired during patient contact to medical equipment, stretchers, and other ancillary tools so as to lessen the chances of cross contamination and infection. 8. Exercise caution in the removal of PPE to prevent inadvertent self-inoculation in the event the PPE has been contaminated with potentially infectious materials. 9. Initiate hand hygiene as soon as feasible after doffing your PPE. Airborne Precautions (All Hazard): Airborne precautions include Standard Precautions, Contact Precautions and the Droplet Precautions outlined above. Airborne precautions should be employed in cases where the infectious agent is spread via an airborne vector which forms small particles that may remain airborne for an extended period of time. (Examples include tuberculosis, measles, chicken pox, small pox and some pandemic illness). In addition Airborne Precautions may be called for in the early phases of pandemic illness when the exact mechanism of transmission is unknown. Tuberculosis should be considered when the patient exhibits the following symptoms: • A protracted cough lasting 3 weeks or longer • Cough productive of bloody sputum • Cough in conjunction with the following: • Fever/chills and • Night sweats and/or • Weight loss 1. Utilize the incident information provided by Communications that alerts providers to a possibly symptomatic patient requiring this level of protection. 2. Providers should limit the number of personnel who have initial contact with the patient by conducting the “View from the Door.” 3. Such a view can provide the necessary impression that will assist to determine the need for extensive medical intervention requiring multiple providers. 4. Should such an impression not be clearly evident, only 1 first responder, in the appropriate PPE(described above), should make patient contact and conduct the initial patient assessment. 5. Providers should don a fitted N95 mask for all patient contact and perform a "fit check" by molding the mask to the face and checking for air leaks after donning. 6. Provide surgical masks to all patients with symptoms of a respiratory illness who can tolerate its placement. 7. For patients who cannot wear a surgical mask in addition to any medical treatment being provided, consider application of oxygen via non-rebreather face mask to limit dissemination of airborne particles. 8. Continue to use airborne precautions to manage patients with respiratory symptoms until it is determined that the cause of symptoms is not an infectious agent that requires precautions beyond standard precautions.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CS – 47 Safe Injection Practices Legend Clinical Indications: System S S To ensure adherence to basic principles of infection control and aseptic Responders technique to prevent or diminish the risk of disease transmission during: B EMT - B B • Initiation of IV access I EMT- I I • Intramuscular/subcutaneous injections • Drawing of medications P EMT- P P • Preparation and delivery of parenteral medications Contraindications: Not Applicable Notes/Precautions: • The primary breaches in infection control practice that contribute to potential disease transmission include, but not limited to: reinsertion of used needles into a multiple- dose vial or solution container (e.g., saline bag) and use of a single needle/syringe to administer intravenous medication to multiple patients • Adherence to basic principles of aseptic technique includes the use of a sterile, single-use, disposable needle and syringe for each injection given and prevention of contamination of injection equipment and medication • Whenever possible, use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients Procedure: 1. Initiate the use of chlorhexidine skin preparation prior to the application of a sharp appliance including, but not limited to venous catheters, intraosseous infusion needles, lancets, and the delivery of medications or immunizations through syringes either intramuscular, dermal, or subcutaneous. 2. Use aseptic technique to avoid contamination of sterile injection equipment. 3. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient. 4. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set. 5. Use single-dose vials for parenteral medications whenever possible. 6. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. 7. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. 8. Multidose vials should be stored in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable. 9. All sharps should be properly disposed into a puncture resistant container as soon as possible.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 48 Spinal Motion Restriction Legend System S S Responders B EMT - B B Clinical Indications: • Need for spinal immobilization as determined by protocol; I EMT- I I Consider the following guidelines: P EMT- P P 1. Long spine boards (LSB) have both risks and benefits for patients. The best use of the LSB may
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VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CP – 49 Splinting Legend Clinical Indications: System S S • Immobilization of an extremity for transport, either due to Responders suspected fracture, dislocation, sprain, or injury B EMT - B B • Immobilization of an extremity for transport to secure medically I EMT- I I necessary devices such as intravenous catheters P EMT- P P 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, consider single attempt at re-alignment of the fracture prior to placement of the splint. 2. Remove all clothing and jewelry 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. In the case of suspected fracture the splint should immobilize the joint above and the joint below the injury whenever possible. 4. Do not secure the splint directly over the injury or device. 5. Place the splint and secure with 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. Document the time, type of splint, and the pre and post assessment of pulse, sensation, and motor function in the patient care report (PCR).
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Legend Clinical Indications: System S S • Standard Precautions are intended to be applied to the care Responders of all patients in all healthcare settings, regardless of the B EMT - B B suspected or confirmed presence of an infectious agent. I EMT- I I Implementation of Standard Precautions constitutes the P EMT- P P primary strategy for the prevention of healthcare- associated transmission of infectious agents among patients and healthcare personnel. Contraindications: • Not Applicable Notes/Precautions: • Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents • The application of Standard Precautions during patient care is determined by the nature of the provider-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves may be needed; during other interactions (e.g., intubation), use of gloves, gown, and face shield or mask and goggles is necessary Procedure: Wear the appropriate level of PPE based on the mode of transmission of the suspected infectious agent when the nature of the anticipated patient interaction indicates contact with blood or body fluids may occur. Where respiratory vectors are considered employ PPE in accordance with the Respiratory Precautions Procedure. Gloves 1. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur. 2. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. 3. Do not wear the same pair of gloves for the care of more than one patient. Gowns 4. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. 5. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions. 6. Remove gown and perform hand hygiene before leaving the patient’s environment. 7. Do not reuse gowns. Mouth, nose, eye protection 8. Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.
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9. During aerosol-generating procedures (e.g., suctioning of the respiratory tract, advanced airway maneuvers) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g. M. tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CP – 51 Stroke Screen Legend Clinical Indications: System S S • Assessment of patient exhibiting signs and symptoms Responders associated with stroke B EMT - B B Contraindications: I EMT- I I • Unconscious patients unable to participate in the stroke scale P EMT- P P Procedure: 1. Initiate assessment and treatment of the suspected stroke patients in accordance with the Stroke protocol. Utilize STROKE CHECKLIST whenever possible. 2. Ascertain the last time the patient was seen normal to establish the time of onset. 3. Obtain a blood glucose level according to the blood glucose procedure. 4. Perform the Cincinnati Prehospital Stroke Screen (CPPS). • Have the patient smile or show their teeth. Look for asymmetry • Assess for arm drift by asking the patient (while sitting upright or standing) to close their eyes and extend their arms, palms up and hold it for 10 seconds. Look for asymmetric pronation (palm turning towards the ground) or drift (one arm drops compared to the other) • Ask the patient to say a simple sentence such as “You can’t teach an old dog new tricks,” looking for incorrect words, slurring or inability to speak • All portions of CPPS must be completed. Any abnormality in the screening is positive for stroke 5. If onset of symptoms (as defined above) is < 24 hrs, the blood glucose reading is > 50 and < 300 and the CPSS is positive declare a STROKE ALERT and initiate transport to a designated Stroke Center. 6. Whenever possible identify a family member or historian to accompany the patient to the hospital.
Cincinnati Prehospital Stroke Screen (CPPS)
Test Finding
Normal – both sides of face move equally Facial Droop: Have the patient smile or show Abnormal – one side of the face does not teeth move as well as the other side
Normal – both arms move the same or both arms are held steady Arm Drift: Patient closes eyes and extends both Abnormal – one arm drifts downward or the arms straight out, palms up, for 10 seconds palm turns towards the ground (pronator drift*) when compared with the other
Normal – patient uses correct words with no Abnormal Speech: Have the patient say “You slurring can’t teach an old dog new tricks.” Abnormal – patient slurs words, uses the wrong words, or is unable to speak
*Pronator drift: the forearm will pronate and the arm will drift downwards.
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Stroke Screen
Van Screen:
1. Identification of emergent large vessel occlusion. 2. If positive Cincinnati Prehospital stroke screen for arm drift 3. If positive emergent transport to Comprehensive stroke center
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CP – 52 Surgical Cricothyrotomy
Clinical Indications: • Can’t intubate and can’t ventilate and • Patient over 10 years of age as indicated by the failed airway protocol Contraindications: • Anytime a less invasive maneuver would allow ventilation and oxygenation of the patient • Tracheal transection Relative Contraindication: • Fractured larynx, significant damage to the cricoid cartilage or larynx or inability to identify appropriate landmarks Notes/Precautions: • In order to minimize the risk of dislodgement: • The individual completing the procedure should direct any/all patient movement • Do not administer paralytic prior to performing procedure. Procedure: 1. Place patient supine. Be careful to not hyperextend patient’s head as this will make it difficult to locate necessary landmarks. 2. Prepare anterior surface of the neck with chlorohexidine as time allows. 3. Locate the cricothyroid membrane. . Place thumb and middle finger of non-dominant hand on either side of the hyoid bone to stabilize the trachea and anchor the skin. . On male • Using index finger locate thyroid cartilage (Adam’s Apple) and slide down to palpate cricothyroid membrane. Slide finger farther down to palpate and locate cricoid ring and back up to cricothyroid membrane. Slide finger up to inferior portion of thyroid cartilage and back down to palpate cricothyroid membrane . On female • Using index finger palpate cricoid ring and slide up to the cricothyroid membrane. Slide finger up and palpate thyroid cartilage and back down to cricothyroid membrane. 4. Leave index finger on cricothyroid membrane to prevent loss of landmark. 5. With scalpel make vertical incision in epidermis and dermis from inferior of thyroid cartilage to cricoid ring and place finger on cricothyroid membrane. Do not cut through or below cricoid ring. 6. Make a small horizontal incision through cricothyroid membrane and place finger or scalpel handle in cricothyroid membrane. 7. With index finger or scalpel handle in place, advance an Eschmann introducer (Bougie) through the incision. Bougie should advance easily until stopping at carina. Remove finger or scalpel handle (secure scalpel appropriately). 8. Advance trach tube over the bougie until the cuff is in the trachea. Inflate cuff “just enough” to fill trachea. 9. Confirm Trach placement as per intubation protocol. (Keep in mind it is possible to create a false track outside the trachea) . If unable to confirm placement, remove and reinsert trach into trachea. 10. Control bleeding as needed. 11. Secure trach tube maintaining continuous stabilization by hand. Trach tube is to be secured at all times.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 2 CP –53 Surgical Cricothyrotomy 12. Apply appropriately sized cervical collar immediately following successful placement and securing of the tube. If cervical collar will not fit, manual inline stabilization with blankets, towels, and tape should be used appropriately to restrict head movement. 13. Transported patients should be secured to an immobilization device such as scoop or backboard unless patient is awake and will not tolerate supine position.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 2 of 2 CP –53 Suctioning-Advanced I EMT- I I Clinical Indications: P EMT- P P 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 naso-tracheal tube, endotracheal tube, tracheotomy tube, or a cricothyrotomy tube Procedure: 1. Ensure suction device is in proper working order. 2. Preoxygenate the patient. 3. Attach suction catheter to suction device, keeping sterile plastic covering over catheter. 4. Using the proximal opening of the airway and the suprasternal notch and the endpoints, 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 (suction off), 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. • If Newly Born, do not exceed 100 mmHg vacuum setting. 8. Small volume (< 10 ml) of normal saline lavage may used as needed. 9. Reattach ventilation device (e.g., bag-valve mask) and ventilate the patient 10. Document time and result in the patient care report (PCR).
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 54 Taser® Probe Removal Legend Clinical Indications: System S S • Patient with uncomplicated conducted electrical weapon (Taser®) Responders probes embedded subcutaneously in non-sensitive areas of skin B EMT - B B Contraindications: I EMT- I I P • Patients with conducted electrical weapon (Taser®) probe EMT-P P penetration in vulnerable areas of body as mentioned below should be transported for further evaluation and probe removal o Probes embedded in skin above level of clavicles, genitalia or female breasts o 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-dominate hand. 3. Grasp probe by metal body using dominate hand. 4. Remove probe in single quick motion. 5. Wipe wound with chlorohexadine wipe and apply dressing. 6. Treat probes as exposed sharps hazard and dispose of accordingly. • Law Enforcement may need to keep as evidence
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 55 Tourniquet Legend Clinical Indications: System S S • Life threatening extremity hemorrhage that can not be controlled Responders by other means B EMT - B B • Serious or life threatening extremity hemorrhage where I EMT- I I conditions (patient location, tactical or hazmat environment, etc) P prevent the use of standard hemorrhage control techniques EMT- P P • Life threatening condition(s) that require immediate attention and significant extremity hemorrhage where the use of a tourniquet is more expedient than standard hemorrhage control Contraindications: • Non-extremity hemorrhage • Proximal extremity location where tourniquet application is not practical Procedure: 1. Place tourniquet proximal to wound according to manufacturer instructions. 2. Tighten until loss of distal pulses. Failure to adequately tighten the tourniquet to the loss of pulses may cause restriction of venous return and result in a compartment syndrome. 3. Secure tourniquet. Tourniquet should be easily visible on the affected limb. 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 (> 30 minutes) and in the absence of amputation or continued hypotension/shock the tourniquet may be LOOSENED to assess for bleeding. Do NOT remove the tourniquet. If bleeding continues re-tighten the tourniquet to loss of distal pulses and notify the receiving facility. If there is no ongoing bleeding leave the tourniquet in place but assure it is loosened to prevent venous occlusion.
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Autovent 3000 (parameters): • Gas driven (non-electrical) ventilator (must have 50psi source). • Not suggested on multi-system (field) trauma patients. • May be used on any patient who weighs >20kgs. • Tidal Volume should be calculated by the patients weight (kg) multiplied by 8-10cc. (i.e. 10cc X 80kg => a TV of 800cc) • Any Medical device is subject to mechanical failure – so every patient should be closely monitored for proper oxygenation and ventilation during the use of this device.
Clinical Indications: This device accurately and safely performs ventilations to both intubated and non-intubated patients. The device is to be utilized at the paramedic’s discretion but the guidelines below should be followed when utilized. The device may not be the best ventilation mode for every patient (i.e. a patient with restricted ventilations, who may require forceful ventilation, with asthma and/or burns). The paramedic must know and understand what the limits of this device are. This particular ventilator is a three setting device with Tidal Volume, Inspirations Time and Rate. It is imperative that routine maintenance, calibration and inspection are performed on this equipment. **This device may not be available on every SMHCEMS unit due to repairs and cost of this equipment. This protocol should be utilized when the device is available. Contraindications: • Patient <20kgs • No other contraindications present unless inadequate oxygenation is present. Relative Contraindications: • Patients that require forceful ventilations. • Patients with active asthma. • Patients with burns. Procedure: 1. Determine need for assisted ventilations. 2. Assure ventilator is attached to a 50psi source. 3. Set Tidal Volume (TV) to proper setting using above formula. 4. Determine which inspiration time will be utilized (child or adult) and set appropriately. 5. Set rate of ventilations. 6. Quickly test pressure alarm feature by placing you hand over the end of the standard 15 mm adapter and listening for high pitched noise. 7. Apply to the patient either by attaching directly to ET tube or by using a face mask. 8. Monitor the patient for proper ventilation:
• SpO2 • Lung sounds • Chest wall expansion • Presence of cyanosis • EtCO2
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 57 Vagus Nerve Stimulator (VNS) B EMT - B B Clinical Indications: I EMT- I I • Patients with an implanted Vagus Nerve Stimulation device P EMT- P P used in the management of seizures and a magnet for increasing stimulation or temporarily disabling the device Contraindications: • Use of magnet for any other condition other than activating the VNS device Notes/Precautions: • The patient and/or family will be familiar with the device and are usually able to manage the patient Procedure: 1. Assist the patient and/or family in using the device as they have been instructed. 2. In the absence of a known procedure the stimulation may be increased in the presence of seizure: . Pass the magnet over the vagal nerve stimulator generator for 1-2 seconds; . Repeat process in 60 seconds; . May repeat up to total of 3 times. 3. Transport patient to hospital.
VERSION 02012020 CLINICAL OPERATING GUIDELINES CLINICAL PROCEDURE UPDATED 02-01-2020 PAGE 1 of 1 CP – 58 Wound Care Legend Clinical Indications: System S S • Protection and care for open wounds prior to and during Responders transport B EMT - B B Procedure: I EMT- I I 1. Use appropriate personal protective equipment, including P EMT- P P 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. 3. Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate: • Avoid if bleeding is difficult to control • Consider analgesia per protocol prior to irrigation 4. Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to ensure the bandage is not too tight. 5. If amputation, place dismembered part in a plastic bag on ice for transport. 6. Monitor wounds and/or dressings throughout transport for bleeding. 7. Document the wound and assessment and care in the patient care report (PCR).
Eye Injury: 1. Asses visual acuity 2. Evaluate pupils and complete neuro exam 3. Consider chemical exposure a. If present irrigate immediately with NS 4. Consider Traumatic Injury a. Cover with NS soaked gauze b. DO NOT Remove impaled objects 5. Always cover both eyes to prevent further injury.
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Appendices
Table of Contents
Appendices ...... Page
Approved Abbreviations ...... A-1 Hospital Transport Guidelines ...... A-2 Infection Prevention and Exposure Management ...... A-3 Interfacility Medical Staffing Requirements ...... A-4 Provider Clinical Performance Review Process ...... A-5 Patient Transport Condition Classification System ...... A-6 Suspected Child Abuse and Reporting ...... A-7 Vital Signs Parameters ...... A-8
Approved Abbreviations
To ensure consistency in patient care reporting, the following is a list of System approved abbreviations -A- Â Before A&Ox3 or Alert & oriented to (1- A&Ox4 Person, 2-Place, 3-Time and 4-Event) AAA Abdominal aortic aneurysm Abd Abdomen AB Abortion ABC Airway, breathing, circulation ABG Arterial blood gas a.c. Before meals A/C Aircraft ACE Angiotensin-converting enzyme ACS Acute Coronary Syndrome a.d. Right ear (auris dexter) ADD Attention deficit disorder A.E. Above elbow (amputation) AED Automated external defibrillator A Fib Atrial fibrillation Af Atrial flutter AIDS Acquired immunodeficiency syndrome AIVR Accelerated Idioventricular A.K. Above knee (amputation) rhythm ALS Advanced Life Support AMI Acute myocardial infarction Ant Anterior AOS TF Arrived On Scene To Find APAP Acetaminophen (APAP) APS Adult Protective Services APGAR Appearance, Pulse, Grimace, ARDS Adult respiratory distress Activity, Respiratory effort syndrome AS Left ear (auris sinistra) ASA Acetyl salicylic acid (Aspirin) ATF Arrived to find AV Atrioventricula AVA Alternate vascular access AVM Arteriovenous malformation
-B- BBB Bundle branch block BBS Bilateral breath sounds B.E. Below elbow (amputation) BGL Blood glucose level b.i.d. Twice a day B.K Below knee (amputation) BLS Basic life support BM Bowel movement BP Blood Pressure BS Breath, bowel sounds BSA Body surface area BVM Bag valve mask
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-C- C With Cº Centigrade C/C Chief complaint c/o Complains / complaining of CA Carcinoma, cancer Ca++ Calcium CABG Coronary artery bypass graft CAD Coronary artery disease CAO x 3 or Conscious, Alert, & Oriented to CAT/CT Computerized axial 4 or PPT Person, Place, Time & Events tomography scanner CBC Complete blood count Cm Centimeter CCB Calcium channel blocker CCU Coronary / critical care unit CHF Congestive heart failure CHI Closed head injury CID Cervical Immobilization Device CK Creatine kinase CK-MB Creatine kinase myocardial band CI Chlorine CNS Central nervous system COPD Chronic obstructive pulmonary CO Cardiac output / carbon disease monoxide CO2 Carbon dioxide +CMS Positive circulatory, motor & sensory function CNS Central nervous system CP Chest pain CPAP Continuous positive airway CPR Cardiopulmonary pressure resuscitation CPS Child Protective Services CRT Capillary refill time C-spine Cervical spine CSF Cerebrospinal fluid CSM Carotid sinus massage CTA Clear to auscultation CVA Cerebrovascular accident CVP Central venous pressure Cx Chest CXR Chest x-ray
-D- DCAP BTLS Deformities, Contusions, DIC Disseminating intravascular Abrasions, Penetrations, coagulation Paradoxical movements, Burns, Tenderness, Lacerations, Swelling Diff Difficulty Disch Discharge D&C Dilatation & curettage dL Deciliter (1/10 liter: 100 ml) DAE Dysbaric air embolism DKA Diabetic ketoacidosis DM Diabetes mellitus DNAR Did not attempt resuscitation
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DNR Do-not-resuscitate DOB Date of birth DOE Dyspnea on exertion DOS Dead on scene DPT Diphtheria, pertussis, tetanus DT’s Delirium tremens D5W Dextrose 5% in water D10W Dextrose 10% in water D25W Dextrose 25% in water D50 50% Dextrose DVT Deep vein thrombosis Dx Diagnosis
-E- ECG/EKG Electrocardiogram EDC Estimated date of confinement EEG Electroencephalogram EF Ejection fraction e.g. For example EPS Electrophysiological study ER/ED Emergency room/department Epi Epinephrine Est. Estimated ESRD End stage renal disease ETA Estimated time of arrival ET Endotracheal ETC02 End-tidal carbon dioxide ETOH Ethyl alcohol, alcoholic beverage ETT Endotracheal tube EXP Expansion EXT Extremity(s)
-F- F Female Fº Fahrenheit FBAO Foreign body airway FHx Family history obstruction FHR Fetal heart rate Fr French FSP Full spinal precaution FUO Fever of unknown origin Fx Fracture
-G- G (+ #) Gravida (G3, G4 etc.) GCS Glasgow coma scale/score GERD Gastroesophageal reflux GI Gastrointestinal disease Gm, g Gram Gtts Drops GU Genitourinary GYN Gynecology
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-H- h, hr Hour H/A Headache HAV Hepatitis A virus HBV Hepatitis B virus HCTZ Hydrochlorothiazide HCV Hepatitis C virus HEENT Head, eyes, ears, nose, throat H&H Hemoglobin and hematocrit Hg Mercury HIV Human immunodeficiency virus HR Heart rate HRT Hormone replacement therapy hs At bedtime HTN Hypertension Hx History
-I- ICD Implanted cardioverter ICP Intracranial pressure defibrillator ICU Intensive care unit IDDM/DM I Insulin dependent diabetes mellitus (Type I) ILS Intermediate life support IM Intramuscular IMV Intermittent mechanical Inf Inferior ventilation IO Intraosseous IPPB Intermittent positive pressure breathing IU International units IV Intravenous IVP IV push IVR Idioventricular rhythm
-J- J Joules JVD Jugular venous distention
-K- K+ Potassium KED Kendrick extrication device KTD Kendrick traction device KVO Keep vein open Kg Kilogram
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-L- L Left or Liter L spine Lumbar spine L&D Labor and delivery L/S Lung sounds Lac Laceration LAD Left axis deviation / left anterior descending Lbs Pounds LBBB Left bundle branch block LGL Lown-Ganong-Levine Liq Liquid syndrome LLQ Lower left quadrant LMA Laryngeal Mask Airway LMP Last menstrual period LOC Level/loss of consciousness Lpm Liter per minute LR Lactated Ringer’s LSB Long spine board LSD Lysergic acid diethylamide LUQ Left upper quadrant LVAD Left Ventricular Assist Device LVH Left ventricular hypertrophy
-M- m Meter M Male mA Milliamperes mg Milligram MAE Moves all extremities MAP Mean arterial pressure Mcg Microgram MCL Midclavicular line, modified chest lead MDI Metered dose inhaler mEq Milliequivalent mL Milliliter mm Millimeter MMR Measles, mumps, rubella MOI Mechanism of injury Mph Miles per hour MS Morphine Sulfate, Multiple Sclerosis MVC Motor vehicle collision MVP Mitral valve prolapse
-N- Na+ Sodium NAD No apparent / acute distress N/C Nasal cannula NES Non-English Speaking NGT Nasogastric tube NH Nursing home NICU Neurological, neonatal NIDDM/DM II Non insulin dependent intensive care unit diabetes mellitus (Type II) NKA No known allergies NKDA No known drug allergies NMB Neuromuscular blockade NOI No obvious injury
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NP Nurse Practitioner NPA Nasopharyngeal airway NPO Nothing by mouth NRB Non-rebreather mask NS Normal saline NSAID Non-steroidal anti- inflammatory drug NT Nasotracheal NTG Nitroglycerin N/V/D Nausea, vomiting, diarrhea
-O- 02 Oxygen OB Obstetrics OBS Organic brain syndrome OBV Obvious OD Overdose, right eye (oculus OLMC On-line medical consultation dexter) OOH Out of hospital OPA Oropharyngeal airway OPP Organophosphate poisoning OR Operating room OS Left eye (oculus sinister) OSS Oregon Spine Splint oz. Ounce Ø No or none OPQRST Onset, Provocation, Quality, Radiation, Severity, and Time
-P- p After p.c. After meals P (+ #) Parity (P3, P4 etc) PA Physician assistant, pulmonary artery PAI Pharmacologically assisted PASTMED Provoking incident, intubation, Pre-Arrival Associated chest pain, Instructions Sputum production, Time of onset, Meds, Exercise tolerance, Diagnosis PCI Percutaneous coronary pC02 Carbon dioxide pressure intervention PCP Phencyclidine, Primary Care PCT Patient care to Physician PE Physical exam, pulmonary PEA Pulseless electrical activity emboli, pulmonary edema PEEP Positive end expiratory PERRL Pupils equal round reactive pressure to light PICU Pediatric intensive care unit PID Pelvic inflammatory disease PMD Primary/Private medical doctor Pn Pain PND Paroxysmal nocturnal dyspnea P02 Partial pressure of oxygen PO By mouth POC Position of comfort
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post. Posterior POV Privately operated/owned vehicle p.r. Per rectum PRBC’s Packed red blood cells PRN As needed PSVT Paroxysmal supraventricular tachycardia Pt. Patient PTA/PTOA Prior to (our) arrival PTS Pediatric trauma score PVC Premature ventricular contraction PVT Polymorphic ventricular P/W/D Pink warm and dry tachycardia
-Q- Q Every Qh Every hour q.i.d. Four times a day
-R- R Right RAD Right axis deviation, reactive airway disease RBBB Right bundle branch block Rbc Red blood cell, red blood (cell) count RCA Right coronary artery RHD Rheumatic heart disease RLQ Right lower quadrant ROSC Return of spontaneous circulation +ROM Positive range of motion RN Registered nurse RR Respiratory rate RSV Respiratory syncytial virus RTS Revised trauma score RUQ Right upper quadrant Rx Prescription
-S- š Without s/s Signs / symptoms SA02 Oxygen saturation of arterial SARS Severe acute respiratory oxyhemoglobin syndrome SBP Systolic blood pressure SC, SQ Subcutaneous SCI Spinal cord injury SCUBA Self contained underwater breathing apparatus SIDS Sudden infant death syndrome SL Sublingual, Saline Lock SOAPE Subjective, Objective, SOB Shortness of breath Assessment, Plan, Enroute SROM Spontaneous Rupture of St States Membranes
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STD Sexually transmitted disease SUV Sport utility vehicle SVT Supraventricular tachycardia Sx Symptoms
-T- T spine Thoracic spine TBI Traumatic brain injury Temp Temperature tab Tablet TB Tuberculosis Tbsp Tablespoon TCP Transcutaneous pacing TCA Tricyclic antidepressant TdP Torsades de Pointes TIA Transient ischemic attack t.i.d. Three times a day TKO To keep open TOT Turned Over To Tsp Teaspoon Tx Treatment
-U- u Unit µg microgram U/A Upon arrival, urine analysis URI Upper respiratory infection UTI Urinary tract infection UTL Unable to locate UTO Unable to obtain
-V- VD Venereal disease Vol Volume VO Verbal order VF Ventricular fibrillation VS Vital signs Vt Tidal volume VT Ventricular tachycardia
-W- w/ With w/o Without, wide open WDWN Well developed, well nourished WNL Within normal limits WPW Wolf-Parkinson-White
-X- X-fer Transfer X-prt Transport
-Y- y/o Years old
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-Symbols- α Alpha ß Beta @ At ? Questionable, possible ♀ Female ♂ Male 1° First degree 2° Second degree 3° Third degree x Times Delta (change) + Positive – Negative = Equal ≠ Not equal to ≈ Approximately Decreased / below / lower Elevated / increased / upper Move/went to Between # Number
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Hays Travis Comal Bexar Guadalupe University Hospital Heart Hospital of Austin Seton Medical Center Hays Dell Seton Medical Center Seton Southwest Hospital Central Texas MedicalBaylor Center Scott & White - Buda Dell Children's Medical CenterSeton Medical Center (Main) Baylor Scott & White - Lakeway St. David's MedicalSt. David's Center South (Main) Austin Hospital Christus SantaResolute Rosa Hospital - New BraunfelsSan - New Antonio Braunfels Military MedicalGuadalupe CenterFAKE Regional TEXTFAKE Medical TEXTFAKE Center TEXTFAKE TEXTFAKE Basic Receiving Facility X X X X ≤17 X X X X X X X X X X Comprehensive/Critical Care Facility X X X ≤17 X X X X X X X X Perinatal Center X X X X X X X X X X
STEMI Alert X X X ≤17 X X X X X X X Stroke Alert* P P P ≤17 (C) C C C P P P C Trauma Alert** X ≤14 X X X
Burns ≤30% 2nd & 3rd Degree ≤14 X X ≤14 Burns >30% 2nd & 3rd Degree ≤14 X ≤14 Hyperbaric Capabilities X (8A-5P) X Sexual Assault (SANE Capabilities)*** X X ≤17 X X X X X
* For Stroke Alerts, P=Primary Receiving Facility C=Comprehensive Receiving Facility ** Please refer to Trauma - T-05 for details on Trauma Alerts and receiving facilities. *** Please call to confirm SANE availability at the receiving facility.
Standby Basic Receiving Facility - 5 Star ER - Dripping Springs may be used as a basic receiving facility only upon patient request.
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Infection Prevention Adherence to infection Prevention principles is the responsibility of each Provider. All EMS Providers must be aware of well-known infectious agents (Hepatitis B, influenza, etc.), as well as emerging new pathogens (Avian Flu, SARS, etc.) that present challenges to medicine and risks to Providers. A personal commitment to employing basic infection Prevention measures on every single incident will provide the simplest and best protection against infectious diseases. Make it a habit! Basic Protection Guidelines and Immunizations The infection "triad" requires a portal of entry, an adequate amount of the infectious agent, and a susceptible host in order for a person to actually become infected. Through the engineering of safer equipment and the use of Personal Protective Equipment (PPE), we can prevent portals of entry and reduce the amount of materials to which you may be exposed. Although it sounds simplistic and obvious, individuals that are well nourished, rested, and physically fit have immune systems that are more responsive and better prepared to mount an effective fight against invading pathogens. Taking care of ourselves decreases our long-term morbidity and allows us to recover more quickly should we become infected. In any health care environment, Providers can expect to be routinely exposed to infectious agents. Immunizations are an extremely important weapon against infection from many of the more common agents. Keeping current on appropriate immunizations protects you, protects patients from becoming infected by you, and decreases overall disease transmission (this is a concept in public health known as herd immunity). As always, you should consult with your regular physician regarding your health care and immunization status. For healthcare workers, the currently available recommended immunizations (or documented immunity) include: • Hepatitis B • Measles • Mumps • Rubella • Varicella • Tetanus • Diphtheria • Pertussis • Influenza (Pandemic & seasonal) • Hepatitis A Attention to ongoing hand washing, especially during the cold and flu season, is very important. Contact with contaminated surfaces provides a ready way for you to become infected and for you to infect others. Hands should be washed after each patient contact, the removal of gloves, and after cleaning all equipment. Waterless, alcohol-based hand cleaners are an acceptable alternative to soap and water provided there is no gross organic material present. To be effective, hand washing with soap and water needs to be performed for a minimum of twenty (20) seconds, using a vigorous rubbing together of all surfaces of lathered hands followed by thorough rinsing under a stream of water. If soap and water are not available at the scene, a waterless hand wash/wipe should be used before boarding the vehicle. Upon return to the station, all Providers should wash their hands with soap and water. Additionally, it is important to conduct a self-check of your skin (particularly hands and exposed surfaces) prior to any potential patient contact. Identify scrapes, wounds, or other non-intact
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surfaces and cover all open and scabbed wounds with bandages. The integrity of any bandages should be monitored during your shift to ensure the continuation of their protection. Personal Protective Equipment (PPE) PPE is designed to stop the transmission chain of an infectious agent by preventing potentially infectious microorganisms from contaminating a Provider's skin, mucous membrane, or clothing, and subsequently being transmitted to others. While PPE reduces the risk, it does not completely eliminate the possibility of infection, and is only effective if chosen and used correctly. Remember, PPE should always be readily available, not just carried in the vehicle for those “surprise” circumstances where the possibility of exposure exists. There are instances that the selection of appropriate PPE should be obvious and regarded by all Providers as standard practice. These include: • Anytime patient contact is made, gloves are to be worn. • During any type of airway management procedure, or other situation that fluid splash contact with the Provider’s face is a possibility, the protection of mucous membrane is crucial. Effective mucous membrane protection may be afforded by use of the combination eye shield and mask apparatus or by other approved eye wear (goggles). • Whenever the possibility exists that a patient’s bodily fluids could be splashed onto a Provider, gowns should be utilized. There are times when the selection of proper PPE, especially respiratory protection, is not so obvious and must be made based on how a disease is spread. In these situations, the difficulty in determining the appropriate level of protection is that a truly informed decision usually can’t be made until a patient assessment is completed and/or a history is obtained. By then, it’s too late! For that reason, a patient exhibiting any of the following signs or symptoms should be a signal to Providers, that in addition to gloves and, possibly a gown, some level of respiratory protection is required: • Productive cough (with or without blood) • Fever and chills with coughing • Night sweats • Dramatic (>10%) unexplained weight loss • Fatigue (in the presence of other symptoms) • Hemoptysis (coughing up blood) • Nuchal rigidity (stiff neck) • Chest and upper torso rash • When encountering any patient that is exhibiting a head ache or fever a combination eye shield and mask should be worn. • For a patient exhibiting signs and/or symptoms of a disease spread via airborne particles, a mask should be worn. • When caring for a patient with signs and symptoms of a disease spread through larger droplets, the combination eye shield and mask should be donned as soon as possible, and worn anytime the Provider is within six (6) feet of the patient. • When airborne or droplet precautions are appropriate, the additional step of placing a non-rebreather mask with supplemental oxygen on the patient should be employed. This will limit the amount of aerosolized agent emitted. • Provide surgical masks to all patients with symptoms of a respiratory illness who can tolerate its placement. Provide instructions on the proper use and disposal of masks.
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• For patients who cannot wear a surgical mask in addition to any medical treatment being provided, provide tissues and instructions on when to use them (i.e., when coughing, sneezing, or controlling nasal secretions), how and where to dispose of them, and the importance of hand hygiene after handling these materials. • Continue to use droplet precautions to manage patients with respiratory symptoms until it is determined that the cause of symptoms is not an infectious agent that requires precautions beyond standard precautions. • When in doubt, maximal rather than minimal PPE should be selected. Sharps Hazards • The greatest risk for an occupational exposure to blood occurs with the use of needles and other sharp utensils. The most common occupational blood exposure occurs when needles are recapped. Needles should never be recapped, re-sheathed, bent, broken, or separated from disposable syringes. • Used needles and other sharps shall be disposed of in approved sharps containers. • Providers should ensure that no sharp is used in a manner inconsistent with its intended purpose or attempt to circumvent the safety features of the device. • See Crime Scene Preservation (in Procedures Section) regarding used sharps at a potential crime scene. Cleaning and Disinfection of Equipment and Work Areas Remember how important it is to keep all medical equipment clean and free from infectious agents. The essential part of cleaning and disinfecting equipment is ensuring the removal of all accumulated organic material. Failure to remove organic material provides a continuing breeding ground for organisms. After the removal of the organic material, disinfecting can take place. Be thorough with your cleaning and consider using your PPE eyewear if you need to do heavy cleaning that may result in splashing. Remember to clean any surface that your gloved hand may have contacted. After applying your disinfectant, permit the equipment to air dry. Wiping dry the wet disinfected surface will negate the effects of the agent and render it useless. Upon completion of the cleaning, make sure you wash your hands. Exposure Follow-up The purpose of PPE, and always using sound infection Prevention practices, is to reduce or eliminate the potential for infection. On occasion, a Provider is exposed to blood, bodily fluids, or airborne particles, and appropriate action must be taken. Many of these actions are time- dependent so it’s important to initiate the reporting and follow up process as soon as possible. Besides adherence to sound infection Prevention practices, the most important thing you can do to ensure your health and well-being is to educate yourself. Become knowledgeable about infectious diseases, and the exposure reporting and follow-up process for your organization. Knowledge of the process specific to your organization ensures the right people are notified in a timely manner should post-exposure testing, follow-up, and documentation be required. Following are general guidelines to be followed should you experience, or suspect that you have experienced, an exposure to blood or other infectious material: • Withdraw from patient care as soon as it is appropriate. This is usually at the completion of care but may need to occur sooner in some cases. • Take self-care steps and cleanse the wound (or irrigate the membranes) with the appropriate solution immediately after any exposure to a patient’s bodily fluids. Don’t
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attempt to “milk” any needle stick injuries. This does not appear to be useful in removing source patient material. Exposures require immediate intervention. Report any suspected exposure to communicable diseases to the appropriate designated individual in your department as quickly as possible. Questions and consultation regarding post exposure actions should be immediately directed to the Infection Control Officer within SMHC EMS. Contact the Battalion Chief for assistance in contacting the Infection Control Officer. Consultation may reveal that medical evaluation of the exposure, testing, follow-up, and/or additional documentation is necessary. In the case of a blood exposure due to needle stick (or other sharps), spray to mucous membrane, or patient blood contacting non-intact skin, the Provider should immediately travel, or be transported to, the closest appropriate facility for evaluation.
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1. All SMHC EMS system field providers should ensure that all appropriate documentation accompanies the patient. Known STEMI/Stroke/Time-dependent conditions are exceptions to this rule and documentation may be faxed directly to the receiving facility. A Memorandum of Transfer (MOT) must be obtained without exception. 2. At minimum, the MOT should have a destination/location, signature of sending physician, and the name of the receiving physician. Any change in destination should be modified on the MOT by the sending facility prior to transport. 3. All SMHC EMS system field providers are responsible for ensuring that they are familiar with the specific needs required for any inter-facility transfer. If a patient is on a continuous infusion pump, ventilator, or is receiving any medication or intervention not in the system clinical guidelines, the provider should communicate directly with the attending RN or physician regarding indications, potential risks associated with stopping treatment, and potential adverse effects of the treatment. Any alternatives to safely transitioning the patient to standard medications and/or equipment as found in the system clinical guidelines should be considered and discussed with the attending RN or physician. If no alternative exists (exceptions to this include antibiotics), or the patient cannot be safely transitioned and a RN or physician from the transferring facility is unable to accompany the patient in transport, the on-duty Battalion Chief or system Medical Director should be contacted for guidance and/or assistance. 4. If transferring facility staff attend the patient transfer, both the transport crew and facility staff are responsible for management of the patient. 5. All EMS treatments must comply with the SMHCEMS System Clinical Guidelines. 6. If the patient deteriorates, the transferring facility should be notified. If additional orders are needed, every attempt should be made to contact the receiving facility/physician. If the patient status deteriorates to the extent that the patient is not able to be adequately managed through existing guidelines of receiving physician orders, the patient may be diverted to the closest appropriate facility for immediate stabilization.
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Scope All Clinical Providers credentialed to practice within the SMHC EMS System Purpose The Provider Clinical Performance Review Process provides a mechanism for the Medical Director to more fully and directly review significant clinical performance concerns in order to identify potential clinical performance improvements. This process also meets the requirements of the Texas Medical Board rules (TAC Title 22, Part 9, Chapter 197). Specifically, the Texas Medical Board requires the Medical Director to “direct an effective system audit and quality assurance program” and to “develop and implement a comprehensive mechanism for the management of patient care incidents”. Background Information At times, preliminary event review findings indicate the possibility of serious adverse actions or omissions on the part of an individual provider(s). In rare cases, such clinical concerns have the potential to result in significant action including a suspension or revocation of a Provider’s System Credentialing privileges. Although suspension of clinical credentials may occur quickly, revocation of clinical credentials will generally occur only after an OMD Clinical Performance Review. However, the Medical Director is ultimately responsible for the providers who practice under their medical license and thus always has the authority to revoke the System Credentialing privileges of any individual provider within the System without utilizing the OMD Clinical Performance Review process. Nothing in this document should be interpreted to limit the authority of the Medical Director to perform as required by Texas laws and regulations, including but not limited to the authority to suspend an individual provider from medical care duties pending review and evaluation or to revoke System Clinical Credentials. Definitions OMD Clinical Performance Review – A formalized process initiated by the Office of the Medical Director intended to review the Clinical Event Review findings and root causes associated with a significant clinical incident. Clinical Event Review/ QA Review - “Clinical Event Review”– A formalized process initiated by a System Organization or the Office of the Medical Director following the identification of a possible clinical event intended to review the circumstances, causes and remedial actions as applicable.
Indications An OMD Clinical Performance Review may be requested by the Medical Director or their designee at any time. However, such reviews are generally reserved for instances in which a Clinical Event Review/ QA Review’s findings suggest a significant clinical performance concern or a pattern of clinical performance concerns involving a provider(s). Examples of cases likely to indicate the need for an OMD Clinical Performance Review include but are not limited to: 1. A Clinical Event Review finding one of the following may have occurred a. Falsification of any clinical documentation b. Knowingly providing false information during a clinical review c. Intentionally withholding care from a patient d. Intentionally harming a patient
VERSION 02-01-2020 CLINICAL OPERATING GUIDELINES APPENDIX UPDATED 02-01-2020 PAGE 1 of 4 A – 5 Provider Clinical Performance Review Process e. Providing care while impaired by drugs or alcohol f. Failure to remediate and/or participate in a required education or clinical review 2. A clinical event in which actual harm to a patient appears to have occurred due to a provider’s actions or omissions 3. Any clinical event with a high likelihood of resulting in an extended suspension or a revocation of a provider’s System Credentialing privileges as determined by the Organization’s Clinical Event Review process or the OMD. Performance Review Team The OMD Clinical Performance Review Team consists of the EMS Medical Director and the Administrative Battalion Chief and may be expanded to include other system credentialed providers at the request of the standing members of the team. Rarely, clinical events involve performance concerns of providers from multiple System Organizations. Generally, Clinical Performance Reviews will be conducted separately for providers within each organization. However, the organizations and the Medical Director may agree to combine review group membership for such reviews. In all cases, individual Review decisions are made for each provider being reviewed regardless of the provider’s organizational affiliation. Conflict of Interest When an OMD Clinical Performance Review is requested any potential conflicts of interest that are identified will be resolved by SMHC EMS prior to the review. The simple matter of expressing a potential conflict of interest does not indicate any wrongdoing on the part of the review group members or the providers being review. It simply means the potential for bias or the perception of bias is present and identified. The provider’s organization will select review group members who do not have a potential or real conflict of interest with regard to the provider being reviewed. An objective review of the provider’s performance is the intent. Confidentiality For quality improvement efforts to be successful, providers and their organizations must be secure in the fact that open discussions regarding less than optimal performance will remain confidential. For this reason, the Texas Health and Safety Code section 773.095 specifically addresses confidentiality of clinical review, evaluation and improvement documents. Section 773.095 states: “the proceedings and records of organized committees of hospitals, medical societies, emergency medical services providers, emergency medical services and trauma care systems, or first responder organizations relating to the review, evaluation, or improvement of an emergency medical services provider, a first responder organization, an emergency medical services and trauma care system, or emergency medical services personnel are confidential and not subject to disclosure by court subpoena or otherwise.” “this section does not apply to records made or maintained in the regular course of business by an emergency medical services provider, a first responder organization, or emergency medical services personnel.”
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In addition, the Texas Health and Safety Code section 773.095 provides a review team member with immunity from damages for an action taken or a recommendation made "within the scope of" a quality review if the member "acts without malice and in the reasonable belief that the action or recommendation" is warranted by the facts. The OMD Clinical Performance Review Team members will maintain the confidentiality of records and proceedings and follow the procedures required to meet the intent of the Texas Health and Safety Code section 773.095. Clinical Performance Review Team members may discuss the proceedings and document contents with other members of the review group. Disclosing such confidential information to any other person or Organization may result in a loss of the confidentiality privilege afforded by the Health and Safety Code. Roles & Responsibilities Office of the Medical Director 1) Determine the need for and request scheduling of an OMD Clinical Performance Review 2) Coordinate scheduling of the Clinical Performance Review 3) Identify and schedule the OMD staff required for the Review 4) Communicate the Review progress with the provider(s) being reviewed) 5) Maintain records of Clinical Performance Reviews 6) Update this procedure as needed 7) Maintain confidentiality of review proceedings Organization Performance Improvement Staff of the Provider Being Reviewed 1) Assist the OMD with scheduling of the Clinical Performance Review as needed 2) Identify Review Group members from the Organization(s) 3) Notify the provider(s) being reviewed 4) Ensure the provider(s) being reviewed are able to attend the Review during the time period(s) required 5) Provide input for improvement of this procedure as needed 6) Maintain confidentiality of review proceedings
Provider Being Reviewed 1) Participate fully, openly and honestly in all Review proceedings 2) Utilize the provided time to review all pertinent documents to be utilized in the Review process 3) Maintain confidentiality of review proceedings
Estimated Timelines Once a decision is made to convene an OMD Clinical Performance Review, all pertinent clinical performance documentation will be assembled. While every effort will be made to review clinical events quickly, the focus must remain on ensuring the review is complete, accurate and objective. Reviews must remain focused on identifying causes for the clinical performance concern and on defining actions for sustained improvement.
Outcome / Resolution / Appeal Upon completion of the OMD Clinical Performance Review, the review group members will provide recommendations to the Medical Director regarding the provider’s performance. The Medical Director will determine whether the provider may be remediated while ensuring future patient safety. In some cases, the Medical Director may choose to revoke the credentialing privileges of the provider.
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In some cases, providers subject to a Clinical Performance Review may be suspended from practice within the SMHCEMS System prior to a decision by the Medical Director. This is generally done to ensure safe and effective care is provided to patients who would otherwise be seen by the provider being reviewed. Suspension from practice does not necessarily imply wrongdoing and does not indicate the decision to be rendered by the Medical Director.
The decision by the Medical Director may result in: • No action resulting in a return to practice for the provider • Change in the credential level for the provider • Extended Suspension from practice as part of a remediation plan • Revocation of the provider’s credential to practice
The Medical Director ultimately determines the course of action in accordance with the requirements of the Texas Medical Board Rules Chapter 197. Thus, all decisions by the Medical Director are final.
Documentation & Recordkeeping All records of the OMD Clinical Performance Review are maintained by the Office of the Medical Director. The final Review document will be provided in an original form to the following persons: • Provider(s) being reviewed • Performance/Quality Improvement designee of the provider’s Organization
VERSION 02-01-2020 CLINICAL OPERATING GUIDELINES APPENDIX UPDATED 02-01-2020 PAGE 4 of 4 A – 5 Patient Transport Condition Classification System 1. Once a patient has been assessed they should be assigned a triage code in the "Red, Yellow, Green, Black" patient triage coding system based on acuity as determined by the transport medic. This system of triage coding is outlined in the SMART Triage Algorithm (T-08) 2. This applies to all patients assessed, treated and transported by SMHC EMS 3. During a Mass Casualty Incident (MCI), patients should be categorized according to a “Triage” coding system, as well.
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Suspected Child Abuse – Recognition and Reporting Children suffer several types of abuse. All are harmful to their physical and emotional development and all require intervention. Under the Child Abuse Prevention and Treatment Act (CAPTA), child abuse and neglect means, at a minimum, “Any recent act, or failure to act, on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” By Texas State law, all healthcare providers are obligated to report cases of suspected child abuse or neglect to either the local law enforcement agency or the Texas Department of Family and Protective Services (TDFPS). State of Texas Definitions of Abuse and Neglect • Abuse includes any of the following acts or omissions by a person: o Mental or emotional injury to a child that results in an observable and material impairment in the child’s growth, development, or psychological well being; o Causing or permitting the child to be in a situation in which the child sustains a mental or emotional injury that results in an observable and material impairment in the child’s growth, development, or psychological well being; o Physical injury which results in substantial harm to the child, or the genuine threat of substantial harm from physical injury to the child, including an injury which is at variance with the history or explanation given and excluding an accident or reasonable discipline by a parent, guardian, or managing or possessory conservator that does not expose the child to a substantial risk of harm; o Failure to make a reasonable effort to prevent an action by another person that results in physical injury that results in substantial harm to the child; o Sexual conduct harmful to a child’s mental, emotional, or physical welfare; o Compelling or encouraging the child to engage in sexual conduct as defined by Section 43.01, Penal Code; o Causing, permitting, encouraging, engaging in, or allowing the photographing, filming, or depicting of the child if the person knew or should have known that the resulting photograph, film or depiction of the child is obscene or pornographic, as defined by the Penal Code; o The current use by a person of a controlled substance, as defined by the Health and Safety Code, in a manner or to the extent that the use results in physical, mental, or emotional injury to the child or o Causing, expressly permitting, or encouraging a child to use a controlled substance. • Neglect includes any of the following acts or omissions by a person: o The leaving of a child in a situation where the child would be exposed to a substantial risk of physical or mental harm, without arranging for necessary care for the child, and the demonstration of an intent not to return by a parent, guardian, or managing or possessory conservator of the child; o Placing a child in, or failing to remove a child from, a situation that a reasonable person would realize requires judgment or actions beyond the child’s level of maturity, physical condition, or mental abilities and that results in bodily injury or substantial risk of immediate harm to the child o Failure to seek, obtain, or follow through with medical care for a child, with the failure resulting in or presenting a substantial risk of death, disfigurement, or bodily injury or with the failure resulting in an observable and material impairment to the growth, development, or functioning of the child;
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o The failure to provide a child with food, clothing, or shelter necessary to sustain life or health of the child, excluding failure caused primarily by financial inability unless relief services have been offered and refused; or, o Placing a child in, or failure to remove a child from, a situation in which the child would be exposed to a substantial risk of sexual conduct harmful to the child; or, o The failure by the person responsible for the child’s care, custody, or welfare to permit the child to return to the child’s home without arranging for the necessary care for the child after the child has been absent from the home for any reason, including having been in residential placement or having run away. Who Must Report / Circumstances • Any person; o When they have cause to believe that a child’s physical or mental health or welfare has been adversely affected by abuse or neglect; o Professionals, including teachers, nurses, doctors, day-care employees, juvenile probation officers, juvenile detention or correctional officers, and employees of a clinic or health care facility that provides reproductive services. o If a professional has cause to believe that a child has been abused or neglected or may be abused or neglected or that a child is a victim of an offense under Section 21.11, Penal Code. Privileged Communications/Confidentiality of Records: • The requirement to report under this section applies without exception to an individual whose personal communications may otherwise be privileged, including an attorney, a member of the clergy, a medical practitioner, a social worker, a mental health professional, and an employee of a clinic or health care facility that provides reproductive services. When Child Abuse or Neglect is Suspected: • Anyone having cause to believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse or neglect MUST report the case immediately to a state or local law enforcement agency or the Texas Department of Family and Protective Services (TDFPS). • Current law requires that professionals such as teachers, doctors, nurses, or child daycare workers must make a verbal report within 48 hours. Failure to report suspected child abuse or neglect is a misdemeanor punishable by imprisonment of up to 180 days and/or a fine of up to $2000. EMS reporting of suspected child abuse can be accomplished by only one of two methods • Reporting it directly to law enforcement (not hospital security) either on scene or at the hospital OR •e Dir ctly contacting the 24 hour TDFPS Family Violence Hotline at 1-800- 252-5400 o The report of child abuse or neglect is confidential and immune from civil or criminal liability as long as the report was made “in good faith” and “without malice” o “In good faith” means that the person making the report took reasonable steps to learn facts that were readily available and at hand. o “Without malice” means that the person did not intend to injure or violate the rights of another person.
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o Provided the report was made “in good faith” and “without malice” the Provider will be immune from liability if asked to participate in any judicial proceedings that may result from the report. Patient or Scene Presentation: • The patient may present with patterned burns or injuries suggesting intentional infliction o Injuries in various stages of healing (old bruises, etc.) o Injuries scattered over multiple areas of the body o Fractures or injuries inconsistent with stated cause of injury o The patient, parent, or caregiver responding inappropriately to the situation o Malnutrition or extreme lack of cleanliness of the patient or environment may indicate neglect o Signs of increased intracranial pressure without a readily explainable cause (fever, head trauma, etc.) Procedures for Dealing with Suspected Abuse Patients: • Stabilize and treat all injuries accordingly • Immediately request law enforcement assistance • Do not initiate a report to law enforcement or social services in front of the patient, parent, or caregiver • If sexual abuse is suspected, discourage the patient from washing • If patient, parent, or caregivers are hostile, immediately request law enforcement assistance • Do not confront or become hostile to the parent or caregiver. • Document o Verbatim (in quotation marks), all statements by the patient, the parent, or caregiver, including statements made about the manner of the injuries. o Document any abnormal behavior of the patient, parent, or caregiver. o Document the condition of the environment and other residents present. o Document in the PCR who received the report of suspected abuse or neglect . If reporting is done after PCR completion, an addendum should be written and attached with reporting date, time, who reported to, etc. This will serve to protect the Provider. • Once a determination of abuse or suspected abuse has been made, notify the appropriate EMS Battalion Chief to provide support for the completion of reporting regulations and processes
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To ensure consistency in the assessment and treatment of patients that may be suffering circulatory system problems, the following definitions will apply:
Tachycardia Resting heart rate greater than 100 bpm in adults
Bradycardia Resting heart rate less than 60 bpm in adults A child’s heart rate should be evaluated based on age and condition. The heart rate of an anxious, sick, or injured child should be rapid. A heart rate less than 60 bpm coupled with signs of poor perfusion in children <8 years of age is an ominous sign.
Hypertension Consistent resting blood pressure greater than or equal to 140/90 mmHg in adults
Hypotension Consistent resting blood pressure (less than) < 90/60 mmHg (or Systolic BP < 90mmHg) in adults with associated signs and symptoms of hypoperfusion. The goal in treating patients suffering from non-compressible bleeding is to maintain a systolic BP of 70 mmHg. This is referred to as permissive hypotension. Trauma Activation Criteria: “Traumatic injury with signs of shock”. The need to rapidly make a determination should be based on signs of hypoperfusion as evidenced by: • Skin color and condition, and; • Pulse rate and location, and; • Capillary refill, and; • Blood pressure The blood pressure SMHC EMS System will use to validate a “Trauma Activation” decision in an Adult will be a systolic blood pressure of < 90 mmHg. BP of < 70mmHg + (age in years x 2), with associated signs and symptoms is considered hypotensive in a child. Hyperglycemic Blood Glucose level of > 300 mg/dl with signs of Hypoperfusion. Hypoglycemic Blood Glucose level of < 60 mg/dl with signs of Altered Mental Status.
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Drug Formulary
Table of Contents Drug Formulary ...... Page Acetaminophen ...... DF-1 Adenosine ...... DF-2 Albuterol ...... DF-3 Amiodarone ...... DF-4 Amyl Nitrite ...... DF-5 Aspirin ...... DF-6 Atropine Sulfate……………………………………………………………………………………………………………………………....DF-7 Brilinta……………………………………………………………………………………………………………………………………………..DF-8 Calcium Gluconate ...... DF-9 Dextrose ...... DF-10 Diltiazem ...... DF-11 Diphenhydramine ...... DF-12 Enalapril………………………………………………………………………………………………………………………………………….DF-13 Epinephrine ...... DF-14 Etomidate…………………………………………………………………………………………………………………………………….. DF-15 Fentanyl Citrate……………………………………………………………………………………………………………………………..DF-16 Glucagon………………………………………………………………………………………………………………………………………..DF-17 Heparin…………………………………………………………………………………………………………………………………………..DF-18 Ipratropium Bromide ...... DF-19 Ketamine………………………………………………………………………………………………………………………………………..DF-20 Labetalol…………………………………………………………………………………………………………………………………………DF-21 Levophed ...... DF-22 Lidocaine ...... DF-23 Magnesium Sulfate ...... DF-24 Methylprednisolone ...... DF-25 Midazolam ...... DF-26 Naloxone ...... DF-27 Nitroglycerin ...... DF-28 Ondansetron ...... DF-29 Oral Glucose ...... DF-30 Pyridoxine ...... DF-31 Rocuronium ...... DF-32 Sodium Bicarbonate ...... DF-33 Sodium Nitrite ...... DF-34 Sodium Thiosulfate ...... DF-35 Terbutaline Sulfate ...... DF-36 Toradol……………………………………………………………………………………………………………………………………….….DF-37 Tranexamic Acid ...... DF-38 Acetaminophen/Tylenol (APAP) Class ...... Analgesic, Antipyretic Action ...... Equivalent to aspirin in both analgesic and antipyretic effects. Unlike aspirin, acetaminophen has little effect on platelet function, no effect on homeostasis, and is not known to produce gastric bleeding. Acetaminophen is not an NSAID, as it has no anti-inflammatory properties. Its function was largely a mystery until the early 1990’s when it was found that it acted on a variant of cyclooxygenase called COX3 that is only expressed in the central nervous system. Because it does not work on COX1 and COX2 (like ASA) it does not cause the downstream effects on platelets or the immune system. Pharmacokinetics ...... Absorption is rapid, peak 1-2h, duration 3-4h, ½ life 1-3h. APAP is processed in the liver. Contraindications ...... Use with caution in children afflicted with arthritic or rheumatoid conditions. Use with caution in known thrombocytopenia. Should not be given to any patients with significant underlying liver disease. Adverse effects ...... N/V, abdominal pain Indications ...... Fever with or without seizures or pain
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 1 Adenosine Class ...... Antidysrhythmic Action ...... Slows AV node conduction, interrupts reentry pathways. Adenosine works in a variety of receptors grouped into a group called P1 receptors. The true mechanism is somewhat unclear. Adenosine works through the activation of cAMP and coupled G-proteins to cause its cardiac effects. Pharmacokinetics ...... Immediate onset and peak, half-life 10s. Contraindications ...... Known hypersensitivity. Sick Sinus Syndrome. Second or third degree AV block. Use with caution in patients with severe asthma. Adverse effects ...... Flushing, CP, HA, N/V, hypotension Indications ...... Symptomatic (poor perfusion) narrow complex tachycardia w/ pulse
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 2 Albuterol Class ...... Sympathomimetic Bronchodilator Action ...... Beta2 adrenergic. Smooth muscle relaxant. Minimal Beta1 effects. Reduces mucous secretion and edema via histamine inhibition. Pharmacokinetics ...... Onset 5-15m, peak 1-1.5h, duration 3-6h, half-life 3h. Contraindications ...... Known hypersensitivity. Adverse effects ...... Tachycardia, palpitations, peripheral vasodilation, tremors, HA, sore throat, dry mouth, PVCs, N/V. Indications ...... Wheezing due to bronchospasm
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 3 Amiodarone Class ...... Antidysrhythmic Action ...... Prolongs the duration of the action potential and refractory period of all Cardiac fibers. Depresses the Phase 0 slope by causing a sodium blockade. Causes a Beta block as well as a weak calcium channel blockade. Therefore it decreases the SA nodes rate of firing, suppresses automaticity, interrupts reentrant pathways and prolongs PR, QRS and QT intervals. Relaxes vascular smooth muscle, decreases peripheral vascular resistance, and increases coronary contractility. Pharmacokinetics ...... Rapid onset, serum concentrations drop to 10% w/in 30-45 minutes. Contraindications ...... Cardiogenic shock, bradycardia, second/third degree block Adverse effects ...... Vasodilation (usually not associated with decreased cardiac output secondary to the negative inotropic effects), hypotension, bradycardia, AV block, increased QT interval, V-Tach Indications ...... Ventricular Arrhythmias or Wide Complex Tachycardia with or without a pulse
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 4 Amyl Nitrite Class ...... Vasodilator Action ...... The mechanism of action may be b inducing low levels of methemoglobinemia. Another postulated mechanism is by acting through nitric oxide synthetase. Airway management and provision of supplemental oxygen increase efficacy. Pharmacokinetics ...... Amyl nitrite vapours are absorbed rapidly through the pulmonary alveoli, manifesting therapeutic effects within one minute after inhalation. The drug is metabolised rapidly, probably by hydrolytic denitration; approximately one third of the inhaled amyl nitrite is excreted in the urine. Contraindications ...... Relative Contraindications: Significant hypotension Methemoglobinemia >40% Carbon monoxide poisoning Absolute Contraindication: Known Allergy to Medication Adverse effects ...... Headache, Hypotension, Reflex tachycardia, Hypoperfusion (shock)
Indications ...... Patients with significant cyanide, cyanogenic compound, or sulfide poisoning.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 5 Aspirin Class ...... Analgesic, Antipyretic, NSAID, platelet inhibitor Action ...... Inhibits the formation of prostaglandins associated with pain, fever, and inflammation. Inhibits platelet aggregation by acetylating cyclooxygenase permanently disabling it so that it cannot synthesize prostaglandins and Thromboxanes. Since Thromboxane A2 is important in clotting its absence does not allow blood to clot effectively. Pharmacokinetics ...... Onset 5-30m, peak in 15m-2h, duration is 1-4h. Contraindications ...... Allergy, ulcer, GI bleeding Precaution ...... Patients with known ASA or NSAIDs sensitive Asthma (defer to OLMC) Adverse effects ...... N/V, diarrhea, heartburn, GI bleeding Indications ...... Cardiac type Chest Pain
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 6 Atropine
Class...... Parasympatholytic
Action ...... Competitive antagonist that selectively blocks all muscarinic responses to Ach. Blocks vagal impulses, thereby increasing SA node discharge, thereby enhancing AV conduction and cardiac output. Potent anti-secretory effects caused by the blocking of acetylcholine at the muscarinic site. Atropine is also useful in the treatment of the symptoms associated with nerve agent poisoning.
Pharmacokinetics ...... Rapid onset, peak in 2-4m IV, half-life 2-3h.
Contraindications ...... A-Fib, A-Flutter, second degree type II or third degree block. Tachycardia, glaucoma. Use with caution in suspected AMI.
Adverse effects ...... Pupil dilation, tachycardia, V-Tach, V-Fib, HA, dry mouth
Indications...... Asystole/Agonal/PEA, Bradycardia and Organophosphate poisoning
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 7 Brilinta (Ticagrelor) Class ...... P2Y12 platelet inhibitor
Action ...... Ticagrelor and its major metabolite reversibly interact with the platelet P2Y12 ADP-receptor to prevent signal transduction and platelet activation. Ticagrelor and its active metabolite are approximately equipotent. Pharmacokinetics Ticagrelor demonstrates dose proportional pharmacokinetics, which are similar in patients and healthy volunteers.
Absorption
Absorption of ticagrelor occurs with a median tmax of 1.5 h (range 1.0–4.0). The formation of the major circulating metabolite AR-C124910XX (active) from ticagrelor occurs with a median tmax of 2.5 h (range 1.5-5.0).
The mean absolute bioavailability of ticagrelor is about 36%, (range 30%-42%). Ingestion of a high-fat meal had no effect on ticagrelor Cmax, but resulted in a 21% increase in AUC. The Cmax of its major metabolite was decreased by 22% with no change in AUC. BRILINTA can be taken with or without food.
Distribution
The steady state volume of distribution of ticagrelor is 88 L. Ticagrelor and the active metabolite are extensively bound to human plasma proteins (>99%).
Metabolism
CYP3A4 is the major enzyme responsible for ticagrelor metabolism and the formation of its major active metabolite. Ticagrelor and its major active metabolite are weak P-glycoprotein substrates and inhibitors. The systemic exposure to the active metabolite is approximately 30-40% of the exposure of ticagrelor.
Excretion
The primary route of ticagrelor elimination is hepatic metabolism. When radiolabeled ticagrelor is administered, the mean recovery of radioactivity is approximately 84% (58% in feces, 26% in urine). Recoveries of ticagrelor and the active metabolite in urine were both less than 1% of the dose. The primary route of elimination for the major metabolite of ticagrelor is most likely to be biliary secretion. The mean t1/2 is approximately 7 hours for ticagrelor and 9 hours for the active metabolite.
Contraindications ...... Intracranial hemorrhage, Active bleeding, Hepatic impairment, Hypersensitivity Adverse effects ...... Major Bleeding, Dyspnea, Headache, Cough, Dizziness, Nausea, A- Fib, Hypertension, Chest Pain Indications ...... Myocardial infarction
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 8 Calcium Gluconate
Class ...... Electrolyte Action ...... Calcium binds to troponin that connects tropomyosin to actin covering myosins binding site to actin. While this binding site is covered, muscular contraction cannot occur. The exposure of this binding site in the presence of ATP (chemical energy) allows the muscle to contract. Enhancing muscular contraction. Contraction in the heart is therefore increased as is smooth muscles (vascular) contraction. Calcium in its ionic (dissolved) state carries a very positive charge. This charge causes the membrane to be stable if the calcium is too low neurons and cardiac cells have a decreased threshold for activation resulting in tetany. Calcium Gluconate is less potent and less irritating to veins than Calcium Chloride. Pharmacokinetics ...... Onset and peak are immediate Contraindications ...... V-Fib, renal/cardiac insufficiency, patients taking digatalis. Adverse effects ...... Tingling sensation in IV site, hypotension, syncope, cardiac arrest. Indications ...... Calcium Channel Overdose, Beta Blocker Overdose, Hydrofluoric Acid Exposure, Hyperkalemia
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 9 Dextrose Class ...... Carbohydrate. Dextrose (aka. glucose) is one of the basic building blocks of all sugars. Glucose is a monomer and is therefore readily processed in the blood. Through glycolysis glucose is turned into pyruvate giving off a small amount of chemical energy (ATP). Pyruvate is further processed through the Citric Acid Cycle (Kreb’s Cycle) yielding even more energy (GTP, FADH2 and NADH) and CO2. The GTP, FADH2 and NADH are then converted into a large amount of ATP through the use of a specialized cell membrane and the ability of Oxygen to receive extra protons and carbon to form water and CO2. Insulin turns excess glucose into glycogen when blood sugars are high. Glucose is a large molecule that forms a ring, this structure is incapable of being absorbed into a cell without a mediator (insulin) and therefore increases damage to epithelium as it floats through the blood stream. It also causes an osmotic pressure as concentrations vary across membranes. The pressure is less with D5 and D10 therefore they are used in pediatrics. Action ...... Principal form of glucose used by the body Pharmacokinetics ...... Rapid absorption in bloodstream Contraindications ...... Use with caution in patients with suspected increased ICP. Adverse effects ...... Patients may complain of warmth, pain, or burning at the injection site. Extravasation causes necrosis. Indications ...... Cardiac Arrest or altered mentation with Glucose level < 50 or Newly Born with heart rate < 60
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 10 Diltiazem (Cardizem)
Class ...... Diltiazem hydrochloride is a calcium ion cellular influx inhibitor (slow channel blocker or calcium antagonist). Action ...... Calcium channel blockers are drugs that block the entry of calcium into the muscle cells of the heart and arteries. The entry of calcium is critical for the conduction of the electrical signal that passes from muscle cell to muscle cell of the heart, and signals the cells to contract. It also is necessary in order for the muscle cells to contract and thereby pump blood. In the arteries, the entry of calcium into muscle cells causes contraction of the cells and thereby dilates (widens) the arteries. Thus, by blocking the entry of calcium, calcium channel blockers reduce electrical conduction within the heart, decrease the force of contraction (work) of the muscle cells, and dilate arteries. Dilation of the arteries reduces blood pressure and thereby the effort the heart must exert to pump blood. Combined with decreases in the force of contraction, this leads to a reduced requirement for oxygen by the heart. Dilation of the arteries provides more oxygen-carrying blood to the heart. The combination of reduced demand for oxygen and increased delivery of oxygen prevents angina or heart pain. (Angina occurs when the heart is not getting enough oxygen relative to the amount of work it is doing.) In addition, calcium channel blockers slow electrical conduction through the heart and thereby correct abnormal rapid heartbeats. Pharmacokinetics ...... Diltiazem hydrochloride is extensively metabolized by the liver and excreted by the kidneys and in bile. Contraindications ...... Diltiazem is contraindicated in (1) patients with sick sinus syndrome except in the presence of a functioning ventricular pacemaker, (2) patients with second- or third-degree AV block except in the presence of a functioning ventricular pacemaker, (3) patients with hypotension, (4) patients who have demonstrated hypersensitivity to the drug, and (5) patients with acute myocardial infarction and pulmonary congestion. Precaution ...... Cardiac Conduction: Diltiazem prolongs AV node refractory periods without significantly prolonging sinus node recovery time, except in patients with sick sinus syndrome. Concomitant use of diltiazem with beta-blockers or digitalis may result in additive effects on cardiac conduction Adverse effects ...... Headache, constipation, rash, nausea, flushing, edema, drowsiness, low blood pressure, and dizziness. Indications ...... Atrial Fibrillation with RVR, Paroxysmal Supraventricular Tachycardia
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 11 Diphenhydramine Class ...... Antihistamine, Ethanolamine, Anticholinergic Action ...... Diphenhydramine blocks the effects of Histamine (H1 histamine) on the H1 receptor site through a competitive competition for the peripheral H1 site. When diphenhydramine is bound the H1 site cannot be stimulated preventing the effects of histamines (swelling, etc…). As an H1 blocker diphenhydramine blocks the effects of H1 on its receptor in the cortex as well this causes a change in the cortex neural potassium channels causing neurons in the cortex to have a higher threshold to depolarize. This results in an increase in sedation as a result of the H1 block. As an antihistamine, diphenhydramine one of the most effective antihistamines. Pharmacokinetics ...... Onset of 15m IV, peak 1-4h, ½ life 2-10h. Contraindications ...... Known allergy. Adverse effects ...... Potent anticholinergic agent. Mydriasis, Photophobia, ataxia, tachycardia Indications ...... Hives/Rash or Adult dystonic reaction
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 12 Enalaprilat (Enalapril)
Class ...... Enalaprilat is an Angiotensin Converting Enzyme (ACE) Inhibitor Action ...... Enalaprilat works on the Renin-Angiotensin Aldosterone System (RAAS) and inhibits the action of ACE on Angiotensin I, therefore preventing the creation and action of Angiotensin II. Contraindications ...... Enalaprilat is contraindicated in patients with a history of ACE- inhibitor induced angioedema, hereditary angioedema, or idiopathic angioedema. The risk of angioedema may be increased in patients with a history of angioedema unrelated to ACE inhibitors. Precautions……………When administering this medication watch for dizziness, hypotension, headache, chest pain, cough, and rash.
Indications ...... Patients with persistent hypertension (MAP >145 mmHg) after CPAP and nitroglycerin administration.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 13 Epinephrine Class ...... Sympathomimetic Action ...... Naturally occurring catecholamine obtained form animal adrenal glands. Acts on alpha and beta adrenergic receptors. The most potent alpha agonist. Beta1: Strengthens myocardial contraction, increase sys BP (may decrease dia BP), increases HR and cardiac output. Beta2: Dilates bronchial smooth muscle and inhibits mucous secretion. Alpha: Constricts bronchiole arterioles, inhibits histamine release, constricts arterioles in the skin, mucous membranes, and kidneys but dilates those in the skeletal muscle. Action is through a natural hormonal mechanism. Pharmacokinetics ...... Onset<2m IV, 3-10m SQ. Peak 5m IV, 20m SQ. Duration 5-10m IV, 20-30m SQ. Contraindications ...... Tachydysrhythmias, coronary artery disease. Adverse effects ...... HA, N/V, tachydysrhythmias, AMI, diaphoresis, anxiety, palpitations. Indications ...... Allergic Reaction/Anaphylaxis, Reactive Airway Disease, PEDI Bradycardia, Cardiac Resuscitation
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 14 Etomidate (Amidate)
Class ...... Etomidate is a hypnotic drug without analgesic activity. Action ...... Pharmacokinetics Intravenous injection of etomidate produces hypnosis characterized by a rapid onset of action, usually within one minute. Duration of hypnosis is dose dependent but relatively brief, usually three to five minutes when an average dose of 0.3 mg/kg is employed. Immediate recovery from anesthesia (as assessed by awakening time, time needed to follow simple commands and time to perform simple tests after anesthesia as well as they were performed before anesthesia), based upon data derived from short operative procedures where intravenous etomidate was used for both induction and maintenance of anesthesia, is about as rapid as, or slightly faster than, immediate recovery after similar use of thiopental. Contraindications ...... Etomidate is contraindicated in patients who have shown hypersensitivity to it. Precautions……………..
1. Carcinogenesis, Mutagenesis, Impairment of Fertility: No carcinogenesis or mutagenesis studies have been carried out on etomidate. The results of reproduction studies showed no impairment of fertility in male and female rats when etomidate was given prior to pregnancy at 0.31, 1.25 and 5 mg/kg (approximately 1X, 4X and 16X human dosage).
2. Pregnancy Category C. Etomidate has been shown to have an embryocidal effect in rats when given in doses 1 and 4 times the human dose. There are no adequate and well-controlled studies in pregnant women. Etomidate should be used during pregnancy only if the potential benefit justifies the potential risks to the fetus. Etomidate has not been shown to be teratogenic in animals. Reproduction studies with etomidate have been shown to: a. Decrease pup survival at 0.3 and 5 mg/kg in rats (approximately 1X and 16X human dosage) and at 1.5 and 4.5 mg/kg in rabbits (approximately 5X and 15X human dosage). No clear dose-related pattern was observed. b. Increase slightly the number of stillborn fetuses in rats at 0.3 and 1.25 mg/kg (approximately 1X and 4X human dosage). c. Cause maternal toxicity with deaths of 6/20 rats at 5 mg/kg (approximately 16X human dosage) and 6/20 rabbits at 4.5 mg/kg (approximately 15X human dosage).
3. Labor and Delivery: There are insufficient data to support use of intravenous etomidate in obstetrics, including Caesarean section deliveries. Therefore, such use is not recommended.
4. Nursing Mothers: It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when etomidate is administered to a nursing mother.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 15 Etomidate (Amidate) 5. Pediatric Use: There are inadequate data to make dosage recommendations for induction of anesthesia in patients below the age of ten (10) years; therefore, such use is not recommended (see also DOSAGE AND ADMINISTRATION).
6. Geriatric Use: Clinical data indicates that etomidate may induce cardiac depression in elderly patients, particularly those with hypertension (see CLINICAL PHARMACOLOGY and OTHER
ADVERSE OBSERVATIONS, Circulatory System). Elderly patients may require lower doses of etomidate than younger patients. Age- related differences in phamacokinetic parameters have been observed in clinical studies (see CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION). Adverse effects ...... Hypertensive patients at risk of excessive hypotension include those with the following concurrent conditions or characteristics: heart failure, hyponatremia, high dose diuretic therapy, recent intensive diuresis or increase in diuretic dose, renal dialysis, or severe volume and/or salt depletion of any etiology. Indications ...... Sedation for airway placement or entrapment.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 15 Fentanyl Citrate Class ...... Narcotic analgesic Action ...... The principal actions of therapeutic value are analgesia and sedation. Pharmacokinetics ...... Opioid (narcotic, CNS-acting) analgesics are derivatives of opium. These drugs modify the perception of pain and provide a sense of euphoria by binding to specific opiate receptors throughout the central nervous system. Many of the characteristics of particular opioids relate to the receptor to which they bind. Fentanyl is classified as a full agonists and binds to mu receptor sites, blocks pain impulses, and produces maximum pain control. Onset immediate, peak 3-5m, duration 30-60m. Contraindications ...... Fentanyl is not indicated for MAOI use, asthma, myasthenia gravis, evidence of hypoperfusion. Adverse effects ...... Fentanyl may cause muscle rigidity, particularly involving the muscles of respiration. In addition, skeletal muscle movements of various groups in the extremities, neck and external eye have been reported during induction of anesthesia with fentanyl; these reported movements have, on rare occasions, been strong enough to pose patient management problems. This effect is related to the dose and speed of injection and its incidence can be reduced by slower administration and lower doses titrated to effect. As with other narcotic analgesics, the most common serious adverse reactions reported to occur with fentanyl are respiratory depression, apnea, rigidity, and bradycardia; if these remain untreated, respiratory arrest, circulatory depression or cardiac arrest could occur. Other adverse reactions that have been reported are hypertension, hypotension, dizziness, blurred vision, nausea, emesis, laryngospasm, and diaphoresis. Indications ...... Acute pain management
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 16 Glucagon Class ...... Hormone Action ...... Causes a breakdown of stored blood glycogen to glucose and inhibits glycogen synthesis. Glucagons acts by binding to glucagon receptor sites and stimulating a secondary messenger through the increase of adenylate cyclase. Beta stimulation causes an increase in the adenylate cyclase. Therefore glucagon has been known to have beta like effects just as Beta drugs such as Epinephrine are known to stimulate Glycogenolysis in the liver. Pharmacokinetics ...... Onset 5-20m, peak 30m, duration 1-1.5h. ½ life30m. Contraindications ...... Not efficacious in poorly nourished individuals as they have no glycogen stores. Adverse effects ...... N/V, HA Indications ...... Hypoglycemia < 50 if unable to obtain IV access for Dextrose
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 17 Heparin Class………………………Anticoagulant Action ...... Heparin inhibits reactions that lead to the clotting of blood and the formation of fibrin clots both in vitro and in vivo. Heparin acts at multiple sites in the normal coagulation system. Small amounts of heparin in combination with antithrombin III (heparin cofactor) can inhibit thrombosis by inactivating activated Factor X and inhibiting the conversion of prothrombin to thrombin. Once active thrombosis has developed, larger amounts of heparin can inhibit further coagulation by inactivating thrombin and preventing the conversion of fibrinogen to fibrin. Heparin also prevents the formation of a stable fibrin clot in inhibiting the activation of the fibrin stabilizing factor. Pharmacokinetics ...... Contraindications……..Heparin sodium should not be used in patients: With severe thrombocytopenia; In whom suitable blood coagulation tests — e.g., the whole blood clotting time, partial thromboplastin time, etc. — cannot be performed at appropriate intervals (this contraindication refers to full-dose heparin; there is usually no need to monitor coagulation parameters in patients receiving low-dose heparin); With an uncontrollable active bleeding state (see WARNINGS), except when this is due to disseminated intravascular coagulation. Adverse effects ...... Bleeding, Local irritation, Hypersensitivity Indications ...... Prophylactic Anticoagulant Therapy
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 18 Ipratropium Bromide Class ...... Parasympatholytic Bronchodilator Action ...... Anticholinergic agent, chemically closely related to atropine and has the same actions as Atropine. Acts directly on the smooth muscle and decreases secretions. Reduces the vagally mediated reflex bronchospasm caused by inhaled irritants. Pharmacokinetics ...... 10% of inhaled dose reaches lower airway, 0.5% reaches systemic distribution. Peak 1.5-2h, duration 4-6h, ½ life 1.5-2h. Contraindications ...... Glaucoma, allergy to soy products or peanuts Adverse effects ...... Dry mouth, HA, cough, dries secretions Indications ...... Obstructive Airway Disease, Reactive Airway Disease
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 19 Ketamine Class ...... Dissociative anesthetic, hallucinogen, psychomimetic Action ...... General anesthetic termed a dissociative anesthetic. A phencyclidine derivative that causes dissociation between cortical and limbic systems, which prevent the higher centers from perceiving visual, auditory, or painful stimuli. Less cardiorespiratory depressant effects and causes some stimulation of cardiovascular system. Pharmacokinetics ...... IM onset up to 2 minutes Contraindications ...... Patient’s with whom a significant elevation in BP would constitute serious hazard, CHF, hypersensitivity Adverse effects ...... Elevated BP and HR, arrhythmia’s, laryngospasm, diplopia, nystagmus, hypersalivation, emergence reactions, enhanced skeletal muscle tone may be manifested by tonic/clonic movements that sometimes resemble seizures. Indications ...... Patient that requires chemical sedation due to being a potential harm to themselves or EMS providers. Or, a patient experiencing a prolonged extrication/entanglement experiencing a large amount of pain.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 20 Labetalol
Class ...... Nonselective beta-blocker/alpha1 blocker
Action ...... α1 and nonselective β-adrenergic receptor blocker; produces dose-related falls in BP without reflex tachycardia and significant reduction in heart rate.
Pharmacokinetics ...... Absorption: Complete; Tmax=1-2 hrs. Distribution: Plasma protein binding (50%); found in breast milk; crosses placenta. Metabolism: Liver (conjugation and glucuronidation). Elimination: Urine (IV, 55-60% unchanged), feces; (Tab) T1/2=6-8 hrs, (IV) T1/2=5.5 hrs. Contraindications ...... Bronchial asthma, overt cardiac failure, >1st-degree heart block, cardiogenic shock, severe bradycardia, other conditions associated with severe and prolonged hypotension, history of obstructive airway disease. Adverse effects ...... Fatigue, dizziness, dyspepsia, N/V, nasal stuffiness, somnolence, ejaculation failure, postural hypotension, increased sweating, paresthesia. Indications ...... (Tab) Management of hypertension. (Inj) Management of severe hypertension.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 21 Norepinephrine (Levophed) Class ...... Adrenergic, Catecholamine, Sympathomimetic amine which differs from epinephrine by the absence of a methyl group on the nitrogen atom. Action ...... LEVOPHED (norepinephrine bitartrate) functions as a peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic stimulator of the heart and dilator of coronary arteries (betaadrenergic action). Pharmacokinetics ...... Onset 1 to 2 minutes Contraindications ...... Levophed should not be given to patients who are hypotensive from blood volume deficits except as an emergency measure to maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be completed. If Levophed is continuously administered to maintain blood pressure in the absence of blood volume replacement, the following may occur: severe peripheral and visceral vasoconstriction, decreased renal perfusion and urine output, poor systemic blood flow despite “normal” blood pressure, tissue hypoxia, and lactate acidosis. Levophed should also not be given to patients with mesenteric or peripheral vascular thrombosis (because of the risk of increasing ischemia and extending the area of infarction) unless, in the opinion of the attending physician, the administration of Levophed is necessary as a life-saving procedure., tachydysrhythmias, HTN Warnings ...... Levophed should be used with extreme caution in patients receiving monoamine oxidase inhibitors (MAOI) or antidepressants of the triptyline or imipramine types, because severe, prolonged hypertension may result. Levophed Bitartrate contains sodium metabisulfite, a sulfite that may cause allergic-type reactions including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in certain susceptible people. The overall prevalence of sulfite sensitivity in the general population is unknown. Sulfite sensitivity is seen more frequently in asthmatic than in nonasthmatic people. Adverse effects ...... Tachydysryhthmias, VF, VT, AMI, N/V, HA. Indications ...... For blood pressure control in certain acute hypotensive states myocardial infarction, septicemia, blood transfusion, and drug reactions. And, as an adjunct in the treatment of cardiac arrest and profound hypotension.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 22 Lidocaine Class ...... Antidysrhythmic, Sodium channel blocker Action ...... Raises the threshold for ventricular contractions and lowers the threshold for defibrillation and cardioversion. Suppresses automaticity in the His-purkinje system and by elevating the electrical stimulation threshold of ventricular contractions. This is accomplished by blocking the rapid influx of Na+ during the initial phase of depolarization. Typically shortens the action potential and the refractory period secondary to a blockade of sodium channels that usually (in procainamide’s blockade) continue to function normally through phase 2 of the action potential. Lidocaine functions well in hyperkalemic and acidotic states therefore it works well on ischemic tissues. Pharmacokinetics ...... Onset 3m, peak 5-7m, duration 10-20m, ½ life 1.5-2h. Contraindications ...... CHF, shock, use caution in the elderly. Adverse effects ...... Seizures, slurred speech, AMS Indications ...... Pain Management for IO Infusion
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF - 23 Magnesium Sulfate Class ...... Electrolyte Action ...... Molecularly Mg+ is very similar to Ca as it has the same electron valence. Because of this it chemically very similarly to Ca+ and in some reactions in the body. Ca+ is significantly larger than Mg+ therefore Mg+ does not adequately replace it in cases that are not purely chemical. Because of these qualities Mg+ can prevent Ca+ from binding to Troponin and prevent muscles from contracting as described in the action for “Calcium Gluconate”. Because of its extremely positive charge it also blocks neuromuscular transmission by changing the electric potentials threshold. Pharmacokinetics ...... Onset immediate, duration 30m Contraindications ...... Renal disease, AV block, previous myocardial damage. Adverse effects ...... Hypotension, asystole, cardiac arrest, respiratory/CNS depression, flushing, sweating. Indications ...... Obstetrical Emergencies/ Seizures (adult only), Reactive Airway Disease, Toxic Exposure (Hydrofluoric Acid), Pulseless Arrest, Tachycardia w/ pulse (adults only).
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 24 Methylprednisolone Class ...... Glucocorticosteroid Action ...... Adrenal Corticosteroid with fewer sodium and water retention effects than hydrocortisone. Methylprednisolone alters the body’s immune response. Swelling is reduced because it prevents the white blood cells traveling to the area. Pharmacokinetics ...... ½ life of 2.5-3.5h. Contraindications ...... None for anaphylaxis. Adverse effects ...... Peptic ulcer, hyperglycemia, hypokalemia, impaired ability to fight infection, in the prolonged use the side effects are so numerous they are the subject of several books. Indications ...... Allergic Reaction/Anaphylaxis, Reactive Airway Disease
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 25 Midazolam Class ...... Sedative, Benzodiazepine Action ...... As a Benzodiazepine this drug functions on GABA similarly to the action of “Diazepam”. Midazolam is a short-acting muscle-relaxant, anticonvulsant, in addition to these effects Midazolam also has anterograde amnestic effects, it is therefore preferred prior to cardioversion. Pharmacokinetics ...... Onset 3-5m IV, 6-14 IN, peak 20-60, duration < 2h, ½ life 1-4h. Contraindications ...... Shock, acute narrow glaucoma, coma Adverse effects ...... Resp. depression, hypotension, bradycardia, HA, N/V Indications ...... Seizures, Violent Patient/Chemical Sedation, Sedation for Electrical therapy and Induced Hypothermia
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 26 Naloxone Class ...... Narcotic Antagonist Action ...... Competitive antagonist for opioids competing for opiate receptor sites in the brain. Displaces narcotic molecules from opiate receptors through this competition. Higher doses are needed to overcome overdoses of opiates that have a higher affinity for the opiate receptor in the brain. Pharmacokinetics ...... Onset <2m, peak <2m, duration 2-20m, ½ life 60-90m. Contraindications ...... Neonates with narcotic-addicted mothers. Adverse effects ...... Withdrawal symptoms. Indications ...... narcotic overdose
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 27 Nitroglycerin Class ...... Nitrate Action ...... Potent vasodilator with antianginal, anti-ischemic, and antihypertensive effects. Relaxes vascular smooth muscle by an unknown mechanism. Decreases peripheral vascular resistance, preload, and afterload. Pharmacokinetics ...... Onset 1-3m SL, 30m transdermal. Peak 5-10m SL. Duration is 20- 30m SL, 3-6h transdermal. Contraindications ...... Hypotension, hypovolemia, severe bradycardia or tachycardia, use of erectile dysfunction drugs within past 24hrs. Adverse effects ...... Hypotension, HA, syncope, tachycardia. Indications ...... Chest Pain, CHF/Pulmonary Edema
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 28 Ondansetron
Class ...... Antiemetic, 5-HT3, receptor antagonist Action ...... Ondansetron is a selective 5-HT3 receptor antagonist. While its mechanism of action has not been fully characterized, Ondansetron is not a dopamine-receptor antagonist. Serotonin receptors of the 5-HT3 type are present both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone of the area postrema. It is not certain whether Ondansetron's antiemetic action is mediated centrally, peripherally, or in both sites. The released serotonin may stimulate the vagal afferents through the 5-HT3 receptors and initiate the vomiting reflex. Pharmacokinetics ...... Rapid onset, half-life 3-4 hours Contraindications ...... If the patient is sensitive to or has ever had an allergic reaction to ondansetron hydrochloride, do not give Zofran. If drugs similar to Zofran (for instance, Anzemet or Kytril) have caused a reaction, Zofran may cause one too. If your patient has phenylketonuria (an excess of the amino acid phenylalanine) Zofran also contains this substance. Adverse effects ...... Blurred vision or temporary blindness, fever, slow heart rate, trouble breathing, anxiety, agitation, shivering, feeling light-headed or fainting Indications ...... Nausea and/or Vomiting
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 29 Oral Glucose
Class ...... Carbohydrate. Dextrose (aka. glucose) is one of the basic building blocks of all sugars. Glucose is a monomer and is therefore readily processed in the blood. Through glycolysis glucose is turned into pyruvate giving off a small amount of chemical energy (ATP). Pyruvate is further processed through the Citric Acid Cycle (Kreb’s Cycle) yielding even more energy (GTP, FADH2 and NADH) and CO2. The GTP, FADH2 and NADH are then converted into a large amount of ATP through the use of a specialized cell membrane and the ability of Oxygen to receive extra protons and carbon to form water and CO2. Action ...... Principal form of glucose used by the body readily absorbed via the digestive tract. Pharmacokinetics ...... Rapid absorption in bloodstream Contraindications ...... Patients that are unconscious or unable to control their airway, not recommended for patients < 2 years of age. Adverse effects ...... Airway compromise during administration Indications ...... Patients with blood glucose level < 50 with altered mentation and who can control their airway and are able to swallow.
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 30 Pyridoxine
Class ...... Vitamin B6 Action ...... Vitamin B6 acts as a coenzyme necessary for the metabolism of fats, proteins and carbohydrates. It helps with the functioning of the immune and nervous systems and the formation red blood cells. Asthma, diabetes and PMS (premenstrual syndrome) sufferers may benefit from this vitamin, plus it may also lower cholesterol and help prevent heart disease. Along with tryptophan, vitamin B6 is used to produce niacin. Contraindications ...... None in the Toxic Exposure of Hydrazine Precaution ...... Pyridoxine is safe for most people. In some people, pyridoxine might cause nausea, vomiting, stomach pain, loss of appetite, headache, tingling, sleepiness, and other side effects. Indications ...... Toxic Exposure of Hydrazine
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 31 Rocuronium Bromide (Zemuron) Class ...... Non-depolarizing neuromuscular blocker Action ...... The relaxation of skeletal muscles which facilitates endotracheal intubation and mechanical ventilation. Pharmacokinetics ...... Binds to receptors and prevents acetylcholine (Ach) from stimulating receptors. It competes with Ach for nicotinic receptor binding sites. The blockade is competitive, hence muscle paralysis occurs gradually. Contraindications ...... None Adverse effects ...... Prolonged paralysis Indications ...... To facilitate intubation
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 32 Sodium Bicarbonate Class ...... Electrolyte Action ...... Short-acting, potent, systemic antacid. Immediately raises the pH of blood plasma by buffering excess hydrogen ions. This occurs because the Na+ (sodium) and the HCO3- (bicarbonate ion) separate in solution. While separate the negative charge on the bicarbonate is able to accept (and will prefer over sodium) hydrogen ions. The HCO3- then becomes H2CO3 which the body will turn into water and CO2. In tricyclic overdoses the Na+ ion is important also in its use to attempt to overcome the sodium blockade that occurs. Pharmacokinetics ...... Onset immediate, duration 1-2h. Contraindications ...... None on an indicate condition. Adverse effects ...... Metabolic acidosis, hypokalemia, fluid overload. Indications ...... Overdose, Hyperkalemic Arrest, Neonatal Resuscitation (OLMC), Burns, Crush Injuries
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF - 33 Sodium Nitrite Class ...... Nitrates and Nitrites Action ...... The mechanism of action may be by inducing low levels of methemoglobinemia. Another postulated mechanism is by acting through nitric oxide synthetase. Airway management and provision of supplemental oxygen increase efficacy. Pharmacokinetics ...... Sodium nitrite antagonizes acetylcholine, epinephrine, and histamine effects; sodium nitrite potentiates hypotensive effects and/or anticholinergic effects of tricyclic antidepressants, antihistamines, and meperidine and related CNS depressants; ethanol increases the toxicity of amyl nitrite. Contraindications ...... Relative Contraindications: Significant hypotension Methemoglobinemia >40% Carbon monoxide poisoning Absolute Contraindications: Known Allergy to Medication Adverse effects ...... Cardiovascular: Tachycardia, syncope, cyanosis, hypotension (associated with rapid infusion), flushing Central nervous system: Dizziness, headache Gastrointestinal: Nausea, vomiting Miscellaneous: Methemoglobin formation Indications ...... Significant cyanide, cyanogenic compound, or sulfide poisioning
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 34 Sodium Thiosulfate Class ...... Crystalline Salt Action ...... Sodium thiosulfate provides sulfane sulfur which is needed by the hepatic enzyme rhodanese to change cyanide into thicyanate that is then excreted in the urine. The availability of sulfane sulfur is a rate- limiting step for this reaction. Endogenous supplies of sulfane sulfur (mostly in sulfur-containing amino acids) are insufficient during cyanide or cyanogenic compound poisoning. Pharmacokinetics ...... When administered intravenously, it is distributed in the extracellular fluid and then rapidly excreted via the urine. Contraindications ...... Relative Contraindications: An unprotected, at risk airway. This is because many patients will vomit and could aspirate. Absolute Contraindications: NONE Adverse effects ...... Cardiovascular: Hypotension Central nervous system: Coma, CNS depression secondary to thiocyanate intoxication, psychosis, confusion Dermatologic: Contact dermatitis Local: Local irritation Neuromuscular & skeletal: Weakness Otic: Tinnitus Indications ...... Significant cyanide or cyanogenic compound poisoning
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 35 Terbutaline Sulfate
Class ...... beta-adrenergic agonist bronchodilator available as a sterile, nonpyrogenic, aqueous solution in vials, for subcutaneous administration. Action ...... Terbutaline is a beta-adrenergic receptor agonist. In vitro and in vivo pharmacologic studies have demonstrated that terbutaline exerts a preferential effect on beta2-adrenergic receptors. While it is recognized that beta2-adrenergic receptors are the predominant receptors in bronchial smooth muscle, data indicate that there is a population of beta2-receptors in the human heart, existing in a concentration between 10% to 50%. The precise function of these receptors has not been established. Controlled clinical studies have shown that terbutaline relieves bronchospasm in acute and chronic obstructive pulmonary disease by significantly increasing pulmonary flow rates (e.g., an increase of 15% or more in FEV1). After subcutaneous administration of 0.25 mg of terbutaline, a measurable change in expiratory flow rate usually occurs within 5 minutes, and a clinically significant increase in FEV1 occurs within 15 minutes. The maximum effect usually occurs within 30 to 60 minutes, and clinically significant bronchodilator activity may continue for 1.5 to 4 hours. The duration of clinically significant improvement is comparable to that observed with equimilligram doses of epinephrine. Contraindications ...... Terbutaline sulfate injection is contraindicated in patients known to be hypersensitive to sympathomimetic amines or any component of this drug product. Precaution ...... Terbutaline, as with all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, including ischemic heart disease, hypertension, and cardiac arrhythmias; in patients with hyperthyroidism or diabetes mellitus; and in patients who are unusually responsive to sympathomimetic amines or who have convulsive disorders. Adverse effects ...... Significant changes in systolic and diastolic blood pressure have been seen and could be expected to occur in some patients after use of any beta-adrenergic bronchodilator.Immediate hypersensitivity reactions and exacerbations of bronchospasm have been reported after terbutaline administration. Indications ...... Respiratory distress in patients > 36 Kg during remote rescue events with significant extraction time and transport delay
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 36 Toradol
Class ...... NSAID Action ...... Analgesic (peripherally acting) anti-inflammatory, Cyclo-oxygenase (COX 1/2) inhibitor Contraindications………Hypersensitivity, Pregnancy, Age <2yrs, Bleeding, Renal dysfunction Adverse effects ...... Nausea, somnolence, heartburn Indications ...... Moderate to severe pain
VERSION 02012020 CLINICAL OPERATING GUIDELINES DRUG FORMULARY UPDATED 02-01-2020 DF – 37 Tranexamic Acid (TXA) Class ...... Anti-fibrionolytic agent Action ...... Used to treat or prevent excessive blood loss due to trauma Pharmacokinetics ...... Tranexamic Acid is a competitive inhibitor of plasminogen activation (inhibiting the activation of plasminogen to plasmin) and, at high doses, noncompetitively blocks plasmin. Contraindications ...... Patients under 17 years old. Administration of TXA should not delay transport. Adverse effects ...... Acute gastrointestinal disturbances (nausea/vomiting, diarrhea). Hypotension has been observed when intravenous injection is too rapid. Indications ...... Multi-system trauma patients exhibiting signs and symptoms of hemorrhagic shock (e.g., cool, clammy skin, tachycardic, hypotensive, AMS). Injury must have occurred within the last 3 hours.
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