Regional Paramedic Protocols

Region V Medical Advisory Committee

2006 Revision V – 15 NOV 2008

Charlotte Hungerford Hospital Danbury Hospital New Milford Hospital Sharon Hospital Saint Mary’s Hospital Waterbury Hospital

1 15 NOV 2008 Revision V Table of Contents Preamble, Disclaimers, Mission Statement……………………..…………………… ……... 3-5 Chapter 1 - General Guidelines…………………………………..………………….…..…... 6 Primary Paramedic Care 7 Patient Assessment 8 Patient Care Reports 9 On-Line Medical Oversight / Communications 10 Release of Patient Care to BLS 11 Refusal of Medical Assistance 12-3 Chapter 2 - Airway Management…………………………………..…………………………. 14 Complete Airway Obstruction 15 Oxygen Therapy 16 Orotracheal Intubation 17-8 Bougie Intubation Stylet 19 Nasotracheal Intubation 20 Medication Facilitated Intubation 21-4 Rapid Sequence Intubation 25-8 Chapter 3 - Alternative Airway Management…………………………..…………………… 29 Laryngeal Mask Airway 30 Combitube 31 Needle Cricothyrotomy 32-3 Chapter 4 - Respiratory Emergencies………………………………….……………………..34 Acute Pulmonary Edema 35 Reactive Airway Disease 36 Exacerbation of COPD 37 CPAP Utilization 38-9 Chapter 5 - ACLS Algorithms……………………………………………..…………………… 40 Adult BLS Guidelines 41 Pulseless Arrest Algorithm 42 Bradycardia 43 Tachycardia 44 Chapter 6 - Cardiac Emergencies……………………….…………………………………….45 Acute Coronary Syndromes 46 Suspected Ischemic Chest Pain 47 12 lead EKG 48 Cardiogenic Shock 49 Chapter 7 - Altered Mental Status………………………………...…………………………... 50 Cerebrovascular Accident / Stroke / Intracranial Bleed 51 Hypoglycemia–Hyperglycemia 52 Opiate Overdose 53 Toxicology 54-5 Seizures 56 Sepsis / Fever 57 Coma of Unknown Etiology 58 Mucosal Medication Administration 59 Chapter 8 - Environmental Emergencies……………………..……………………………... 60 Allergic Reaction 61 Anaphylaxis 62 Cold Emergencies 63 Hypothermic Arrest 64 Heat Emergencies 65 Near Drowning 66 Chapter 9 - General Medical Emergencies……………………..…………………………... 67 Acute Abdomen 68 Gastrointestinal Bleeding 69 Psychiatric Emergencies 70 Dystonic Reactions 71 2 15 NOV 2008 Revision V Pain Management for Procedures 72 Intraosseous Access via EZ-IO™ 73-4 Chapter 10 - Adult Trauma Care………………………………..…………………………….. 75 Injured Patient Triage Protocol 76 Trauma Alert Criteria 77-8 Assessment & Treatment of the Trauma Patient 79-82 Spinal Assessment and Immobilization Criteria 83 Isolated Trauma Pain Management 84 Burn Management 85-9 Chapter 11 - OB-GYN / Neonatal Resuscitation………………………………...……………90 Pre-eclampsia and Eclampsia 91 Antepartum Hemorrhage 92 Trauma in Pregnancy 93 Emergent Childbirth 94 Neonatal Assessment & Treatment 95 Delivery Complications 96 Postpartum Maternal Care 97 Chapter 12 - Pediatrics……………………………………………………………….………... 98 Primary Paramedic Pediatric Assessment and Care 99 Pediatric Development and Vital Signs by Age 100-2 Pediatric Airway Management 103 Pediatric Respiratory Distress 104 Pediatric Asthma 105 Pediatric Suspected Croup or Epiglottitis 106 Pediatric Allergic Reaction 107 Pediatric Anaphylaxis 108 Pediatric Pulseless Arrest 109 Pediatric Bradycardia 110 Pediatric Tachycardia 111 Pediatric Altered Mental Status / Hypoglycemia / Coma 112 Pediatric Seizures / Status Epilepticus 113 Pediatric Rectal Diazepam Administration 114 Pediatric Trauma Injured Patient Triage Protocol 116-9 Pediatric Burns 120 Pharmacology……………………………………………………………………………………. 121-56 Release Notes……………………………………………………………………………………. 157

3 15 NOV 2008 Revision V

4 15 NOV 2008 Revision V Mission Statement For the Region V Medical Advisory Committee Clinical Coordinators Sub-Committee

The mission of the Clinical Coordinators Sub-Committee on regionalization is to facilitate uniform medical oversight of EMS through a cooperative committee represented by all sponsor hospitals in the region. Under the auspices of the Medical Advisory Committee, and working in collaboration with the EMS providers, the sub-committee will standardize the EMS practices and policies for all of the services and providers sponsored by the hospitals in EMS Region V.

Sponsor Hospital Specific Guidelines

While every effort has been made to regionalize our guidelines, there are certain treatment modalities available that are sponsor hospital specific. Throughout these protocols if a treatment is sponsor hospital specific the name of the sponsor hospital is listed under the main heading for that treatment. This does not indicate the receiving hospital, but your service’s medical oversight sponsor hospital. If you are unsure, please check with you service prior to initiation of patient care.

Important Caution

Information contained in these protocols is compiled from sources believed to be reliable and accurate, however, this cannot be guaranteed. Despite our best efforts there may be typographical errors and/or omissions. The Region V EMS Council and the Members of the Medical Advisory Committee are not liable for any loss or damage that may result from these errors or omissions.

Online Medical Oversight

It is agreed upon that Region V prehospital providers will contact the Region V receiving hospital to obtaining patient care orders. This does not apply for specialty care procedures where indicated by guideline. When transporting to a hospital outside of Region V, prehospital providers must contact their Region V Sponsor Hospital for Medical Oversight.

Communication Failure

In the event of complete communication failure, these protocols will act as the parameters for pre- hospital patient care. If communication failure occurs the Paramedic may follow the guidelines through standing orders only to render appropriate and timely emergency care to the patient.

Upon arrival at the receiving hospital the Paramedic will immediately complete an incident report relating to the communication failure. This incident report must be filed with the Paramedic’s sponsor hospital EMS Coordinator along with a copy of the patient care report within 24hr of the event.

5 15 NOV 2008 Revision V Chapter 1 General Guidelines Primary Paramedic Care 7 Patient Assessment 8 Patient Care Reports 9 On-Line Medical Oversight / Communications 10 Release of Patient Care to BLS 11 Refusal of Medical Assistance 12-3

6 15 NOV 2008 Revision V Primary Paramedic Care

1) Assess / Address Airway, Breathing, Circulation according to current ECC Guidelines with Cervical Spine Protection per NHTSA Standards where indicated. 2) Place patient in position of comfort unless otherwise indicated. 3) Initiate Basic Life Support (BLS) Care and Oxygen Therapy per current NHTSA Standards or regional guideline. 4) Perform Patient Assessment (see patient assessment guideline). 5) Obtain and record Baseline Vital Signs. 6) Initiate Pulse Oximetry monitoring as indicated. 7) Initiate Cardiac Monitoring as indicated. 8) Initiate Capnography as indicated. 9) Establish Intravenous Access as indicated. 10) Initiate specific treatment per protocol / guideline based upon patient presentation. 11) Obtain and record Serial Vital Signs (pre- and post-intervention or as indicated by patient condition [q5min for unstable patients and q15min for stable patients]) 12) Destination hospital choice is based upon Patient Condition, Patient Request, Trauma Regulation, or Online Medical Oversight. 13) Contact destination hospital for patient notification and pending arrival as required by the receiving facility, and/or specific protocol, giving as much notification as possible for in hospital activation of special services as required by the patient’s condition. For example, hen transporting patients with signs and symptoms of a stroke such as: a) Unilateral weakness or numbness of an extremity b) Unilateral weakness or numbness of the face or body c) Unilateral vision loss or deficit (not trauma related) d) Difficulty walking e) Cannot understand what someone is saying f) Feeling dizzy or losing their balance g) Difficulty speaking Request that C-MED announce a Stroke Alert when setting up your patch.

7 15 NOV 2008 Revision V Patient Assessment

Each patient is to have an initial assessment as outlined in this section. Depending upon the results of this patient assessment, the provider will advance to provide appropriate treatment. This constitutes the minimal acceptable assessment. More detailed assessments may be required dependant on patient complaint and condition. 1) General Appearance a) Age and gender b) General state of health c) Amount of distress (mild, moderate, severe) 2) Objective Signs a) Level of consciousness b) Respiratory assessment c) Skin: Temperature, color, moisture d) Pupil status e) Glasgow Coma Scale / Trauma Score if indicated 3) Vital Signs a) Pulse: rate, quality, and rhythm b) Respiratory rate, character of breath sounds c) Blood pressure d) Pulse oximetry 4) History of Episode (obtained from patient, family, or observer) a) Chief complaint b) Time of incident or onset of symptoms c) Prior treatment if related to present illness or injury d) Mechanism of injury if trauma 5) Pertinent Medical History a) Previous medical problems or conditions b) Routine medications c) Allergies 6) Other Pertinent History a) Social (substance abuse, smoking, violence, etc.) b) Family (cardiac, diabetic, asthma) c) Obstetrical / Gynecological (GxPx, LMP) d) Systems review focused to presentation Written Documentation shall be left with every patient in the form of service specific Patient Care Reports (see Patient Care Report Protocol).

8 15 NOV 2008 Revision V Patient Care Reports

Procedure: Emergency Medical Service Patient Care Report (PCR) or a state authorized equivalent will be used to document each patient encounter in the prehospital setting. PCR's will be routinely completed at the time of patient delivery to the receiving facility. In the event the PCR cannot be completed prior to being dispatched to another emergency call, the PCR will be completed and delivered to the receiving emergency department as soon as possible after the call and within that working shift. All PCRs will be completed as follows: 1) The hospital copy of the PCR will be left with the Emergency Department Staff and/or attached to the patients Hospital Medical Record. 2) An EKG rhythm strip will be obtained on all patients who have pertinent EKG tracings (related to patient condition) and any aberrant EKGs. The strip will be affixed with tape or staple to each part of the run report. Please do not tape over any section of the strip, or monitor identifier, as this may destroy the printing. The patient's name and date of the incident will be written on the strip. . 3) All areas of the PCR will be completed including all times. 4) Each PCR will be signed by the attending EMS staff. 5) One copy of each PCR will be left with the receiving hospital’s EMS Coordinator. 6) Any addendum paperwork will be attached to each copy of the PCR. 7) The receiving Medical Control Physician will sign the PCR as required by the services primary Sponsor Hospital policy. 8) The PCR will be legible and complete. 9) All vital signs, interventions and drug dosages will be listed along with their time of initiation. 10) Any service/agency/provider utilizing electronic patient care reports (EPCR) shall make arrangements with their Sponsor Hospital for quality assurance compliance.

9 15 NOV 2008 Revision V Establishing Online Medical Oversight

When establishing Online Medical Oversight for special procedures or medication administration, it is crucial to use a triple verification process to ensure all orders are heard and carried out appropriately. 1) Request a patch from C-MED stating the need for a physician for “Medical Control”. When C- MED contacts the hospital they will request a physician for you. 2) Confirm that you are speaking with a physician, and the name of the physician, whenever possible. 3) When giving your patch, relay all ongoing treatments, relative and absolute contraindications, and make your specific request for treatment. This shall include: a) The name of the medication being requested. b) The dosage of the medication being requested. c) The route to administer the medication being requested (e.g., “I would like to administer 100mg of Lidocaine IV Push”). 4) If you are unsure of the proper dose, please relay the weight of the patient, and ask for the dose they would like administered. 5) The physician will confirm or deny the order as “Affirmative, administer 100mg of Lidocaine IV Push” or “Negative, do not administer Lidocaine at this time”. 6) You must reply to the physician that you have received the order, and that you are going to carry that order out (e.g., “Received, I am going to administer 100mg of Lidocaine IV Push” or “Received, I am withholding Lidocaine at this time”). 7) You must document the Online Physician name, the time, amount of medication administered, or denial of the order. Communications

Medical Oversight will be obtained primarily from patching through a regional dispatch or C- MED center. If you are unable to contact a center, Medical Oversight will be obtained from the hospital where the patient is being transported. If the patient is going to be transported to a hospital other than those listed below, then your sponsor hospital will be utilized as Online Medical Oversight. Charlotte Hungerford Hospital can be reached by telephone at the following numbers: (860) 496-6650 Emergency Department (860) 496-6666 Hospital Operator Danbury Hospital can be reached by telephone at the following numbers: (203) 739-6757 Emergency Department – Medical Control (203) 739-7100 Emergency Department – RN Station (203) 739-7000 Hospital Operator New Milford Hospital can be reached by telephone at the following numbers: (860) 350-7222 Emergency Department (860) 355-2611 Hospital Operator Saint Mary's Hospital can be reached by telephone at the following numbers: (203) 709-6004 Emergency Department (203) 709-6000 Hospital Operator Sharon Hospital can be reached by telephone at the following numbers: (860) 364-4111 Emergency Department (860) 364-4141 Hospital Operator Waterbury Hospital can be reached by telephone at the following numbers: (203) 573-6290 Emergency Department (203) 573-6000 Hospital Operator The Northwest Connecticut Public Safety Communications Center, Inc (Northwest C-MED) is capable of conducting patches to receiving facilities via telephone. They can be reached by telephone at the following numbers: (203) 758-0054 Primary Recorded Telephone Line (203) 758-0050 Secondary Recorded Telephone Line

10 15 NOV 2008 Revision V Release of Patient Care to BLS Transport

Paramedics are frequently dispatched to incidents that ultimately do not require advanced life support (ALS) intervention. Due to the limited availability of paramedic resources it is necessary to provide a mechanism whereby paramedics may clear from such incidents and become available for other emergencies. However, priority shall always be given to the needs of the patient immediately at hand. This Guideline applies to routine incidents that do not, in and of themselves, overtax the available ALS resources. The requirements of this Guideline may be waived in the setting of multiple casualty or mass casualty incidents. 1) It is acceptable for a paramedic to release a patient to the care of basic life support (BLS) EMS personnel if all of the following criteria are met: a) The paramedic has assessed the patient using BLS assessment tools and has, with a high degree of confidence, determined that prehospital ALS intervention and monitoring are not indicated and will not be indicated subsequently. b) The BLS ambulance personnel agree to accept responsibility for subsequent prehospital patient care. c) The paramedic and BLS crew agree on a plan for the subsequent prehospital care of the patient. 2) The paramedic may not release the patient to BLS care in any of the following circumstances: a) The paramedic’s assessment findings indicate the need for prehospital ALS care or monitoring. b) The paramedic has performed ALS assessments or treatments, including cardiac monitoring, 12 lead EKG, or capnography. c) BLS personnel are unwilling to accept responsibility for patient care. d) The paramedic and BLS personnel cannot reach agreement on a plan for the patient’s subsequent prehospital care. 3) Once the paramedic has established contact with a patient, that patient becomes the paramedic’s primary responsibility. A decision to release the patient to BLS care shall be made solely on the basis of a thorough and objective assessment of the patient’s clinical status and needs. Other factors (e.g., pending calls, imminent shift change, destination hospital, etc.) must not be factored into a decision to release a patient to BLS care. 4) Documentation: All cases in which patients are released to the care of BLS personnel must be thoroughly documented using an appropriate Documentation Form. All aspects of patient assessment and treatment prior to release of care to BLS shall be documented. 5) All BLS downgrades are subject to Quality Assurance/Improvement review.

11 15 NOV 2008 Revision V Refusal of Medical Assistance

In most cases, patients have a legal right to refuse medical care and transportation to a hospital. However, there are many situations in which a patient’s refusal of medical assistance (RMA) may not be legally valid and there is a significant risk of civil liability associated with an invalid RMA. It has been estimated that between 50% and 90% of all litigation against prehospital EMS providers results from cases involving refusal of medical assistance. This Guideline has been developed to provide a standardized process for dealing with RMA cases that minimizes clinical risk to patients and legal risk to paramedics.

There are three components to a valid RMA. Absence of any of these components will most likely result in an invalid RMA. The three components are as follows: 1) Competence: In general, a patient who is an adult or a legally emancipated minor is considered legally competent to refuse care. A parent or legal guardian who is on-scene may refuse care on his or her minor children’s behalf. 2) Capacity: In order to refuse medical assistance a patient must have the capacity to understand the nature of his or her medical condition, the risks and benefits associated with the proposed treatment, and the risks associated with refusal of care. 3) Informed Refusal: A patient must be fully informed about his or her medical condition, the risks and benefits associated with the proposed treatment and the risks associated with refusing care.

The paramedic must make every reasonable effort to convince a reluctant patient to accept medially indicated care and transportation to a hospital before accepting a patient’s RMA as a final disposition. This includes assessing the patient, advising the patient about the situation and attempting to persuade him/her to accept care and transportation. 1) Assess the patient. a) Perform a complete clinical assessment of the patient, including the following: i) Chief complaint and associated complaints ii) History of present illness iii) Past medical history iv) Thorough physical exam, including assessment of mental status and vital signs. b) To the extent possible, assess the patient’s legal competence to refuse care. c) Assess the patient’s capacity to comprehend the implications of the refusal. 2) Advise the patient. a) Explicitly advise the patient of his/her medical condition, the proposed treatment and the risks associated with refusing care. b) Avoid the use of complex medical terminology. c) Explain the limitations of a prehospital clinical assessment. d) Assess the patient’s understanding of the situation as you have explained it. Ask the patient to repeat back to you, in his/her own words, what you have just explained to them. 3) Attempt to persuade the patient. a) Attempt to convince the patient of the necessity for treatment and/or transport. Candidly reiterate the potential consequences of the RMA. Exploit any uncertainty on the patient’s part. b) Contact on-line medical control if indicated or mandated. On-line medical control is a resource that may be accessed at any time to assist in preventing an RMA or in determining the need for protective custody as an option. c) Contact police if appropriate. Patients who refuse medical assistance but do not meet the criteria for a valid RMA can be problematic. Consider involving law enforcement in such situations. 4) Document When dealing with patients who are refusing treatment and/or transportation, thorough documentation is especially critical in avoiding significant liability. Using the appropriate report form, the following information should be documented for every RMA case: a) Accurate patient information, times of occurrence and date b) A complete physical assessment, including vital signs 12 15 NOV 2008 Revision V c) The patient’s chief complaint, associated complaints, history of present illness and past medical history d) Evidence of the patient’s capacity to refuse medical assistance e) The patient’s signature on the RMA statement f) The signature of a police officer or other reliable witness to the refusal should be obtained on the RMA statement g) Itemized refusals (i.e. refusing an IV, but accepting transport and oxygen) should be documented clearly on the Paramedic Report Form

Establish Online Medical Oversight Possible Physician Orders: Several situations require the use of on-line medical control to determine disposition. These involve refusal of medical care or transportation by: 1) Patients who have had advanced life support initiated or would require advanced life support intervention based on their chief complaint and assessment 2) Patients who have suicidal ideation resulting in any gesture or attempt at self-harm, or any verbal or written expression of suicidal ideation regardless of any apparent ability to complete a suicide 3) Patients who are unemancipated minors (under the age of 18yr) not accompanied by parents 4) Patients who, for any reason, have an impaired capacity from making informed decisions 5) Patients who present with an altered mental status or diminished mental capacity, or who present a threat to themselves 6) Patients whose initial complaint was indicative of stroke, or displayed signs/symptoms of stroke, but has now resolved

The paramedic must provide Online Medical Oversight with all relevant information and should allow the physician to converse directly with the patient by radio or telephone if necessary. The physician may determine if protective custody is to be pursued via police department. If the patient is allowed to RMA, then the paramedic will document the on-line medical control physician’s name on the cancellation or run form.

13 15 NOV 2008 Revision V

Chapter 2 Airway Management

Complete Airway Obstruction 15 Oxygen Therapy 16 Orotracheal Intubation 17-8 Bougie Intubation Stylet 19 Nasotracheal Intubation 20 Medication Facilitated Intubation 21-4 Rapid Sequence Intubation 25-8

14 15 NOV 2008 Revision V Complete Airway Obstruction

Conscious Patient 1) Assess to determine airway obstruction. 2) Perform Abdominal Thrusts for conscious patient. 3) Continue Abdominal Thrusts until airway is cleared or patient is rendered unconscious.

Unconscious Patient 1) Assess to determine unresponsiveness. 2) Attempt to establish airway to determine airway obstruction. 3) Initiate rescue breathing for unconscious patient as per current AHA Guidelines. 4) If airway is still obstructed perform direct laryngoscopy. 5) Attempt to remove any foreign bodies using Magill forceps. 6) If airway is still obstructed, attempt endotracheal intubation (if not already done).

Establish Online Medical Oversight Possible Physician Orders 1) Needle Cricothyrotomy 2) Other maneuvers as directed by Online Medical Oversight

15 15 NOV 2008 Revision V Oxygen Therapy

No patient in respiratory distress is to be denied oxygen therapy.

Patients who are in respiratory distress should be administered oxygen concentrations as appropriate to their condition. The preferred method of delivery is via nonrebreathing mask at 10-15l/min. Patients who cannot tolerate a facemask may be given oxygen via nasal cannula at 4- 6l/min.

Patients who are not in respiratory distress should receive oxygen therapy as indicated by patient presentation and/or protocol. Patients who are not in respiratory distress and are on home oxygen therapy should continue to receive oxygen at the same concentration as their home dose.

If a patient is not breathing adequately on his/her own, the treatment of choice is ventilation, not just oxygenation.

Monitor the patient receiving high concentrations of oxygen closely for signs of decreased level of consciousness and/or increased respiratory distress. Be prepared to provide ventilations if indicated.

16 15 NOV 2008 Revision V Orotracheal Intubation

Indications: To control the airway of an apneic patient, who requires assisted ventilation, lacks a gag reflex or has an altered mental status from a serious head injury. Orotracheal intubation is available on standing orders for apnea or respiratory depression.

Equipment: 1) Endotracheal tube (appropriate size for patient) 2) Laryngoscope handle and blade 3) Endotracheal tube stylet 4) 10ml syringe 5) Suction apparatus 6) Bag-valve-mask 7) Tube securing device 8) Capnography or colormetric end-tidal CO2 detector

Procedure: 1) Assemble equipment. 2) Check laryngoscope light. 3) Choose appropriate size tube. Be sure cuff is intact. 4) Prepare suction equipment. 5) If using a stylet, it should be placed inside the tube with the tip at least ½ inch from the distal end, proximal to Murphy’s eye. 6) Provide the patient with high concentration oxygen prior to intubation. If the patient’s respiratory rate is >= 10/min., use non-rebreather mask. If the patient’s respiratory rate is <10/min., ventilate with BVM and OPA or NPA. 7) Place patient’s head in “sniffing position.” Hyperextension should not be used for patients with suspected spine injuries or for newborns and young children. Have an assistant stabilize the neck during intubation if a neck injury is possible. 8) Insert laryngoscope with the left hand while keeping the blade to the right of the midline and pushing the tongue to the left. 9) Slowly advance the blade. Remember, the curved (Macintosh) blade seats in the vallecula, while the straight (Miller) blade goes beneath the epiglottis. Exert gentle traction upward. Do not use the teeth as a fulcrum. If necessary, using the right hand, apply gentle, backward, upward, rightward pressure (BURP maneuver) to the thyroid cartilage to improve view of vocal cords. If available, an assistant may maintain this pressure. 10) Visualize the vocal cords. If there is difficulty in visualizing the vocal cords or in passing the endotracheal tube, see the Bougie Intubating Stylet protocol. Insert the tube with the right hand from the right side of the mouth through the vocal cords. 11) If a cuffed tube was used, inflate the cuff. 12) Assess endotracheal tube placement (see Algorithm for Confirming Endotracheal Tube Placement below) and secure or remove endotracheal tube accordingly. 13) While ventilating, auscultate the epigastrium and both sides of the chest. Confirm correct tube placement by the presence of bilateral breath sounds and absence of epigastric sounds. Visualize chest rise and fall with ventilations. 14) Assess for presence and waveform of end-tidal CO2 using capnography monitor. If no capnography monitor is available, use a colormetric end-tidal CO2 detector. End-tidal CO2 should be continuously monitored for all intubated patients. 15) Secure the tube. 16) Apply a cervical collar. Excess head movement has been shown in studies to cause movement of the ETT by up to 9cm. A cervical collar will help prevent this. 17) Intubation should not take more than 15-20sec from the end of BVM ventilations to the start of ventilations through the ETT.

Documentation shall include the following: 1) Tube depth 2) Number of attempts 17 15 NOV 2008 Revision V 3) Assessment of breath sounds and epigastric sounds 4) End-tidal CO2 levels and waveform 5) Application of cervical collar 6) Use of the Bougie Intubation Stylet

All intubated patients with a pulse should have pulse oximetry continuously monitored throughout transport and documented on the PCR.

Anytime the patient is moved, or a change in the lung compliance with ventilation is detected, the tube placement should be reassessed by auscultation and capnography and documented on the PCR.

18 15 NOV 2008 Revision V Bougie Intubation Stylet

Indications: Orotracheal Intuabtion attempt with difficulty visualizing the full glottic opening but positive visualization of the epiglottis.

Contraindications: 1) Patient <14yr. 2) Suspected inability to pass at least a 6.0mm endotracheal tube.

Protocol: 1) During laryngoscopy insert the Bougie Intubation Stylet with the 30-degree tip directed below the epiglottis. 2) Tactile confirmation of tracheal clicking will be felt as the distal tip of the Bougie Intubation Stylet bumps against the tracheal rings. 3) If tracheal clicking cannot be felt, continue to gently advance the Bougie Intubation Stylet until “hold up” is felt. 4) Tracheal clicking and “hold up” are positive signs that the Bougie Intubation Stylet has entered the trachea. 5) If no tracheal clicking or “hold up” is felt, esophageal placement is assumed, and reinsertion of the Bougie Intubation Stylet may be attempted twice. 6) When positive signs are felt, advance the bougie to a depth of approximately 25cm so that the distal tip lies at least 2-3cm beyond the glottic opening. 7) While holding the Bougie Intubation Stylet securely, advance the endotracheal tube over the proximal tip of the Bougie Intubation Stylet, guiding it to its normal depth. 8) Holding the endotracheal tube securely, remove the Bougie Intubation Stylet. 9) Return to the Orotracheal Intubation Protocol at Step 11.

19 15 NOV 2008 Revision V Nasotracheal Intubation

In cases where nasal intubation is indicated, Online Medical Oversight must be obtained prior to performing the procedure.

Indications: 1) Suspected trauma to the cervical spine 2) Trauma to the mouth / mandible 3) Trismus 4) Respiratory depression from drugs, alcohol, and stroke 5) Inability to intubate orally

Contraindications: 1) Apnea or Agonal Respirations 2) Known defect in blood clotting mechanism 3) Possible basilar skull fracture 4) Severe nasal polyps or other obvious nasal deformity

Procedure: 1) Gather appropriate equipment a) ET Tube 0.5-1mm smaller than you would use orally b) Neo-Synephrine spray c) Appropriate size NPA d) Water soluble lubricant (KY jelly or Surgi-Lube) e) Laryngoscope* f) Magill forceps* g) Suction h) Tape or tube tie 2) Place patient’s head in neutral or sniffing position. 3) Instill Neo-Synephrine spray in selected nostril. 4) Lubricate NPA with water soluble lubricant and place in selected nostril. 5) Pre-Oxygenate the patient. 6) Lubricate the selected ET Tube with a water soluble lubricant. 7) Remove the NPA. 8) Pass the tube through one nostril, parallel to the hard palate. Never try to force a nasotracheal tube past a point of resistance. 9) Grasp larynx with opposite hand, to stabilize the trachea in the mid-line, and sense the location of the tube as it advances. 10) Once the tube reaches the pharynx, listen for airflow noise and look for condensation in the tube, then guide the tube through the larynx into the trachea during inspiration. 11) If air is not heard through the tube, the tube may be in the esophagus. Withdraw until air is heard, and reattempt passing the tube. 12) The tube may be visualized while superior to the trachea using a laryngoscope. In this situation, the patient may tolerate manipulation of the tube with McGill Forceps into the trachea. Please note that orotracheal intubation is preferable to nasotracheal intubation and should be used instead of nasotracheal intubation whenever possible. 13) If unsuccessful after second attempt withdraw the tube completely and resume BLS Airway management. 14) If passed successfully the patient may cough. Hold tube securely so it is not coughed out of position. 15) Inflate the cuff. 16) Check the position of the tube by listening for breath sounds bilaterally as the patient is ventilated. Auscultate 5 points. Apply capnography if available. 17) Secure the tube in place.

*Note: If you are able to visualize the vocal cords, oral intubation will be the preferred method of airway management. 20 15 NOV 2008 Revision V Medication Facilitated Intubation

Charlotte Hungerford Hospital, Danbury Hospital, St. Mary’s Hospital, New Milford Hospital, Waterbury Hospital

Medication Facilitated Intubation should be considered in cases where endotracheal intubation has been deemed necessary but the patient cannot tolerate conscious intubation. Online Medical Oversight from your service’s sponsor hospital is required, regardless of receiving facility. The paramedic should request an order for “Medication Facilitated Intubation”. This will include pre- sedation medication, Etomidate, and post-sedation medication, as well as ancillary medications.

Indications: 1) A critical need for airway control exists, such as: a) Patients who present hypoxic refractory to oxygen administration and underlying pathology treatment. b) Patients with a depressed level of consciousness refractory to treatment. c) Combative patients with compromised airway control. d) Patients who cannot tolerate conscious intubations. 2) At any time risk for potential / actual airway compromise is suspected.

Absolute Contraindications: 1) <8yr. 2) Upper airway obstruction. 3) Acute epiglottitis. 4) Patients whom you cannot ventilate with a Bag Valve Mask. 5) Patients in who needle cricothyroidotomy would be difficult or impossible. 6) Patients with trismus.

Complications: 1) Myoclonus. 2) Pain at injection site. 3) Apnea and hypotension in overdosage. 4) Inadequate sedation in under dosage. 5) Reflex hypertension and tachycardia. 6) Aspiration.

Assessment Sequence: MEDICTUBES + T is the assessment sequence you must follow for your guideline. These are relative contraindications (with the exception of trismus) because they may yield difficult intubations. Remember to treat underlying pathologies. 1) Mandible / Mouth: Assure proper range of motion of the mandible. Make sure the mandible is free from fracture and / or dislocation. Check the width of the mouth’s opening. A three- finger width is optimal. 2) Excessive Weight: Obese patients can have short necks that can make aligning the axis of the airway difficult. 3) Deformity: Inspect the face, mouth, mandible, neck, and oropharynx for deformity or anything that may obscure visualization. 4) Incisors: Inspect the size of the patient’s teeth. “Buck Teeth” or large incisors can obstruct visualization. Check for and remove any dental appliances that may be loose, or become loosened during the procedure. 5) C-Spine: Patients that are in cervical immobilization must have in line stabilization maintained. 6) Thyromental Distance: Measure the distance from the tip of the chin to the trachea. A three- finger width is ideal. A less than three finger width indicates an anterior trachea. 7) Uvula: Have the patient open their mouth and visualize the uvula. The greater the visualization of the uvula, the larger the mouth’s opening and the smaller the tongue size. 8) Burns: Be cautious of oral burns as swelling and burning may obscure or obstruct visualization. 9) Emisis: Be sure to have working suction at hand, and suction the oropharynx of vomit or blood. 10) Stridor: Rule out foreign body obstruction and possible epiglottitis. Apply BVM ventilation to 21 15 NOV 2008 Revision V assure mask seal. If you are unable to make a mask seal, do not proceed with Etomidate. 11) Trismus: If present, do not use Etomidate.

Preparation: 1) Assemble all necessary equipment and personnel (suction, BVM with correctly sized mask, appropriately sized ET Tubes, working laryngoscope, pulse oximeter, end-tidal CO2 monitor, heart monitor) Ensure Combi-Tube or LMA and Needle Cricothyroidotomy equipment are prepared. 2) Assure free flowing IV access in appropriate location. 3) Connect cardiac monitor and pulse oximetry. 4) Assign specific duties to scene personnel. (Bagging, application of cricoid pressure, medication administration) 5) Position the patient in the sniffing position or use in line cervical stabilization if indicated.

Oxygenation: The goal of a rapid induction is to have a controlled intubation. Once properly assessed the patient must be pre-oxygenated. 1) It is ideal to allow the patient to spontaneously breath 100% oxygen for 4-5min to “wash out” the nitrogen reservoir in the lungs and replace it with an oxygen reservoir. 2) If the patient is not breathing adequately or if you are unable to wait 4-5min, 4 vital capacity breaths with a BVM and 100% oxygen are sufficient. 1-2min of assisted ventilation with a BVM are ideal. 3) Do not allow the patient to be aggressively bagged as this may yield gastric distention and increase the risk of vomiting and aspiration. A properly pre-oxygenated patient can be safely apneic for 2-3min without serious hypoxia.

Procedure: 1) Assess patient with MEDICTUBES+T. 2) Contact Online Medical Oversight from service sponsor hospital requesting permission for a “Medication Facilitated Intubation” which will include orders for Lorazepam or Diazepam, pre- and post-intubation, Etomidate, and Lidocaine. 3) Pre-oxygenate as above and monitor pulse oximetry. (Pulse oximeter is required). 4) Position the patient. 5) Pre-medicate as appropriate a) Lidocaine: 1-1.5mg/kg IV 2-3min prior to intubation attempt if you suspect increased intracranial pressure (bleeding, trauma, CVA) b) Lorazepam 1-2mg or Diazepam 3-5mg for sedation. 6) Administer 0.3mg/kg Etomidate IV 7) Apply cricoid pressure 8) Continue to oxygenate with BVM and 100% oxygen. 9) Once patient is adequately relaxed, perform a controlled intubation. Patient may cough. Confirm tube placement by 5-point auscultation, checking oxygen saturation, and end-tidal CO2 if available. 10) If unable to intubate, ventilate patient with 100% oxygen via BVM. 11) Once adequately oxygenated reattempt intubation and confirm tube placement as above. 12) Once intubated, inflate the cuff, secure the endotracheal tube and: a) Administer 3-5mg diazepam or 1-2mg lorazepam for further sedation. b) Place bite block to prevent patient from biting the tube. c) Ventilate the patient with 100% oxygen. 13) If unable to intubate provide BVM ventilations with cricoid pressure and proceed to Failed Intubation Algorithm. 14) Complete all necessary documentation including quality assurance and peer review forms and submit with a copy of your “Code Summary” directly to the EMS Coordinator.

22 15 NOV 2008 Revision V New Milford Hospital St. Mary’s Hospital Waterbury Hospital

Etomidate Usage Information for QA/PI Patient Name: D.O.B.:

Call Location: Case Number:

Patient Presentation:

Patient Weight: Etomidate Dosage:

Lorazepam Dosage: Intubation Condition Achieved:

Intubation Success: Number of Attempts:

Intubation Complications:

Receiving Facility:

Medical Control Physician:

Additional Comments:

PLEASE INCLUDE A COPY OF YOUR PCR WITH THIS FORM

23 15 NOV 2008 Revision V Danbury Hospital

DO NOT PLACE THIS FORM ON THE PATIENT’S ED CHART!

Prehospital Airway Management QA/PI Form (MUST be completed for every patient that receives pre-hospital airway management)

Warning: The purpose of this form is to perform studies of morbidity and mortality. It contains protected health information, the unauthorized disclosure of which is a violation of HIPAA and of Hospital and Medical Staff Policies.

Date: ____ / ____ / ______C-Med Run #: ______Service: ______Time of Call: ____:____ Med-Con MD: ______PRE-AIRWAY MANAGEMENT DATA: Pt. Name: ______Age: _____ Gender: M F Est. Wt.: ______kg Pt. Med Record #: ______C-Spine Precautions? Y N Glasgow Coma Scale: Eye Opening:____ Verbal Response:____ Motor Response:____ Total:____ Eye Opening (4=Spontaneous, 3=To Voice, 2=To Pain, 1=None) Verbal Response (5=Oriented, 4=Confused, 3=Inappropriate, 2=Incomprehensible, 1=None) Motor Response (6=Obeys, 5=Localizes, 4=Withdraws, 3=Flexion, 2=Extension, 1=None) Initial Vital Signs: Time: ____:____ Respirations: _____ Pulse: _____ B/P: _____/_____ Sp02: _____% Airway Clear? Y N Suction? Y N Airway Adjuncts? N/A OPA NPA Pre-oxygenated/Pre-ventilated (min. 30sec)? Y N AIRWAY MANAGEMENT DATA: Time Airway Size Blade/Size Success Drug Dose Route Type Y/N : : : : : : Reason if meds required to intubate: Combative Emesis Trismus Laryngospasm Seizure Activity Anatomical Other: ______Level of relaxation: Good Fair Poor If unsuccessful, could airway be managed with BVM/BLS Airway? _____ If no, why not? ______Stylet Used? Y N Sellick’s Maneuver? Y N Alternative Airway Used? LMA Quick-Trach Complications: Vomiting? Y N Aspiration? Y N Arrhythmia? Y N POSTAIRWAY MANAGEMENT DATA: Primary Confirmation: Cords Visualized? Y N Breath Sounds? - L + - R + Misting? Y N Secondary Confirmation: EDD Inflated? Y N Easy Cap? Purple Tan Yellow ETCO2:____ Post Vital Signs: Time: ____:____ Respirations: _____ Pulse: _____ BP: _____/_____ Sp02: _____% Securing: Lip Line: _____cm Thomas Tube Holder? Y N C-Collar? Y N

PLEASE WRITE ADDITIONAL COMMENTS ON BACK OF FORM.

Paramedic Name: ______

EMT-B / EMT-I Name: ______

ATTACH COMPLETED FORM TO QA COPY ONLY AND PLACE IN THE EMS COORDINATOR’S RUN FORM BOX AT THE EMS DESK

*DO NOT PLACE THIS FORM ON THE PATIENT’S ED CHART!*

24 15 NOV 2008 Revision V Rapid Sequence Intubation Waterbury Hospital

Assessment Sequence: MEDICTUBES is the assessment sequence you must follow for your guideline. These are relative contraindications because they may yield difficult intubations. Remember to treat underlying pathologies. 1) Mandible / Mouth: Assure proper range of motion of the mandible. Make sure the mandible is free from fracture and / or dislocation. Check the width of the mouth’s opening. A three- finger width is optimal. 2) Excessive Weight: Obese patients can have short necks that can make aligning the axis of the airway difficult. 3) Deformity: Inspect the face, mouth, mandible, neck, and oropharynx for deformity or anything that may obscure visualization. 4) Incisors: Inspect the size of the patient’s teeth. “Buck Teeth” or large incisors can obstruct visualization. Check for and remove any dental appliances that may be loose, or become loosened during the procedure. 5) C-Spine: Patients that are in cervical immobilization must have in line stabilization maintained. 6) Thyromental Distance: Measure the distance from the tip of the chin to the trachea. A three- finger width is ideal. A less than three finger width indicates an anterior trachea. 7) Uvula: Have the patient open their mouth and visualize the uvula. The greater the visualization of the uvula, the larger the mouth’s opening and the smaller the tongue size. 8) Burns: Be cautious of oral burns as swelling and burning may obscure or obstruct visualization. 9) Emesis: Be sure to have working suction at hand, and suction the oropharynx of vomit or blood. 10) Stridor: Rule out foreign body obstruction and possible epiglottitis. Apply BVM ventilation to assure mask seal. If you are unable to make a mask seal, do not proceed with Etomidate.

Indications: 1) Patient requiring intubation that will not tolerate manipulation of the airway due to an intact gag reflex, trismus, or combativeness. 2) Patient in which blind nasal tracheal intubation is contraindicated. Examples: GCS<8, respiratory burns, CVA resulting in respiratory compromise, respiratory insufficiency refractory to other interventions, combative, hemodynamically unstable multisystem trauma.

Relative Contraindications: 1) Anatomically difficult intubations: severe maxillofacial malformations naturally occurring or caused by trauma (see MEDICTUBES Assessment Sequence): a) Large overbite b) Mouth opening <2 fingers width c) Chin to thyroid <2 fingers width, very short neck d) Upper airway obstructions e) Tracheal-bronchial injuries

Contraindications: 1) Provider not trained by Waterbury Hospital's RSI Program. 2) Contraindications to any RSI medications: 3) Allergies or acetyl cholinesterase inhibitors 4) Malignant hyperthermia 5) Hyperkalemia risk: a) Renal dialysis/failure b) CVA>7dy c) Muscular dystrophy, amyotrophic lateral sclerosis (ALS)… d) >7dy post: significant burn, crush, or spinal cord injuries 6) Open eye injury 7) Insufficient skilled personnel to assist pre and/or post intubation. 25 15 NOV 2008 Revision V 8) Potential inability to ventilate with a bag valve mask. 9) Inability to obtain MEDICAL CONTROL approval. 10) <12yr

Patient Preparation: 1) Routine BLS airway and spinal immobilization as indicated. 2) Hemodynamic monitoring: vital signs, EKG and pulse oximetry. 3) Establish vascular access. 4) Consider: 5) Hypoglycemia 6) Opiate overdose 7) Prepare intubation and suction equipment: 2 tubes, 2 blades, and stylet. 8) Have LMA and surgical cricothyroidotomy equipment within reach.

Equipment: 1) Secure, functioning IV line 2) 2 ET tubes with tested cuffs 3) O2 source 4) Bag and mask 5) 2 tested laryngoscope blades 6) Tested vacuum suction unit 7) Skilled assistant for cricoid pressure 8) Cricothyroidotomy tray or equipment 9) LMA (proper size) 10) Etomidate, Diazepam, Midazolam 11) Succinylcholine 10ml vial (200mg) 12) Atropine and Lidocaine 13) EKG, BP, pulse oximetry and end tital C02

Preparation: Assemble the following RSI medications:

Rx Preparation Dose

Atropine 1.0mg/ 10ml bristojet 0.5mg-1.0mg

Lidocaine 100mg/5ml bristojet 1.0mg/kg

Etomidate 20mg/10ml 20mg

Succinylcholine 200mg/10ml 1.5mg/kg-may repeat

Procedure: 1) Pre-oxygenate and ventilate as appropriate, for several minutes prior to RSI implementation. Suction as necessary. 2) Verify proper hemodynamic monitoring and patent vascular access. 3) CONTACT Online Medical Oversight, request “RSI”, state any and all contraindications. 4) If the patient is conscious, explain your treatment. 5) Apply cricoid pressure until intubation is completed and cuff inflated. 6) Using a three-way-stopcock sequentially inject IV/IO (use dosage table): a) Atropine for adults requiring a second dose of SUX. b) Atropine for adults with preexisting bradycardia c) Lidocaine- known/ suspected increasing intracranial pressure. d) Etomidate: After administering Etomidate 1 attempt at intubation may be made prior to using Succinylcholine. If intubation is successful, withhold Succinycholine and sedate if necessary with 2.0>4.0mg of Midazolam. If unable to intubate proceed to Succinylcholine. e) Succinylcholine for paralysis 26 15 NOV 2008 Revision V 7) Test for adequate paralysis, usually within 1-2min, by gently pushing the mandible forward, and decreased resistance to bag-mask ventilation. If fasciculation’s occur, wait for them to stop before attempting jaw manipulation or intubation. 8) Intubate, verify placement frequently, and secure tube with a bite block. 9) If unable to intubate, BVM assist and insert an LMA 10) If unable to ventilate, follow Failed Intubation Protocol 11) Assure continued sedation as warranted utilizing one of the following agents:

Rx Preparation Dose______

Midazolam 2mg/2ml in a 3ml syringe 2.0mg

Diazepam 10mg/2ml vial 0.1mg/kg

12) Upon call completion, attach a copy of the PCR to the CQI form, and leave with EMS Coordinator. 13) Report any atypical events to the Waterbury Hospital EMS Coordinator and Medical Director promptly.

27 15 NOV 2008 Revision V

Emergency Medical Services Tracheal Intubation Confirmation Form

Patient’s Name: ______

Age: ______Sex: ______Weight (kg): ______Date: ______

Reason for Intubation: ______

Patient’s Chief Complaint: ______

Patient’s Medical History: ______

Patient’s Medications: ______

Contraindications to RSI: ______Intubation Attempts: ______

Times: Onscene: ______Enroute to Hospital: ______At Hospital: ______

Vocal chords visualized? Yes____ No____ ETT seen to pass through the chords? Yes____ No____ Intubation successful? Yes____ No____ LMA used? Yes____ No____ ETCO2: ______

Drugs/dosages administered (only drugs given to facilitate intubation):

Etomidate dose______Midazolam dose______

Atropine dose______Lidocaine dose______

Succinylcholine dose______Diazepam dose______

Describe any difficulties encountered during or following the RSI procedure, your actions and the result. ______

______

______

______

Paramedic (print name): ______Signature: ______

E.D. Physician (print name): ______Signature: ______

Please attach a copy of the PCR!

28 15 NOV 2008 Revision V Chapter 3 Alternative Airway Management

Laryngeal Mask Airway 30 Combitube 31 Needle Cricothyrotomy 32-3

29 15 NOV 2008 Revision V Laryngeal Mask Airway Danbury Hospital, Waterbury Hospital

Indication: Unresponsive patients without a gag reflex in whom endotracheal intubation is unsuccessful after three attempts.

Contraindications: Ingestion of a caustic substance.

Procedure: 1) Have the first assistant maintain cricoid pressure while the second continues BVM ventilations. 2) Prepare the LMA according to training recommendations, assuring the correct size. 3) Ensure that 2 suction devices are present at the patient’s side and working properly. 4) Ensure that the patient is unresponsive to command / external stimuli with absent gag reflex during and post insertion. Should a gag reflex be present during the procedure, discontinue attempt. Should a gag reflex be present post-insertion, remove the LMA and prepare to suction. 5) Discontinue cricoid pressure, insert and inflate the LMA, ensure clear and equal breath sounds, bilateral chest rise, and absence of sounds over the epigastrum 6) If unable to insert the LMA, ventilate the patient with a BVM. 7) If unable to ventilate the patient with a BVM see Complete Airway Obstruction Protocol.

30 15 NOV 2008 Revision V Esophageal-Tracheal Combitube Charlotte Hungerford Hospital, Danbury Hospital, New Milford Hospital, St. Mary’s Hospital

Indication: Apneic patient without a gag reflex in whom endotracheal intubation is unsuccessful after three attempts.

Contraindications: 1) Patient under the age of 16yr. 2) Patient under 5’0’’ or over 6’6” in height (for patients under 5’0” a Combitube SA [small adult] may be used). 3) Ingestion of a caustic substance. 4) Severe oral facial trauma. 5) Esophageal disease. 6) Patient with a stoma.

Procedure: 1) Use basic precautions including gloves and goggles. 2) Ensure that 2 suction devices are present at the patient’s side and working properly. 3) Hyperoxygenate (NOT HYPERVENTILATE) patient before attempting placement. 4) Test equipment while patient is being oxygenated. 5) If basic airway is in place remove it; Keep head in neutral or slightly flexed position. 6) With one hand, grab tongue/mandible and lift towards ceiling. 7) With the other hand place the Combitube so that it follows the natural curve of the pharynx. 8) Insert to the tip of the mouth and advance gently until the printed ring is aligned with the teeth. 9) Do not force the Combitube. If the Combitube does not advance easily withdraw and reinsert. 10) Inflate the blue tube balloon with 100ml of air. Inflate the white tube balloon with 15ml of air. #1 Blue - will inflate the posterior pharyngeal balloon. #2 White - will inflate the distal balloon. 10) Begin ventilation through the longer blue connecting tube. If auscultation of breath sounds is positive and auscultation of gastric insufflation is negative, continue ventilations. 11) IF NECESSARY, if auscultation of breath sounds is negative, and gastric insufflation is positive, immediately begin ventilation through the shorter connecting clear tube. Confirm tracheal ventilation by ausculation of breath sounds and absence of gastric insufflation. 12) If unable to insert the Combitube, ventilate the patient with a BVM. 13) If unable to ventilate the patient with a BVM see Complete Airway Obstruction Protocol.

+ Removal of Combitube: 1) Reassure patient 2) Have suction ready and roll patient on their side. 3) Remove 100ml of air from #1 (Blue line). 4) Remove 15ml of air from #2 (White line). 5) Gently withdraw Combitube, suction patient as necessary

31 15 NOV 2008 Revision V Needle Crichothyrotomy

Adequate exhalation never forcefully occurs with this technique. The patient may develop hypercarbia (increased CO2) and increased air pressure in the lungs possibly causing alveoli to rupture.

Indication: Inability to secure the patient’s airway by any other procedure.

Cautions: 1) Needle cricothyrotomy is an invasive procedure and requires proper training and certification through one of the Regional Sponsor Hospitals. 2) Carbon dioxide (CO2) build-up occurs rapidly. The procedure can be used only for a short period of time (30min maximum) at which time a definitive airway must be established such as a Pertrach device. 3) The patient must have a patent airway or a means established to allow outflow of air from the lungs.

Contraindications: 1) The ability to establish an easier and less invasive airway rapidly. 2) Acute laryngeal disorders such as laryngeal fractures that cause landmark distortion or obliteration of landmarks. 3) Bleeding disorders. 4) Injury or obstruction below the level of the cricothyroid membrane.

Complications: 1) Pneumothorax 2) Subcutaneous emphysema 3) Catheter dislodgment 4) Hemorrhage 5) Esophageal or mediastinal injury 6) Hypercarbia

Equipment: 1) 14ga over-the-needle catheter 2) 10ml syringe 3) 3ml syringe 4) 15mm adapter from a 7.0mm ET tube 5) Bag-valve-mask 6) Oxygen 7) Providone iodine swabs 8) Adhesive tape 9) Trauma shears 10) Suction equipment 11) Gloves and Goggles

Procedure:

Establish Online Medical Oversight Possible Physician Orders: 1) Observe basic BSI precautions. 2) Prepare equipment: remove plunger from barrel of 3ml syringe. Attach 15mm adapter from the 7.0mm ET tube. 3) Palpate the thyroid cartilage, cricothyroid membrane, and suprasternal notch. 4) Prep the skin with two providone iodine or alcohol swabs. 5) You may attach the 10ml syringe to the over-the-needle catheter, or you may elect to use the catheter-needle assembly by itself. Puncture the skin over the cricothyroid membrane. 6) Advance the needle at a 45-degree angle caudally (toward the feet). 32 15 NOV 2008 Revision V 7) Carefully push the needle until it pops into the trachea (aspirate with the syringe as you advance the needle if you are using a syringe). 8) Free movement of air confirms you are in the trachea. 9) Advance the plastic catheter over the needle, holding the needle stationary, until the catheter hub comes to rest against the skin. 10) Holding the catheter securely, remove the needle. 11) Reconfirm the position of the catheter. Securely tape the catheter. 12) Attach the 3ml syringe with the 7.0ET adapter to the catheter hub. Attach the BVM to the adapter and forcefully ventilate the patient. Forcefully squeeze the BVM over one second to inflate and then remove the BVM to allow for exhalation (for 4seconds). 13) Constantly monitor the patient’s breath sounds, ventilation status, and color.

33 15 NOV 2008 Revision V Chapter 4 Respiratory Emergencies

Acute Pulmonary Edema 35 Reactive Airway Disease 36 Exacerbation of COPD 37 CPAP Utilization 38-9

34 15 NOV 2008 Revision V Acute Pulmonary Edema

CHF Vs Pneumonia: If the clinical impression is unclear and transport time is not prolonged, consider using nitroglycerin and withholding furosemide, or contacting Online Medical Oversight.

SBP >100mmHg 1) Primary Paramedic Care 2) Nitroglycerin 0.4mg (1/150gr.) SL a) Repeat NTG q5min to a total of 3 doses, symptom free or SBP <100mmHg. b) Do not give NTG if: i) IV unobtainable – administer 1st dose of NTG if SBP >=120mmHg and contact Online Medical Oversight ii) Patient took a phosphodiesterase inhibitor: (erectile dysfunction Rx) (1) Sildenafil (Viagra) or vardenafil (Levitra) within 24hr (2) Tadalafil (Cialis) within 48hr 3) CPAP utilization where available 4) Nitropaste 1-2in TD a) If systolic blood pressure falls below 120mmHg, remove nitropaste and clean the area. Elevate the patient’s legs, and contact medical control. 5) Furosemide a) If patient is not on furosemide daily, administer 40mg SIVP. b) If patient has NOT taken their daily dose of furosemide, administer 2x their usual daily dose up to 200mg SIVP. c) If patient has taken their daily dose of furosemide, repeat the daily dose up to 100mg SIVP. 6) Morphine Sulfate 2-5mg IV. Morphine may cause respiratory depression. Be prepared to assist ventilations or intubate as indicated

Establish Online Medical Oversight Possible Physician Orders 1) Repeat nitroglycerine 2) Repeat furosemide 3) Repeat morphine sulfate 2-5mg IV

SBP <100mmHg 1) Primary Paramedic Care

Establish Online Medical Oversight Possible Physician Orders: 1) Nitroglycerin SL 2) Furosemide 3) Morphine Sulfate 2-5mg IV 4) Dopamine IVI 5-20mcg/kg/min if SBP<70mmHg

35 15 NOV 2008 Revision V Reactive Airway Disease / Asthma

1) Primary Paramedic Care 2) If respirations begin to decrease in rate or depth with a change in mental status, begin to assist ventilations immediately. 3) Albuterol nebulizer treatment 2.5mg in 3ml NS, may repeat treatment x 2 a) Severe cases: ipratroprium bromide* 0.5mg nebulized in 2.5ml NS and albuterol will be combined (Combivent or DuoNeb) 3) Methylprednisolone 125mg SIVP

Establish Online Medical Oversight Possible Physician Orders: 1) Epinephrine** (1:1000) 0.3mg (0.01mg/kg) SQ, or 0.3mg of 1:10,000 SIVP 2) Repeat Nebulizer Treatment

*Do NOT use ipratroprium bromide, Combivent or Duoneb in patients with known peanut allergy. ** Use with caution with preexisting dysrhythmias, hypertension, cardiac history, or history of ischemic cardiac chest pain, and patients over the age of 50. 36 15 NOV 2008 Revision V Exacerbation of COPD

1) Primary Paramedic Care 2) Albuterol nebulizer treatment 2.5mg in 3ml NS, may repeat treatment x 2 a) Severe cases: ipratroprium bromide* 0.5mg nebulized in 2.5ml NS and albuterol will be combined (Combivent or DuoNeb) 3) May repeat albuterol x 2

Establish Online Medical Oversight Possible Physician Orders: 1) Repeat nebulizer treatment 2) Methylprednisolone 125mg SIVP 3) CPAP per sponsor hospital guideline

*Do NOT use ipratroprium bromide, Combivent or Duoneb in patients with known peanut allergy. 37 15 NOV 2008 Revision V Continuous Positive Airway Pressure

Indications: Hypoxemia secondary to congestive heart failure, acute cardiogenic pulmonary edema, or chronic obstructive pulmonary disease exacerbation, in a patient who has adequate and spontaneous respirations.

Contraindications: 1) Respiratory Arrest 2) Agonal Respirations 3) Unconscious 4) Shock associated with cardiac insufficiency 5) Pneumothorax 6) Penetrating chest trauma 7) Persistent nausea/vomiting 8) Facial Anomalies / Stroke Obtundation / Facial Trauma

Signs and Symptoms: 1) Dyspnea and Tachypnea. 2) Chest Pain, Hypertension, Tachycardia. 3) Anxiety, Restlessness, Altered LOC 4) Rales and Often Wheezes, Frothy Sputum (severe cases)

Procedure: 1) Primary Paramedic Care 2) Attach heart monitor and pulse oximeter 3) If SBP <100mmHg, contact Medical Control prior to beginning CPAP 4) Verbally instruct patient. a) Patient requires “verbal sedation” to be used effectively. i) Example: Patient: “I can’t get air in!” Paramedic: “This will help you get air in.” “This will help you breathe easier as the pressure on the machine is increased”. b) Start CPAP at ambient pressure (‘0’ cmH2O) if available c) Instruct patient to breath in through their nose slowly and exhale through their mouth as long as possible (count slowly and aloud to four then instruct to inhale slowly). d) Explain to the patient that you will begin to slowly increase the pressure and to continue exhaling out against the pressure as long as possible before inhaling. 5) Slowly titrate the pressure to 10cmH2O or manufacturer’s recommended setting. 6) Treatment should be given continuously throughout transport to ED. 7) Vital Signs q5min 8) In the event of life-threatening complications: a) Stop treatment b) Offer reassurance c) Institute BLS/ALS support d) Adverse reactions to therapy are to be documented using an Occurrence Report. The Paramedic must immediately notify Medical Control and ED staff upon arrival 9) Documentation in the PCR narrative should include: a) CPAP level b) FiO2 100% c) SpO2 q5min

38 15 NOV 2008 Revision V Emergency Medical Services CPAP Confirmation Form

Patient’s Name: ______Age: ______Sex: ______Date: ______

Patient’s Chief Complaint: ______

Patient’s Medical History: ______

Patient’s Medications: ______

Times: Onscene: ______Enroute to Hospital: ______At Hospital: ______

Informed consent obtained? Yes____ No____ Application of CPAP was successful? Yes____ No____ The patient was able to tolerate CPAP? Yes____ No____ Did the patient improve? Yes____ No____ Intubation required? Yes____ No____ Was BVM ventilation required? Yes____ No____

SpO2 pre-CPAP: ______SpO2 post-CPAP: ______

ETCO2 pre-CPAP: ______ETCO2 post-CPAP: ______

BP pre-CPAP: ______/______BP post-CPAP: ______/______Drugs/dosages/routes administered:

______

______

______Describe any difficulties encountered during or following the CPAP procedure, your actions and the result. ______

______

______

______

Paramedic (print name): ______Signature: ______

E.D. Physician (print name): ______Signature: ______

Please attach a copy of the PCR!

39 15 NOV 2008 Revision V Chapter 5 ACLS Algorithms

Adult BLS Guidelines 41 Pulseless Arrest Algorithm 42 Bradycardia 43 Tachycardia 44

The following guidelines reflect the American Heart Association ECC Guidelines 2005. These guidelines are to be utilized as the basis for treatment of patients experiencing “Pulseless Arrest”, “Bradycardia”, and “Tachycardia”. Please refer to the “Pharmacology” section of these protocols for specific guidelines and information regarding the usage of any medications listed in this section. Any part of the following which calls for "Expert Consultation" indicates the need to contact Online Medical Oversight for further interventions.

40 15 NOV 2008 Revision V Adult Basic Life Support

41 15 NOV 2008 Revision V Pulseless Arrest

Consider Sodium Bicarb, Dextrose, and Narcan as indicated.

42 15 NOV 2008 Revision V Bradycardia

43 15 NOV 2008 Revision V

Tachycardia with Pulses

44 15 NOV 2008 Revision V Chapter 6 Cardiac Emergencies

Acute Coronary Syndromes 46 Suspected Ischemic Chest Pain 47 12 lead EKG 48 Cardiogenic Shock 49

45 15 NOV 2008 Revision V Acute Coronary Syndromes

Cardiac disease can manifest itself in several ways. When assessing a patient suspected of suffering acute coronary syndrome, the paramedic should note each presenting complaint and obtain a history appropriate to the presenting symptom. Common presenting symptoms include: 1) Chest pressure or discomfort 2) Shoulder, neck, arm or jaw pain 3) Dyspnea 4) Syncope 5) Palpitations 6) Diaphoresis 7) Nausea 8) Anxiety

Chest pain or discomfort is a common presenting symptom of cardiac disease. Chest pain is the most common presenting symptom of myocardial infarction. When confronted by a patient with chest pain, obtain the following essential elements of the history: 1) Specific location of the chest pain (midsternal, etc.) 2) Radiation of pain, if present (e.g., to the jaw, back, or shoulders) 3) Duration of the pain 4) Factors that precipitated the pain (exercise, stress, etc.) 5) Type or quality of the pain (dull or sharp) 6) Pain scale (1-10) 7) Associated symptoms (nausea, dyspnea) 8) Anything that worsens, intensifies or alleviates the pain (including medications, moving or a deep breath) 9) Previous episodes of a similar pain (e.g., angina)

It is important to remember that chest pain has many causes other than cardiac disease. The history, therefore, is an important determining factor.

Shoulder, arm, neck, or jaw pain or discomfort may also be an indicator of cardiac disease. Any of these may occur with or without associated chest pain, especially in older patients or patients with diabetes. If the patient has any of these symptoms and you suspect heart disease, obtain information similar to that described above for chest pain.

46 15 NOV 2008 Revision V Suspected Ischemic Chest Pain

1) Primary Paramedic Care 2) Aspirin: a) 324-325mg PO i) Do not give aspirin if the patient has a known allergy to aspirin or NSAIDS (e.g., ibuprophen) 3) Acquire 12 Lead EKG and transmit at first possible opportunity based on patient condition and location. (See 12 lead EKG Guideline for transmission parameters) 4) Nitroglycerin (NTG): a) 0.4mg (1/150gr.) tab SL or 0.4mg metered dose spray SL b) Repeat NTG q5min to a total of 3 doses, total relief of symptoms, or SBP <100mmHg. c) Do not give NTG if: i) IV unobtainable – administer 1st dose of NTG if SBP >=120mmHg and contact Online Medical Oversight ii) SBP <100mmHg iii) Patient took a phosphodiesterase inhibitor: (erectile dysfunction Rx) (1) Sildenafil (Viagra) or Vardenafil (Levitra) within 24hr (2) Tadalafil (Cialis) within 48hr d) If SBP decreases to <100mmHg, place in Trendelenberg position e) If hypotension persists, administer 250ml IV fluid bolus of normal saline 5) Nitroglycerin (NTG): (As maintenance after resolution of symptoms with SL NTG) a) 1-2in (0.4mg) paste TD, to the anterior chest (in addition to the 3 SL doses) b) Do not give NTG if: i) IV unobtainable – administer 1st dose of NTG if SBP >=120mmHg and contact Online Medical Oversight ii) SBP <100mmHg iii) Patient took a phosphodiesterase inhibitor: (erectile dysfunction Rx) (1) Sildenafil (Viagra) or Vardenafil (Levitra) within 24hr (2) Tadalafil (Cialis) within 48hr c) If SBP decreases to <100mmHg, remove NTG paste, wipe area clean and place in Trendelenberg position. d) If hypotension persists, administer 250ml IV fluid bolus of normal saline. 6) Morphine Sulfate: (If persistent pain after 3x NTG doses above) a) 2-4mg IV in 1-2mg increments q5min b) If hypoventilation develops, administer Naloxone 2mg IV. c) If SBP decreases to <100mmHg, place in Trendelenberg position. d) If hypotension persists, administer 250ml IV fluid bolus of normal saline. 7) If suspected STEMI/12 lead EKG transmitted, identify the call to the ED as a “Cardiac Alert” – report to the ED physician, based on receiving hospital (same as Trauma Alert protocol)

Establish Online Medical Oversight Possible Physician Orders: 1) Additional dose(s) of NTG, either SL or TD 2) Additional dose(s) of morphine sulfate

47 15 NOV 2008 Revision V 12 Lead EKG

Indications: Any patient suspected of acute coronary syndrome, based on history and clinical findings including any of the following: 1) Chest pain, pressure or discomfort 2) Radiating pain to neck or left arm. Also right arm, shoulder or back 3) Dyspnea 4) CHF 5) Cardiac Arrhythmias 6) Syncope / near syncope 7) Profound weakness 8) Epigastric discomfort 9) Sweating incongruent with environment 10) Nausea, vomiting 11) Previous cardiac history 12) Other cardiac risk factors (i.e. HTN, Smoker, Obesity) 13) Before and after any rhythm conversion including PSVT and rapid a-fib.

Precautions:Do not delay scene time more than 4min to perform 12 lead EKG. Perform 12 lead EKG enroute to the hospital if scene time will be delayed and/or patient is hemodynamically unstable.

Procedure: 1) Remove patient clothing above waist. Use a gown or sheet to preserve modesty 2) Apply limb leads 3) Print rhythm strip 4) Apply precordial leads 5) Place patient in position of comfort (supine or semi-fowlers preferred) 6) Verify that all leads are securely attached 7) Have patient relax and limit movement 8) Acquire 12 lead EKG 9) Prepare to repeat 12 lead EKG at 10min intervals or on change in condition

If 12 lead EKG reveals 1mm of ST segment elevation in two or more contiguous limb leads, or 2mm of ST segment elevation in two or more contiguous precordial leads, transmit 12 lead EKG to receiving hospital, where applicable, as soon as possible.

NB: A normal 12 lead EKG does not rule out the possibility of ischemic cardiac disease and must not be used to screen patients (rule out ACS in the pre-hospital setting).

48 15 NOV 2008 Revision V Cardiogenic Shock

Ensure the clinical manifestation of hypoperfusion is due to an underlying cardiac problem. If hypoperfusion is due to a rate problem, (i.e. tachycardia or bradycardia), follow the specific treatment guidelines relating to the rate. 1) Primary paramedic care 2) If no signs of acute pulmonary edema are present administer one 250ml Normal Saline fluid bolus 3) SBP <90mmHg or pulmonary edema present contact Online Medical Oversight

Establish Online Medical Oversight Possible Physician Orders: 1) Additional normal saline fluid bolus 2) Dopamine IVI 5-20mcg/kg/min if SBP <70mmHg

49 15 NOV 2008 Revision V Chapter 7 Altered Mental Status

Cerebrovascular Accident / Stroke / Intracranial Bleed 51 Hypoglycemia–Hyperglycemia 52 Opiate Overdose 53 Toxicology 54-5 Seizures 56 Sepsis / Fever 57 Coma of Unknown Etiology 58 Mucosal Medication Administration 59

50 15 NOV 2008 Revision V Cerebrovascular Accident / Stroke / Intracranial Bleed

Description: Cerebrovascular Accidents will fall into two categories: 1) Thrombosis/embolus: A sudden occlusion of a cerebral artery, causing brain cell ischemia and tissue death. 2) Hemorrhagic: A rupture of an Arteriovenous Malformation or Aneurism within the brain, causing both distal tissue ischemia, and an increase in intracranial pressure.

Procedure: 1) Primary Paramedic Care 2) Monitor and protect airway as indicated by patient presentation. If GCS <9 consider Medication Facilitated Intubation or Rapid Sequence Intubation 3) Obtain blood glucose level and treat if below 60mg/dl 4) Establish time of onset of symptoms, specifically the last time seen neurologically intact to their “normal” baseline 5) Perform Cincinnati Stroke Scale (Range 0-3): a) Facial Droop (have patient show teeth or smile): i) Normal 0 both sides of face move equally ii) Abnormal 1 one side of face does not move as well as the other side b) Arm Drift (patient closes eyes and holds both arms straight out for 10sec): i) Normal 0 both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful) ii) Abnormal 1 one arm does not move or one arm drifts down compared with the other c) Abnormal Speech (have the patient say "you can’t teach an old dog new tricks"): i) Normal 0 patient uses correct words with no slurring ii) Abnormal 1 patient slurs words, uses the wrong words, or is unable to speak d) Interpretation: If any one of these three signs is abnormal, the probability of a stroke is 72% 6) Notify receiving hospital as soon as possible of a “Stroke Alert” per receiving facility guidelines.

51 15 NOV 2008 Revision V Hypoglycemia / Hyperglycemia

1) Primary Paramedic Care 2) Assess blood glucose level 3) Assess ability to swallow and protect airway

Hypoglycemia (Blood Glucose Level <60mg/dl, or symptomatic) 1) Oral Glucose 15g (one tube)PO if able to swallow 2) Dextrose 50% 25g IV 3) Glucagon 1mg IM if unable to establish IV access 4) Thiamine 100mg IV if indicated

Establish Medical Oversight Possible Physician orders: 1) Additional Dextrose

Hyperglycemia with signs of Diabetic Ketoacidosis (AMS, Kussmal Respirations, Dry Skin, Blood Glucose Level >400mg/dl) 1) Normal Saline 500ml fluid bolus and 200ml/hr for volume replacement

52 15 NOV 2008 Revision V Opiate Overdose

Patient presentation and history: Decreased mentation, decreased respiratory drive with hypoxemia, pinpoint pupils, possible scarring of the superficial veins (track marks), possible history of opiate abuse either in medication form (e.g., Fentanyl, Methadone, Morphine), or injected form (e.g., heroin).

1) Primary Paramedic Care 2) Assess Level of Consciousness and Respiratory Drive 3) If respiratory rate is <12 initiate BVM Support 4) Naloxone 1mg per nostril, where available (See IN Addendum)

If patient does not respond within 3-5min proceed with return of mentation and respirations: 5) IV Normal Saline 6) Assess blood glucose level and treat as indicated 7) Naloxone 1-2mg IV

If no change in 3-5min 8) Reassess LOC and respiratory status, if RR<12breaths/min, consider intubation.

Establish Online Medical Oversight Possible Physician Orders 1) Repeat Naloxone 2) Repeat Dextrose

53 15 NOV 2008 Revision V Toxicology (Non-opiate Overdose strongly suspected)

1) Primary Paramedic Care 2) In cases of inhalation / absorption consider HAZ-MAT as appropriate. 3) Gather all essential information related to the overdose: a) Name and ingredients of the substances taken. b) The total amount taken or length of exposure. c) Method of exposure: Injection, Ingestion, Inhalation, or Absorption. d) Approximate time of exposure / ingestion. e) Look for the containers of substance ingested and if appropriate transport with the patient. f) Vomiting prior to arrival. g) Reason for the ingestion if intentional. 4) Obtain blood glucose level and treat if indicated. 5) Contact Connecticut Poison Control at (800) 222-1222 and Online Medical Oversight with the essential information.

Establish Online Medical Oversight Possible Physician Orders: 1) Activated charcoal 30-50g PO 2) Management for Specific Agent a) Atropine b) Calcium Chloride c) Glucagon d) Sodium Bicarbonate

54 15 NOV 2008 Revision V Potentially Cardiotoxic Drugs, Cardiopulmonary Signs of Toxicity, and Therapies

Potentially Toxic Drugs by Agent Cardiopulmonary Signs of Toxicity Therapies Stimulants Amphetamines ACS Benzodiazepines Cocaine Hypertensive Crisis Lidocaine Ephedrine Impaired Conduction Nitroglycerine Methamphetamines Shock Phencyclidine (PCP) Supraventricular Arrhythmias Tachycardia Ventricular Arrhythmias Cardiac Arrest Calcium Channel Blocker Diltiazem Bradycardia Calcium Chloride Nifedipine Cardiac Arrest Epinephrine IV Verapamil Impaired Conduction Glucagon Shock Normal Saline Bolus Pacing Beta Blocker Atenolol Bradycardia Calcium Chloride Metropolol Cardiac Arrest Epinephrine IV Propanolol Impaired Conduction Glucagon Sotalol Shock Normal Saline Bolus Pacing Tricyclic Antidepressant Amitriptyline Tachycardia Sodium Bicarbonate Desipramine Bradycardia Hyperventilation Imipramine Ventricular Arrhythmias Normal Saline Bolus Nortriptyline Impaired Conduction Mag Sulfate Shock Lidocaine Cardiac Arrest Epinephrine IV Cardiac Glycosides Bradycardia Atropine Digoxin Cardiac Arrest Lidocaine Foxglove Impaired Conduction Pace with Caution Oleander Shock Volume Replacement Supraventricular Arrhythmias Ventricular Arrhythmias Sodium Channel Blockers Disopyramide Bradycardia Lidocaine (except for Flecanide Cardiac Arrest Lidocaine overdose) Lidocaine Impaired Conduction Pacing Procainamide Seizures Sodium Bicarbonate Propafenone Shock Ventricular Arrhythmias

Contact Online medical oversight for any specific treatment modality.

55 15 NOV 2008 Revision V Seizures

Description: There are many causes of seizures including, but not limited to trauma, epilepsy, hypoxemia, meningitis, stroke, hypoglycemia, drug overdose, drug withdrawal or eclampsia. Primary Paramedic Care: Initiate treatment based upon history and clinical presentation. It is important to make the distinction between focal motor, general motor seizures, and status epilepticus. Not all seizures require emergent intervention.

Types of Seizures: 1) General or Grand Mal Motor seizures are tonic and clonic movements that are usually followed by a postictal state. The components of a grand mal seizure include aura, loss of consciousness, tonic phase (extreme muscular rigidity), clonic phase (rigidity and relaxation in rapid succession), postictal state altered level of consciousness). 2) Partial or Focal Motor seizures usually involve unilateral motor activity, but may not cause changes in consciousness. Partial seizures may progress to generalized seizures. 3) Psychomotor seizures consist of personality alterations, staring, or peculiar motor activity with periods of bizarre behavior. 4) Status Epilepticus is present when (a) 2 or more general motor seizures without a lucid interval are witnessed by EMS personnel or (b) there exists continuous seizure activity lasting for greater than 10min.

General/Grand Mal Seizures and Status Epilepticus 1) Primary Paramedic Care 2) CONSIDER: Trauma, Hypoglycemia, Overdose/ Toxicology - Go to appropriate protocol 3) Protect the patient from personal injury 4) If blood glucose level is less than 60mg/dl or symptomatic then follow hypoglycemia protocol.

If patient is actively seizing: 5) Administer one of the following: a) Diazepam 2-5mg (0.03mg/kg) IV/IM (over 30sec) b) Midazolam 2-4mg IV/IM c) Lorazepam 1-2mg (0.02mg/kg) IV/IM

Establish Online Medical Oversight Possible Physician orders: 1) Additional anti-seizure medication 2) Additional Dextrose

56 15 NOV 2008 Revision V Sepsis / Febrile Illness

Patients with an infection of known or unknown origin that produces changes in mentation, diminished level of consciousness, hypotension, tachycardia and tachypnea with or without fever will be considered septic. 1) Primary Paramedic Care 2) Obtain blood glucose level 3) If hypotensive administer 250ml fluid bolus to maintain SBP >90mmHg 4) Initiate volume replacement at 100-150ml/hr 5) Manage and treat any arrhythmias per guidelines

57 15 NOV 2008 Revision V Coma of Unknown Etiology

Patients that present with a GCS <9 without underlying medical condition, known overdose or ingestion, known trauma, and is not hypo- or hyper-glycemic. 1) Primary Paramedic Care 2) Stabilize and maintain in-line cervical spine protection 3) Ensure adequate ventilation. 4) Consider Medication Facilitated Intubation or Rapid Sequence Intubation if unable to adequately protect airway and ventilate. 5) Thiamine 100mg IV (if possible history of alcohol abuse) 6) Naloxone 1-2mg IM, IN, or IV (if possible history of opiate overdose)

58 15 NOV 2008 Revision V Mucosal Atomization Device (MAD)

Contraindications (if present, proceed with IV medication administration): 1) Epistaxis 2) Nasal Septum Deviation 3) Nasal Trauma

Procedure: 1) Draw Naloxone into syringe 2) Remove and dispose of needle in appropriate sharp proof container 3) Attach Mucosal Atomization Device 4) Place tip of MAD into nostril and deliver 1mg per nostril 5) MAD can be reused on a single patient, and discarded after use 6) Note medication delivery time 7) If no response, proceed with intravenous access and intravenous medications 8) Absorption may be inhibited by

59 15 NOV 2008 Revision V Chapter 8 Environmental Emergencies / Anaphylaxis

Allergic Reaction 61 Anaphylaxis 62 Hypothermia 63 Hypothermic Arrest 64 Hyperthermia 65 Near Drowning 66

60 15 NOV 2008 Revision V Allergic Reaction

Description: An allergic reaction is a hypersensitivity to a given antigen. It is usually not life threatening, merely uncomfortable for the patient. The patient is hemodynamically stable and complains of minor to moderate skin manifestation (erythema, pruritus or urticaria) or mild inspiratory/expiratory wheezing.

Stable Hemodynamics (blood pressure >90mmHg systolic) with minor or moderate skin manifestations and/or inspiratory/expiratory wheezing: 1) Primary Paramedic Care 2) Diphenhydramine 1mg/kg IV or IM (max 50mg) 3) If wheezing is present administer Albuterol 2.5mg/3ml NS via nebulizer

Establish Online Medical Oversight Possible Physician orders: 1) Epinephrine 1:1,000 0.3mg SQ 2) Methylprednisolone 125mg SIVP

61 15 NOV 2008 Revision V Anaphylaxis

Description: Anaphylaxis refers to the introduction of a foreign substance (antigen) into the body, which, because of patient sensitivity, produces a severe systemic reaction. This systemic reaction may include shock, laryngospasm, angioedema, and/or respiratory distress. It can be fatal. The patient may complain of respiratory symptoms, such as tightness in the chest, wheezing, or shortness of breath. Other symptoms may include swelling, urticaria, nausea, vomiting, abdominal pain, or diarrhea. These symptoms are due to the release of certain substances within the body, e.g., histamine, SRSA (slow reactive substance of anaphylaxis) and bradykinin. Hypotension and bradycardia may also result.

Anaphylaxis is a true emergency in that death may occur within minutes of the introduction of antigen.

Unstable Hemodynamics with hypotensive patient (blood pressure <90mmHg systolic) or impending upper airway obstruction, stridor, severe wheezing and/or respiratory distress: 1) Primary Paramedic Care 2) Epinephrine 1:1,000 0.3mg SQ 3) IV Normal Saline titrated to a SBP >100mmHg 4) Diphenhydramine 1mg/kg SIVP (max. 50mg) 5) If wheezing is present administer Albuterol 2.5mg/3ml NS via nebulizer 6) Methylprednisolone 125mg SIVP

Establish Online Medical Oversight Possible Physician orders: 1) Epinephrine 1:10,000 0.3-0.5mg SIVP 2) Epinephrine IVI 2-10mcg/min 3) Dopamine IVI 5-20mcg/kg/min

62 15 NOV 2008 Revision V Hypothermia (Cold Exposure)

Description: When the body’s core temperature decreases, the body will first respond by shivering. This is an attempt by the body to generate heat from muscle activity. Vasoconstriction will shunt blood from the skin and an increase in the patient’s metabolic rate will increase heat. If these mechanisms cannot compensate for severe temperature drops then the body’s systems begin to fail (e.g., respiratory function will deteriorate and lead to hypoxemia). The patient may also develop dysrhythmias and cardiopulmonary arrest may occur. Patients are particularly at risk for cardiac dysrhythmias during the warming phase of treatment.

Localized cold injury: 1) Follow BLS Guidelines.

Generalized Hypothermia: 1) Avoid rough handling or excessive movement 2) Remove patient from cold environment 3) Protect C-spine as necessary 4) Remove all wet clothing 5) Protect from further heat loss 6) Primary Paramedic Care

Moderate Hypothermia: Clinical presentation may include: conscious (but often lethargic), shivering, pale and cold skin. 1) Follow Generalized Hypothermia Protocol 2) Primary Paramedic Care 3) Do not delay transport 4) Establish an IV of Normal Saline (warmed) en route 5) Obtain blood glucose level

Establish Online Medical Oversight Possible Physician orders: 1) Dextrose 25g IV 2) Naloxone 0.4-2.0mg IV

Severe Hypothermia: Clinical presentation may include: Unconsciousness or altered mental status, ice cold skin, inaudible heart sounds, unobtainable or severely hypotensive BP, non- reactive pupils, very slow or absent respirations. Handle these patients very carefully, as the heart is more susceptible to fibrillation. Avoid rubbing the skin, hyperventilation (an extreme drop in CO2 may cause ventricular fibrillation), and rewarming frostbitten extremities until after the core is rewarmed (to prevent vascular complications to the limb and the transportation of cold blood and detrimental by-products to the core). 1) Primary Paramedic Care 2) If respiratory rate is less than 5breaths/min, assist ventilations at a rate of 10breaths/min and consider intubation. 3) Normal Saline (warmed) IV bolus (200-500ml) warmed if possible 4) If CPR is required refer to Hypothermic Arrest Protocol 5) Transport the patient in Trendelenberg position

Establish Online Medical Oversight Possible Physician Orders: 1) Dextrose 25g IV 2) Naloxone 0.4-2.0mg IV

63 15 NOV 2008 Revision V Hypothermic Arrest

Once you have started CPR, do not give up. The hypothermic cardiac arrest patient is not dead until they are warm and dead. The lack of detectable pulse, blood pressure, or respirations may be physiologic for a severely hypothermic patient. Successful resuscitation (with CNS complications) has been accomplished in patients with a core temperature less than 70°F. Also, do not administer medications unless directed to do so by Online Medical Oversight Physician.

If spontaneous pulse is absent: 1) Apply EKG. 2) If the EKG shows Pulseless Ventricular Fibrillation/ Ventricular Tachycardia, defibrillate once at 360J or the highest energy setting available. 3) Initiate CPR (deliver 40-50 compressions per minute). 4) Transport

Establish Online Medical Oversight Possible Physician Orders: 1) ACLS medications 2) Repeat defibrillation at 360J

64 15 NOV 2008 Revision V Hyperthermia (Heat Exposure)

Description: The body’s normal core temperature is regulated by a number of factors that balance heat loss and heat production. As the body’s temperature rises, vasodilation will lead to heat loss by radiation, convection, and conduction. However, if the temperature outside the body exceeds the temperature of the skin, this process is ineffective and evaporation by diaphoresis is necessary. The body’s physiological response to excessive temperatures includes tachycardia (as the heart attempts to increase cardiac output), diaphoresis (with consequent loss of fluid [dehydration] and electrolytes), and signs of decreased cerebral perfusion (e.g., headache, decreased response to verbal and/or painful stimuli). Always determine the patient’s past medical history and history related to present event.

Heat Cramps: Pain in muscles due to loss of fluid and salt. Frequently affects lower extremities and abdomen. Cool, moist skin, normal to slightly elevated temperature, nausea. 1) Move patient to a cool environment 2) Primary Paramedic Care as indicated by patient presentation 3) Do not massage cramping muscles 4) Monitor vital signs

Contact Online Medical Oversight as needed

Heat Exhaustion: The state of more severe fluid and salt loss leading to syncope, headache, nausea, vomiting, diaphoresis, tachycardia, pallor and/or weak pulse. 1) Move patient to a cool environment and elevate legs 2) Remove clothing as practical and fan moistened skin 3) Primary Paramedic Care 4) Normal Saline IV to maintain Blood Pressure >100mmHg

Contact Online Medical Oversight as needed

Heat Stroke: A very serious condition. The patient may present with hot and flushed skin, strong bounding pulse and altered mental status. The situation may progress to coma and/or seizures. Sweating may still be present in up to 50% of heat stroke patients. Heat stroke is caused by a failure of the body’s normal temperature regulating mechanism. This results in a cessation of sweating and subsequent surface evaporation. It generally results when the body temperature reaches 105° F or more. A delay in cooling may result in brain damage or even death. Vigorous efforts should be employed to decrease the temperature. 1) Move patient to a cool environment 2) Remove as much clothing as possible 3) Cool the patient with a wet sheets 4) Apply cold packs under the arms, around the neck, and at the groin to cool large vessels 5) Primary Paramedic Care 6) Beware of possible seizures

Contact Online Medical Oversight as required by patient condition

65 15 NOV 2008 Revision V Near Drowning

Near drowning refers to the initial recovery period after immersion. All near drowning victims must be transported to the hospital as they are at risk for Adult Respiratory Distress Syndrome (ARDS). 1) Primary Paramedic Care 2) Protect the cervical spine and establish a patent airway appropriate to the clinical situation 3) If hypothermic, follow Hypothermia Protocol 4) If wheezing/bronchospasm is present administer Albuterol 2.5mg/3ml NS via nebulizer

Contact Online Medical Oversight Possible Physician Orders: 1) CPAP Utilization 2) Medication Facilitated Intubation

66 15 NOV 2008 Revision V Chapter 9 General Medical Emergencies

Acute Abdomen 68 Gastrointestinal Bleeding 69 Psychiatric Emergencies 70 Dystonic Reactions 71 Pain Management for Procedures 72 Intraosseous Access via EZ-IO™ 73-4

67 15 NOV 2008 Revision V Acute Abdomen

Abdominal complaints may be vague, nonspecific, and vary from patient to patient. Any patient where aortic aneurysm/dissection or hemorrhage is suspected should be treated for shock and transported immediately. 1) Primary Paramedic Care 2) Assessment to include and ensure hemodynamic stability, Onset, Provocation, Quality, Radiation, Severity, Time of onset, and 1-10 pain scale, both pre- and post-treatment. 3) Antiemetic: If the patient presents with nausea or vomiting, administer one of the following: a) Ondanasetron 4mg IV b) Prochlorperazine 5-10mg deep dorsogluteal IM c) Metoclopramide 10mg deep dorsogluteal IM 4) IV Normal Saline: Provide fluids at 250ml/hr provided no signs of Pulmonary Edema or CHF are present 5) Morphine Sulfate: >50kg 2-5mg IV, IM, or SC; <50kg 0.1mg/kg diluted with 5ml normal saline, administered over 3min.

Contact Online Medical Oversight Possible Physician Orders: 1) Additional Morphine

68 15 NOV 2008 Revision V Gastrointestinal Bleeding

Gastrointestinal Bleeding is evidenced by the passage of digested or undigested blood. Digested blood will be passed as either melena or coffee-ground hematemesis. Undigested blood may be frank blood, or clotted blood. Since blood is an irritant, patients will commonly be nauseated and may vomit. 1) Primary Paramedic Care 2) Treat for shock based upon patient condition and complaint.

Contact Online Medical Oversight as needed

69 15 NOV 2008 Revision V Psychiatric Emergencies

Anxiety disorders may manifest as an acute onset of impending doom or terror with a fear of losing control. May present with hyperventilation, chest discomfort, palpitations, headache, dyspnea, choking/smothering sensations, faintness/syncope, a feeling of unreality, trembling, sweating, urinary frequency, and diarrhea. 1) Primary Paramedic Care 2) Rule out other etiology (i.e. hypo- or hyper-glycemia, hypoxemia, AMI, trauma, metabolic condition, etc.) 3) All psychiatric emergencies require hospital notification as early as possible 4) Benzodiazepine administration for relaxation: administer one of the following: a) Diazepam 2-4mg IV/IM b) Midazolam 2mg IV/IM c) Lorazepam 2mg IV/IM

Contact Online Medical Oversight Possible Physician Orders: 1) Repeat Benzodiazepines 2) Haloperidol 5mg IM

Please Note: Patients who need to be physically restrained for their safety or the safety of the attendant in the pre-hospital setting must be done so with a police officer present. If police restraints are used, an officer must accompany the patient to the hospital in the ambulance, or follow behind the ambulance in their police vehicle. No patient is to be “hog-tied” or restrained in a prone position. In order to maintain the airway, place the patient in the left lateral recumbent position for transport.

For services carrying lorazepam as their benzodiazepine, halperidol and lorazepam may be mixed in the same syringe, and injected IM at the same time. Online Medical Oversight approval is still required to administer the haloperidol.

70 15 NOV 2008 Revision V Dystonic Reaction

Description: This is an idiosyncratic reaction to a neuroleptic and antiemetic medication. It frequently involves acute onset of involuntary muscle spasm, which is painful and uncontrollable, possibly leading to respiratory compromise. Spasms of the neck muscles and the face are common presentations. There is also commonly difficulty with speech, swallowing, and breathing. Individuals may have ingested these medications unknowingly, especially having purchased them “on the street” or given by family “as a sleeping pill.” Clinically dystonia can give the appearance of anxiety reactions, tetanus, strychnine toxicity, CVA, or atypical seizures. 1) Primary Paramedic Care 2) Diphenhydramine 50mg IV or IM

71 15 NOV 2008 Revision V Pain Management for Procedures

In the event of a painful procedure (i.e. Cardioversion and Transcutaneous Pacing) the paramedic may administer: 1) For analgesia: a) Morphine Sulfate: >50kg 2-5mg IV, IM, or SC, <50kg 0.1mg/kg diluted with 5ml normal saline, administered over 3min. 2) For sedation, administer one of the following: a) Diazepam 2-4mg IV b) Midazolam 2mg IV c) Lorazepam 0.5-1.0mg IV

Contact Online Medical Oversight Possible Physician Orders: 1) Repeat analgesics or sedatives

72 15 NOV 2008 Revision V TM Intraosseous Access via EZ- IO (Adult or Pediatric Patient)

The useTM of this device is reserved only for paramedics who have received proper training on the EZ-IO system and have demonstrated competency with the procedure. Intraosseous needle insertion allows for rapidTM circulatory access in order to provide necessary intravenous fluids and medications.TM The EZ-IO AD® system is to be used for patients weighing 40kg and over, while the EZ-IO PD® system is to be used for patients weighing 3-39kg. Due to anatomy of the IO space, flow rates may be slower than those achieved throughTM IV access. Use a pressure bag or pump for continuous infusions. Insertion of the EZ-IO in conscious patients causes mild to moderate discomfort, but is usually no more painful than a large bore IV. IO infusion, however, may cause severe discomfort for conscious patients.

Indications: 1) Administration of intravenous fluids or medications is needed, AND 2) Peripheral IV cannot be established in 2 attempts or 90sec, AND 3) Altered mental status (GCS <8), OR respiratory compromise (Sp0 80% or less after appropriate oxygen therapy, and/or respiratory rate <10breaths/minute2 or >40breaths/minute)

IO access may also be considered PRIOR to peripheral IV attempts in the following situations: 1) Cardiac arrest (medical or traumatic) 2) Profound signs of hypoperfusion with altered mental status (GCS <8)

Contraindications: 1) Fracture of the tibia or femur (consider alternate tibia or humerus) 2) Previous orthopedic procedures (e.g., IO within 24hr, knee replacement) 3) Pre-existing medical condition (e.g., tumor near site or peripheral vascular disease) 4) Infection at insertion site (consider alternate site) 5) Inability to locate landmarks (often secondary to significant edema) 6) Excessive tissue at insertion site

Procedure: Consult manufacturer instructions for use of device. There will be no deviation from the insertion instructions provided by Vidacare. A summary of these instructions follows. 1) Don appropriate body substance isolation equipment. 2) Locate appropriate insertion site. Multiple sites are acceptable, such as the proximal tibia, distal tibia, and proximal humerus. 3) Prepare insertion site using aseptic technique. 4) Prepare the EZ-IO® driver and appropriate needle set. 5) Stabilize the site, and insert the appropriate needle set. 6) Remove EZ-IO® driver from the needle set while stabilizing the catheter hub. 7) Remove the stylet from the catheter. Confirm placement by noting the stability of the needle within the bone. A properly inserted needle should not feel "loose" or "wobbly". TM 8) Connect primed EZ-Connect® tubing. DO NOT attach a syringe directly to the EZ-IO catheterTM to flush the line or administer medications or fluids. Directly attaching a syringe to an EZ-IO catheter may generate forces capable of dislodging the catheter, resulting in the possibility of extravasations. 9) If the patient is conscious, then administer lidocaine 2% (preservative free), 0.5mg/kg, to a maximum of 40mg, slow IO push (20mg/min). 10) To ensure patency of the IO site, and after any bolus of medication, administer normal saline, 5ml for patients weighing <40kg, or 10ml for patients weighing >40kg. 11) Begin the infusion, utilizing pressure (syringe bolus, pressure bag, or infusion pump) for continuous infusions where applicable. 12) Dress the insertion site, secure the tubing, and affix the included dated yellow wristband. 13) Monitor the insertion site and the patient's condition. 14) Upon arrival at emergency department, immediately advise he physician of the placement of the IO needle. 73 15 NOV 2008 Revision V 15) Ensure that the emergency department staff is aware of proper IO needle removal technique.

74 15 NOV 2008 Revision V Chapter 10 Adult (>13yr) Trauma Care

Injured Patient Triage Protocol 76 Trauma Alert Criteria 77-8 Assessment & Treatment of the Trauma Patient 79-82 Spinal Assessment and Immobilization Criteria 83 Isolated Trauma Pain Management 84 Burn Management 85-9

75 15 NOV 2008 Revision V Injured Patient Triage Protocol1

When transport to a Level I or II Trauma facility is indicated, but the ground transport time to that hospital is judged to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with medical control.

All EMS providers transporting trauma patients to hospitals shall provide receiving hospital with a complete OEMS approved patient care form prior to departing from the hospital. 1) Measure vital signs and level of consciousness. If: a) Glasgow Coma Scale 12 or less, or b) Systolic blood pressure <90mmHg, or c) Respiratory rate <10breaths/min or >29breaths/min Then transport to Level I or II Trauma Center. 2) Assess anatomy of injury. If: a) Gunshot wound to chest, head, neck, abdomen or groin, or b) Third degree burns >15% BSA, or third degree burns of face, or airway involvement, or c) Evidence of spinal cord injury, or d) Amputation other than digits, or e) Two or more obvious proximal long bone fractures Then transport to Level I or II Trauma Center. 3) Assess mechanism of injury and other factors. If: a) Fall >20feet, or b) Apparent high-speed impact, or c) Ejection of patient from vehicle, or d) Death of same car occupant, or e) Pedestrian hit by car >20MPH, or f) Rollover, or g) Significant vehicle deformity- especially steering wheel, or h) Age >55yr, or i) Known cardiac disease or respiratory distress, or j) Penetrating injury to thorax, abdomen, neck or groin (other than gunshot wounds) Then Contact Online Medical Oversight for direction and transport decision. 4) If the patient is negative for the above, evaluate as per usual protocol.

When in doubt, consult with Online Medical Oversight.

1State of Connecticut Regulation of Department of Public Health and Addiction Services Concerning Statewide Trauma System: Sections 19a-177-5. 76 15 NOV 2008 Revision V Trauma Alert Protocol

Description: The “Trauma Alert” is designed for those patients who are severely injured, have a high likelihood for need of immediate resuscitation/treatment, and/or for whom the time factor may be critical for a successful outcome. Triage will focus on these categories: Physiologic parameters, Systemic/Anatomical Criteria, Mechanism of Injury and Relative Indicators.

Any trauma patient that meets the following criteria should be transported to a Level I or II trauma center and identified as a “Trauma Alert” by the pre-hospital EMS staff. Notification to the receiving facility should be as early as possible so as to give the receiving facility time to mobilize the appropriate and needed resources to the ED to meet the patient/EMS staff upon arrival.

Trauma patients meeting any of the below criteria must be designated a “Trauma Alert”. The receiving facility must be notified by direct communication with the on-duty ED Attending physician, or delegate. Primary notification should occur via C-MED. If C-MED is unavailable then direct contact to the ED should be made by calling the numbers listed in chapter one under “Communications”.

Mandatory EMS Trauma Alert Physiologic Parameters 1) Glasgow Coma Scale (GCS) <14 or 2) Systolic blood pressure <90mmHg at any time in adults and age specific hypotension for pediatrics or 3) Respiratory compromise (rate <10breaths/min or >29breaths/min), intubation or obstruction 4) Trauma transfer patients from other facilities receiving blood or blood products

Systemic/Anatomical Criteria 1) All penetrating injuries to head, neck, chest, abdomen, groin and extremities proximal to elbow and knee (including gun shot wounds) 2) Third degree burns covering more than fifteen (15) percent of the body, or third degree burns of the face with or without airway involvement 3) Evidence of spinal cord injury with or without limb paralysis 4) Two (2) or more proximal long bone fractures 5) Amputation proximal to wrist or ankle, other than digits 6) Flail chest 7) Pelvic fractures 8) All trauma patients arriving by helicopter

Mechanism of Injury 1) Falls from over twenty (20) feet or twice the patient’s height 2) High speed impact MVA (initial speed >40mph) 3) Ejection of patient from vehicle 4) Death of occupant in the same vehicle 5) Auto vs. pedestrian or auto vs. bicyclist injury with significant (>5mph) impact 6) Rollover 7) Significant vehicle deformity a) Exterior motor vehicle deformity >20inches b) Passenger compartment intrusion >12inches c) Steering wheel deformity 8) Pedestrian or bicyclist thrown or run over 9) Motorcycle accident >20mph or separation of rider from motorcycle 10) Extrication time greater than 20min

Discretionary EMS Trauma Alert Relative Indicators 1) Age <5yr or >55yr 77 15 NOV 2008 Revision V 2) Known cardiac or respiratory disease 3) Insulin dependent diabetes, cirrhosis or morbid obesity 4) Pregnancy 5) Immunosuppressed patients 6) Patients with bleeding disorders or on anticoagulants

When in doubt, consult with online medical oversight!

All EMS providers transporting trauma patients to the hospital shall provide the receiving hospital with a complete OEMS approved patient care form prior to departing the hospital. (Ref. State of Connecticut Regulations of Department of Public Health and Addiction Services concerning statewide trauma system: Section 19a-177-5)

78 15 NOV 2008 Revision V Assessment and Management of the Trauma Patient2

It is impossible to fully stabilize the unstable patient in the pre-hospital setting. There must be a balance of lifesaving skills (such as endotracheal intubation) with minimizing scene time (<10min) and rapid transport in order to reduce the time from injury to definitive surgical treatment.

Early “trauma notification” to the receiving hospital is essential to ensure the immediate availability of an appropriate in-hospital response. A “Trauma Alert” is called by the Emergency Room Physician based upon your report to the hospital; therefore, it is crucial that EMS provide a prompt accurate “Trauma Notification” to any leveled receiving facility. 1) Initial Assessment (to be completed onscene) a) Airway (airway management techniques must maintain in-line cervical immobilization) b) Presenting Sign/Symptom and Management / Treatment: i) Airway Compromise (1) Manual Control (a) Jaw Thrust (2) Mechanical Control (a) Suction (b) Oropharyngeal Airway (c) Nasopharyngeal Airway (d) Pocket Mask (e) Orotracheal tube with in-line immobilization (f) Nasotracheal tube with in-line immobilization (g) Medication facilitated intubation with in-line immobilization (h) Transtracheal Airway with in-line immobilization c) Breathing i) Inadequate Ventilation (1) Mouth to mask (2) Bag Valve Mask ii) Flail Chest (1) Bulky dressing splint iii) Open Pneumothorax (1) Partially occlusive dressing (3-sided) iv) Assist ventilations as needed with supplemental O2 v) Tension Pneumothorax vi) Decompression* (1) Large bore needle with plastic catheter (angiocath) (2) Second intercostal space (ICS) in Midclavicular Line, superior aspect of the Third Rib, or Fifth ICS in Midaxillary Line Hypoxia is common in the trauma patient and correcting it is of the highest priority. A spinal injury may be present and the airway should be managed as if C-spine instability exists. Concern about a spinal injury must not delay institution of adequate ventilation and oxygenation. The neck should be maintained in a neutral position. If an endotracheal tube is required, neutral stabilization of the spine must be maintained throughout its insertion, so that the mandible and tongue are moved forward and the head is not tilted backwards. d) Circulation and Bleeding Control i) Evaluation (1) Pulse (a) Rate (b) Strength (c) Location (2) Skin (a) Color (b) Moisture (c) Temperature ii) Begin Chest Compressions as indicated 79 15 NOV 2008 Revision V iii) Hemorrhage Control (1) Direct pressure on wound and/or pack wound with sterile gauze (2) Pressure Bandage and elevate extremity (3) Pressure points (usually not required) (4) Tourniquet (seldom, if ever, indicated) (5) Traction splint (6) PASG (for unstable pelvic fracture with hypotension in the adult >13yr) (7) Pale skin color and pulse characteristics are accurate parameters used in assessing the status of tissue perfusion. Blood pressure is obtained later in the patient’s assessment. Hemorrhage control in the primary survey is used only for massive bleeding. Minor bleeding takes a lesser priority. For patients with an unstable femur fracture, application of a traction splint is the most important field technique for control of this type of internal hemorrhage. Patients with “open book” pelvic fracture will benefit from stabilization and “direct pressure” from the PASG. e) Disability i) Glasgow Coma Score (1) Eye Opening (a) 4 - Spontaneous (b) 3 - To voice (c) 2 - To pain (d) 1- None (2) Verbal response (a) 5 - Oriented (b) 4 - Confused (c) 3 - Inappropriate words (d) 2 - Incomprehensible words (e) 1 – None (3) Motor response (a) 6 - Obeys commands (b) 5 - Localizes pain (c) 4 - Withdrawal (pain) (d) 3 - Flexion (pain) (e) 2 - Extension (pain) (f) 1 – None f) Exposure (may be completed during transport) i) Exposure of the body for examination: It may be necessary to partially or completely expose the body to control hemorrhage and perform lifesaving procedures. It is important to consider modesty, time, and conservation of body heat. Always respect the individual’s needs. Nothing should be done to delay transport of the critically injured patient. 2) Resuscitation (to be completed during transport) a) Supplemental oxygen should be delivered @100% for all multisystem trauma patients b) Volume replacement (critically injured patients should be placed as rapidly as possible in the ambulance and IVs started enroute to the hospital) i) Blood pressure should be monitored (1) Systolic/diastolic (2) Pulse pressure ii) Venous access (1) Peripheral IV (a) Large bore catheters (14g-18g) (b) Two sites preferred (2) Fluid Normal Saline: Titrated to maintain perfusion and Systolic Blood Pressure ≥90mmHg 3) Detailed Physical Exam (should encompass a head-to-toe process looking for and treating injuries not discovered or treated in the primary survey) a) Presenting Sign/Symptom and Management / Treatment: i) Head (Most injuries to the face and head require hospital treatment - therefore delay in 80 15 NOV 2008 Revision V evaluation other than hemorrhage control is usually not necessary. Lacerations of the scalp may have a fracture beneath; therefore, unnecessary pressure is to be avoided. Use only enough pressure to control hemorrhage. Transportation to the hospital should not be delayed other than to correct life threatening airway problems) (1) Airway (a) Reevaluate and Correct Problems (2) Open Wounds (a) Control hemorrhage with gently direct pressure (b) Apply clean dressings to all wounds (3) Eyes (a) Protect from further injury (b) Irrigate to remove contaminants and debris (c) Do not remove foreign bodies (4) Nose and Ears (a) Pre-hospital evaluation for fluid (blood, CSF) (b) Treatment usually not required ii) Neck and Throat (1) Spinal Immobilization (Spinal immobilization should be accomplished without using the chin as a point of control. If the patient vomits into a closed mouth, aspiration almost inevitably results. Studies have shown that the cervical collar does not provide immobilization; therefore, a rigid cervical collar is used in conjunction with a long or short backboard and other head immobilization devices. A patient should never be secured to a backboard by the head alone. If such a patient became uncooperative, severe damage to the C-spine could result. Wounds of the neck should not be probed. Frequently a clot will have formed on the carotid artery or jugular vein, which probing could dislodge, causing severe hemorrhage. Compression dressing should not be tight enough to restrict blood flow to or from the brain and should not be circumferential. (a) Any blunt injury above the clavicle (b) Unconscious patient (c) Multiple trauma (d) High speed crash (e) Neck pain (f) Complaints of extremity numbness / tingling (g) Gunshot wound involving the torso (2) Wounds (a) Leave foreign bodies in place, but stabilized (b) Use direct pressure to control hemorrhage (c) Occlusive dressing for open neck lacerations iii) Thorax (with the exception of myocardial contusion and pericardial tamponade, most of the chest conditions that result from trauma are either managed when identified during the primary survey or at the hospital. Chest injuries are the second leading cause of death and disability and these patients need to have a high transport priority as part of their treatment plan.) (1) Ventilation (a) Assure adequacy of ventilation (b) Reevaluate injuries identified and managed in the primary survey (2) Myocardial Contusion (a) EKG monitoring (b) Treat dysrhythmias according to ACLS (3) Pericardial Tamponade (a) Fluid Bolus (4) Chest Wall Injuries (a) Simple isolated rib fractures (i) No pre-hospital management necessary (b) Flail Chest (i) Airway/ventilation management as necessary 81 15 NOV 2008 Revision V (ii) Bulky dressing splint (c) Hemothorax (i) Fluid replacement to treat shock (ii) Ventilatory support as necessary (d) Open Pneumothorax (i) Three-sided dressing (e) Tension Pneumothorax (i) Needle decompression* iv) Abdomen (prolonged evaluation of the abdomen for signs of an acute abdomen by checking for guarding, rebound tenderness or bowel sounds require extra delay and should be avoided. Most patients with intra-abdominal injuries require hospitalization, evaluation, and treatment so delay to perform such diagnostic techniques is not indicated.) (1) Evisceration (a) Clean, moist dressing (b) Occlusive Dressing (2) Foreign body (a) Do not remove except by direct order of Online Medical Oversight*. (b) Stabilize foreign body to prevent further injury during transport (3) Intra-abdominal hemorrhage (a) Intravenous fluids (4) Pelvic fracture (a) Long backboard immobilization (b) Consider PASG stabilization v) Extremities (1) Examine for swelling and deformity (2) Check for neurovascular function (3) Apply direct pressure to control bleeding (4) Splint-reassess neurovascular status after splinting (5) Consider PASG for multiple lower extremity fractures vi) Neurological (head, spinal cord, and peripheral nerve trauma) (1) Suspect associated C-spine injury and treat accordingly (2) If GCS <9 consider intubation and ventilation to protect/manage airway (3) Serial GCS determinations at least every 10min (4) Pupillary evaluation (a) Reactivity (b) Equality (c) Size (5) Reassess motor and sensory function (6) IV fluids should be restricted unless shock is present (7) If shock is present, look for other causes of blood loss, as brain injury alone is usually not the cause

Early “trauma notification” to the receiving hospital is essential to ensure the immediate availability of an appropriate in-hospital response. A “Trauma Alert” is called by the Emergency Room Physician based upon your report to the hospital; therefore, it is crucial that EMS provide a prompt accurate “Trauma Notification” to any leveled receiving facility.

* Requires Online Medical Oversight 2Committee on Trauma; American College of Surgeons; Resources for Optimal Care of the Injured Patient.

82 15 NOV 2008 Revision V Spinal Assessment and Immobilization Criteria

Immobilize for any "Yes" Answers 1) High Risk Mechanism of Injury: a) Patient Ejected from Vehicle? b) Death in Same Passenger Compartment? c) Fall Greater than 15ft or 3 times the Patient's height? d) Vehicle Rollover (Patient's Vehicle)? e) High Speed Collision? (Witnessed collision speed of >40mph, >20in of major front end deformity, or >12in of deformity into the passenger compartment) f) Vehicle vs. Pedestrian or Vehicle vs. Bicycle Collision? g) Motorcycle Collision/Accident? h) Unresponsive or Altered Mental Status following Fall/Collision? i) Penetrating Injury to Head, Chest, or Abdomen? 2) Unreliable Patient History/Exam a) Confused or Disoriented? b) Intoxicated (suspected use of ETOH or drugs, or impairment by high doses of medication)? c) Psychological/Psychiatric Conditions? d) Head Injury? e) Loss of Consciousness? f) Distracting Injury/Injuries? g) Unable to Communicate Adequately? 3) Neck/Back Pain or Abnormal Sensory/Motor Exam a) Neck or Back Pain/Tenderness (remember to palpate the entire spine)? b) Inability to Move? c) Asymmetrical Movement of any Extremity? d) Unable to Communicate Adequately? e) Complaining of Burning, Tingling, or Numbness in any Extremity?

83 15 NOV 2008 Revision V Isolated Trauma Pain Management

Isolated musculoskeltal injury includes, but is not limited to, extremity strain, sprain, or fracture, (including suspected femoral neck fractures), or back or chest wall muscle strain or spasm. Assessment to include and ensure hemodynamic stability, Onset, Provocation, Quality, Radiation, Severity, Time of onset, and 1-10 pain scale, both pre- and post-treatment. 1) Primary Paramedic Care 2) Splint, Ice, and Elevate when applicable 3) Administer one of the following: a) For analgesia: i) Morphine Sulfate (1) >50kg 2-5mg IV preferred. IM or SQ if IV unavailable (2) <50kg 0.1mg/kg diluted with 5ml normal saline over 3min b) For sedation or muscle spasms relaxation (i.e. back spasm), administer one of the following: i) Diazepam 2-4mg IV ii) Midazolam 2mg IV iii) Lorazepam 0.5-1.0mg IV

Contact Online Medical Oversight Possible Physician orders 1) Repeat analgesics or sedatives

84 15 NOV 2008 Revision V Burn Management

Description: Burn patients are often victims of multiple traumas. Treatment of all major traumatic injuries takes precedence over burn wound management. Protect yourself from exposure at all times. For prognostic and management reasons burns are classified in several different ways. 1) Mechanism of burn: thermal, chemical, electrical or inhalation (e.g., smoke, carbon monoxide, chemicals). 2) Depth of burns wound: a) Superficial (1st degree) involvement of superficial layers of the skin, producing redness and pain. b) Partial thickness (2nd degree) penetration to deeper layers of the skin producing pain, blistering, and edema. c) Full thickness (3rd degree) involvement of all skin layers and can also involve underlying muscle, bone, and/or other structures. Lack of pain is characteristic. 3) Extent (size) of burn wound; this is expressed as percent of total body surface area and can be calculated using the Rule of Nines or the palm rule (patient’s palm=1% TBSA). 4) Location of burn wound: Burns of the face, neck, hands, feet, perineum, and circumferential burns carry a higher risk of morbidity than burns of similar size in other locations. Facial burns are often accompanied by upper airway edema. Be prepared to intubate this patient. 5) For every patient suspected of carbon monoxide or other inhalation injury (particularly in closed space environmental fires, presence of singed nasal hairs or carbonaceous sputum), begin oxygen at highest possible flow rate.

85 15 NOV 2008 Revision V Thermal Burns

Evaluate the causative agent before initiating treatment. Stop the burning process by removal of the patient from the source of exposure or eliminate the source as per guidelines noted below. Do not apply creams, ointments, or antibiotics to burn. Do not remove any loose tissue or skin. 1) Primary Paramedic Care 2) Protect against hypothermia 3) Check for the presence of signed facial or nasal hair, hoarseness, wheezing, cough, or stridor and document. Consider “Medication Facilitated Intubation”/RSI per protocol. 4) Assess percentage of Total Body Surface Area Burned. 5) Establish IV Normal Saline (in area not affected by burn) run at 200ml/Hr. Titrate to SBP >90mmHg. Do not establish IV Access in a burned location whenever possible. 6) Remove loose clothing and jewelry/constriction hazards. 7) Apply clean dry towels or sheets to area. If the burns are less than 10% and are superficial or partial thickness you can moisten the towels or sheets with sterile normal saline for comfort. 8) Administer one of the following: a) For analgesia: i) Morphine Sulfate (1) >50kg 2-5mg IV preferred. IM or SQ if IV unavailable (2) <50kg 0.1mg/kg diluted with 5ml normal saline over 3min b) For sedation or muscle spasms relaxation (i.e. back spasm), administer one of the following: i) Diazepam 2-4mg IV ii) Midazolam 2mg IV iii) Lorazepam 0.5-1.0mg IV 9) Transport to appropriate facility

Contact Online Medical Oversight Possible Physician Orders: 1) Repeat analgesics or sedatives

86 15 NOV 2008 Revision V Chemical Burns/Exposures

Consider any chemical burn/exposure situation as a Hazmat situation. Whenever this situation arises contact the local fire department for scene management and gross decontamination. Never transport a patient that has not been appropriately decontaminated. If potential Hazmat situation exists, notify receiving hospital ASAP for further direction. Never bring a grossly decontaminated patient directly into the emergency department unless instructed to do so by the receiving facility. 1) Personal Safety / Protective Equipment 2) Identify the situation if possible (including the type and amount of chemical) 3) Upon receiving the patient from the fire department, remember they are still contaminated. 4) Primary Paramedic Care 5) Obtain name of the chemical or its I.D. and relay this information to the receiving facility as soon as possible. Bring a copy of the MSDS Sheet whenever possible. 6) Flush with copious amounts of water or saline unless contraindicated. Irrigate burns to the eyes with a minimum of 1000ml of normal saline. Alkaline burns should receive continuous irrigation throughout transport. 7) Administer one of the following: a) For analgesia: i) Morphine Sulfate (1) >50kg 2-5mg IV preferred. IM or SQ if IV unavailable (2) <50kg 0.1mg/kg diluted with 5ml normal saline over 3min b) For sedation or muscle spasms relaxation (i.e. back spasm), administer one of the following: i) Diazepam 2-4mg IV ii) Midazolam 2mg IV iii) Lorazepam 0.5-1.0mg IV

Contact Online Medical Oversight Possible Physician Orders: 1) Repeat analgesics or sedatives

87 15 NOV 2008 Revision V Electrical Burns

Without placing yourself at risk, remove patient from the source of electricity or have the power cut off. 1) Primary Paramedic Care 2) Suspect spinal injury secondary to tetanic muscle contraction 3) Treat any cardiac rhythm disturbances per protocol 4) Treat any trauma secondary to electrical insult as per protocol 5) Administer one of the following: a) For analgesia: i) Morphine Sulfate (1) >50kg 2-5mg IV preferred. IM or SQ if IV unavailable (2) <50kg 0.1mg/kg diluted with 5ml normal saline over 3min b) For sedation or muscle spasms relaxation (i.e. back spasm), administer one of the following: i) Diazepam 2-4mg IV ii) Midazolam 2mg IV iii) Lorazepam 0.5-1.0mg IV

Contact Online Medical Oversight Possible Physician Orders: 1) Repeat analgesics or sedatives

88 15 NOV 2008 Revision V Rule of Nine

89 15 NOV 2008 Revision V Chapter 11 Obstetrical / Gynecological Emergencies

Pre-eclampsia and Eclampsia 91 Antepartum Hemorrhage 92 Trauma in Pregnancy 93 Emergent Childbirth 94 Neonatal Assessment & Treatment 95 Delivery Complications 96 Postpartum Maternal Care 97

90 15 NOV 2008 Revision V Pre-eclampsia and Eclampsia Pregnancy Induced Hypertension / Toxemia of Pregnancy

Assess patient, careful consideration should be paid to the CNS and cardiorespiratory function. Verify by either history or observation the presence of tonic/clonic activity. Determine the gestational age of the fetus (will be 2nd or 3rd trimester and pregnancy should be apparent) and previous history of pregnancy-induced hypertension. 1) Primary Paramedic Care 2) If hypoglycemia or drug overdose induced status epilepticus is suspected, treat according to appropriate protocol.

Establish Online Medical Oversight Possible Physician Orders: 1) Magnesium Sulfate 4g in 20ml normal saline SIVP (over 5min) a) Follow with infusion of Magnesium Sulfate @ 1-2g/hr 2) Diazepam 5-10mg SIVP 3) Midazolam 2-4mg IV or IM 4) Lorazepam 1-2mg IV

If seizures recur or do not subside, Establish Online Medical Oversight for repeat of above. Be alert for respiratory depression, if this occurs, stop medication, support respiration, and Establish Online Medical Oversight.

91 15 NOV 2008 Revision V Antepartum Hemorrhage

Antepartum hemorrhage can produce serious life threatening blood loss for the mother, and it can be associated with fetal demise. Remember that rapid transport to the closest facility must be initiated any time bright red vaginal bleeding is present in the gravid female. Advise receiving hospital as soon as possible for Labor and Delivery notification. Placenta Previa: placenta overlying the cervix. Abruptio Placenta: separation of the placenta from the uterine wall, often but not necessarily associated with abdominal pain. Uterine Rupture: sudden severe abdominal pain and shock. 1) Do not delay- immediately initiate transport. 2) Primary Paramedic Care 3) Use a wedge to tilt patient to the left to move fetus off Inferior Vena Cava 4) Titrate IV Normal Saline to SBP >100 5) Keep patient warm 6) Elevate lower extremities

Establish Online Medical Oversight Possible Physician Orders: 1) Transport destination decision

92 15 NOV 2008 Revision V Trauma in Pregnancy

The most common cause of fetal death is maternal death. Rapidly assess fetal viability - is uterus (fundus) above (viable fetus) or below the umbilicus (non-viable fetus). Assessing the fundus (Gravid Uterus) by palpation can be used to help determine the length of pregnancy to date. Please be advised this should only be used as a gross assessment tool, and is not to basis for treatment differentiation of the mother. The fetus may be in jeopardy while mother’s vital signs appear stable. Treat mother aggressively for injuries based on mechanism of injury. Follow Trauma Protocol with the following considerations. 1) Do not delay- immediately initiate transport 2) Primary Paramedic Care 3) Check externally for uterine contractions 4) Check externally for vaginal bleeding and amniotic fluid leak (broken water) 5) If patient becomes hypotensive while supine on blackboard elevate right side of backboard (to relieve pressure on the inferior vena cava by uterus)

93 15 NOV 2008 Revision V Emergent Childbirth

1) Primary Paramedic Care 2) If no crowning or no urge to push, begin transport and reassess every 2min 3) If crowning or urge to push, prepair for imminent delivery. a) Control delivery with the palm of the hand so the infant does not “explode” out of the birth canal. b) Support the infant’s head as it emerges and support perineum with gentle hand pressure. c) Support and encourage the mother to control the urge to push. d) Tear the amniotic membrane, if it is still intact and visible outside the vagina. e) Check for cord around the neck. 4) Gently suction mouth and then nose (with bulb syringe) of infant as soon as head is delivered. 5) Note the presence or absence of meconium staining. If meconium is present in the airway suction extremely well. If necessary intubate and suction airway for thick meconium. When possible use a meconium aspirator. 6) As shoulders emerge, guide head and neck slightly downward to deliver anterior shoulder, then the posterior shoulder. 7) The rest of the infant should deliver with passive participation. Get a firm hold on the baby. 8) Repeat gentle suctioning then proceed to postpartum care of infant and mother. 9) Dry and keep infant warm. If possible skin-to-skin contact with the mother while covering the infant with a blanket provides a good warming source. 10) Clamp cord 6” to 8” from infant’s body. Cut cord with sterile scissors (blunt side next to infant) between clamps. Clamping of cord is not critical, and does not need to be done immediately, but keep the infant level with mom if cord is not clamped. This will prevent infant CHF (blood from mom to baby) or infant anemia (blood from baby to mom). If there is any bleeding from the cord clamp, reclamp again in close proximity to the “leaking” clamp. 11) Allow mother to hold baby next to her if her condition does not contradict this. Wrap both baby and mother together in blanket to diminish heat loss. 12) Establish date and time of birth and record. Perform immediate neonatal assessment and record APGAR at 1min and 5min. a) Appearance (Skin Color) i) Blue all over: 0 ii) Blue at extremities: 1 iii) Normal: 2 b) Pulse (Heart Rate) i) No Pulse: 0 ii) Less than 100 beats per minute: 1 iii) Greater than 100 beats per minute: 2 c) Grimace (reflex to suctioning) i) None: 0 ii) Some grimacing noted: 1 iii) Cries, coughs or sneezes: 2 d) Activity (Muscle Tone) i) None: 0 ii) Some flexion: 1 iii) Active movement: 2 e) Respirations i) No Respirations: 0 ii) Irregular or Ineffective: 1 iii) Good respiratory effort, effective, good cry: 2

94 15 NOV 2008 Revision V Neonatal Assessment / Treatment

Pediatric Resuscitation Triangle

95 15 NOV 2008 Revision V Delivery Complications

Nuchal Cord (cord around baby’s neck) 1) Slip two fingers around the cord and lift over baby’s head. 2) If unsuccessful: Double clamp cord, cut cord between clamps with sterile scissors (blunt side next to baby, never use a scalpel) allow cord to release from baby’s neck. 3) Continue with normal delivery protocol.

Prolapsed Cord (cord presenting before the baby) 1) Elevate mother’s hips in knee-chest position or left side down in Trendelenberg position. 2) Protect cord from being compressed by placing a sterile gloved hand in vagina and pushing up firmly on the presenting part of the fetus. 3) Palpate cord for pulsation 4) Keep exposed cord moist and warm. 5) Keep hand in position and transport immediately to approved OB facility. 6) Do not remove hand until relieved by OB personnel.

Breech Birth (legs or buttocks presenting first) 1) Never attempt to pull baby from the vagina by the legs or trunk. 2) After shoulders are delivered, gently elevate the trunk and legs to aid in delivery of head (if face down) 3) Head should deliver in 30sec. If not, reach 2 fingers into the vagina to locate the baby’s mouth. Fingers in mouth will flex baby’s head and should assist in spontaneous delivery. If not: Press vaginal wall away from the baby’s mouth to create an airway. If head does not deliver in 2min, keep your hand in position and transport ASAP.

Extremity Presentation 1) Proceed immediately to the hospital 2) Do not attempt out of hospital delivery 3) Encourage mother to perform slow deep breathing

Establish Online Medical Oversight

Post Partum Hemorrhage May be due to placental fragments not being delivered 1) Primary Paramedic Care 2) Massage the Fundus 3) Put the infant to breast 4) Rapid Transport

96 15 NOV 2008 Revision V Postpartum Maternal Care

1) Primary Paramedic Care 2) Place patient in position of comfort, unless otherwise indicated by signs of hypoperfusion 2) Observe for signs of bleeding. Treat for shock as indicated. 3) If the perineum is torn and bleeding, apply direct pressure to outside of vagina only. Never pack or place anything inside vaginal opening. 4) Prepare for placental delivery. This should occur within 30min. Protect umbilical cord from being pulled. 5) Titrate IV fluids to maintain SBP >100mmHg

97 15 NOV 2008 Revision V Chapter 12 Pediatrics (Patients <8yr or <55lbs)

Primary Paramedic Pediatric Assessment and Care 99 Pediatric Development and Vital Signs by Age 100-2 Pediatric Airway Management 103 Pediatric Respiratory Distress 104 Pediatric Asthma 105 Pediatric Suspected Croup or Epiglottitis 106 Pediatric Allergic Reaction 107 Pediatric Anaphylaxis 108 Pediatric Pulseless Arrest 109 Pediatric Bradycardia 110 Pediatric Tachycardia 111 Pediatric Altered Mental Status / Hypoglycemia / Coma 112 Pediatric Seizures / Status Epilepticus 113 Pediatric Rectal Diazepam Administration 114 Pediatric Trauma Injured Patient Triage Protocol 116-9 Pediatric Burns 120

98 15 NOV 2008 Revision V Primary Paramedic Pediatric Assessment and Care An organized pediatric assessment is crucial for determining and delivering timely, appropriate care to the pediatric population. There are currently three pediatric educational courses; Pediatric Advanced Life Support, Pediatric Education for the Prehospital Provider, and Prehospital Pediatric Care Course. These courses differ slightly in the approach and delivery of pediatric care, while maintaining the same basic principals. The following guideline has been established combining all three courses. The most important point to remember is to find an assessment style you, as a care provider, are comfortable with, and to apply it consistently.

When initiating pediatric care it is considered to be the “standard of care” to utilize a length/weight based tape. 1) General Appearance a) Perfusion to Skin b) Interaction with Environment (observe mental status and muscle tone) c) Work of Breathing 2) Airway a) Child maintains own airway b) Maintainable by BLS Intervention c) Maintainable only with ALS Intervention 3) Breathing a) Tidal Volume adequate (Unobstructed Pathway) b) Tidal Volume inadequate (Obstructed Pathway) c) Absent d) Initiate Oxygen therapy and/or ventilatory support per patient condition 4) Circulation a) Normal Skin Signs with + Peripheral Pulses and + Central Pulses (Normal) b) Abnormal Skin Signs with + Peripheral Pulses and +Central Pulses (Compensated) c) Abnormal Skin Signs with – Peripheral Pulses and + Central Pulses (Decompensating) d) Abnormal Skin Signs with – Peripheral Pulses + Weak Central Pulses (Decompensated) e) Absent Pulses 5) Obtain vascular access (IV/IO) per patient condition. Administer fluid bolus at 10-20ml/kg as indicated 6) Vital Signs a) Pulse: Rate, Quality, Rhythm, and Location b) Respiratory Rate, Character, and Breath Sounds c) Blood Pressure (check it early and check it often) d) Capillary Refill: Time to refill and location e) Cardiac Monitor when indicated f) Pulse Oximetry when indicated g) Capnography when indicated h) Blood Glucose Level in cases of AMS, dehydration, and when indicated 7) History of Episode (Obtained from primary caregiver on scene) a) Nature of Call / Mechanism of Injury b) Time of Onset c) Prior treatment related to present illness or injury 8) Pertinent Medical History a) Previous Medical Problems or Conditions b) Routine Medications c) Allergies d) Current Weight e) Immunization Status 9) Social History as dictated by developmental age 10) Initiate specific treatment per protocol / guideline

99 15 NOV 2008 Revision V Pediatric Development and Vital Signs by Age

1) Newborn (Birth to 1mo) a) Normal Development Characteristics i) Muscle tone and Body Position (1) Reflexive Movements (2) Equal hand, arm, leg movement (3) Will Grasp objects, but not reach (4) Cannot sit upright ii) Mental Status and Social Interaction (1) Appears alert when awake (2) Looks at objects and faces, but will not follow (3) Will not follow sounds iii) Verbal Abilities (1) Cries when hungry, cold, startled or in pain iv) Cognitive (1) Will look, listen, and taste to learn v) Keys to Successful Interaction (1) Likes to be kept warm and held (2) May be soothed by something to suck on (3) Avoid bright lights and loud noises b) Normal Vital Signs i) Blood Pressure 60mmHg ii) Heart Rate 120-160beats/min 2) Infant (1-12 Months) a) Normal Development Characteristics i) Muscle tone and Body Position (1) Equal hand, arm, and leg movements (2) Reaches for objects (4-6mo) (3) Crawls (4-10mo) (4) Sits upright (6-8mo) (5) Stands (12mo) ii) Mental Status and Social Interaction (1) Appears alert when awake (2) Can fix and follow objects and smile (2mo) (3) Turns to sound (4-6mo) (4) Fear of strangers (6-8mo) iii) Verbal Abilities (1) Cries when hungry, cold, startled or in pain (2) Imitates basic sounds (e.g., ma-ma) (6-8mo) iv) Cognitive (1) Will look, listen, and taste to learn v) Keys to Successful Interaction (1) Likes to be held (2) Distract with toy (3) Keep parents nearby (4) Toe-to-head exam b) Normal Vital Signs i) Blood Pressure >70mmHg ii) Heart Rate 120-140beats/min 3) Toddler (1-3yr) a) Normal Development Characteristics i) Muscle tone and Body Position (1) Walk and climb stairs (18mo) (2) Wriggles and squirms when restrained ii) Mental Status and Social Interaction (1) Appears alert when awake 100 15 NOV 2008 Revision V (2) May run if frightened (3) Feels modesty (4) Fear of strangers iii) Verbal Abilities (1) Basic language skills, may be talkative (2) Comprehension exceeds their spoken words iv) Cognitive (1) Emergence of reasoning (2) Increased independence (3) Remembers and fears pain (4) Does not make up false symptoms (5) Cannot reliably explain where pain is located v) Keys to Successful Interaction (1) Distract with toy (2) Respect modesty (3) Toe-to-head exam b) Normal Vital Signs i) Blood Pressure >70 + (2 X (age in years))mmHg ii) Heart Rate 100-140beats/min 4) Preschooler (3-6yr) a) Normal Development Characteristics i) Muscle tone and Body Position (1) Walks, runs, skips, and climbs ii) Mental Status and Social Interaction (1) Active when awake (2) Interacts with strangers (3) Feels modest about undressing (4) Will initiate and control activities iii) Verbal Abilities (1) Imitates conversations without (2) Believes others share their viewpoint and may not explain clearly iv) Cognitive (1) Thinking is literal, concrete, and rooted in present (2) Thought process is absolute (e.g., it hurts or doesn’t, things are good or bad) (3) Fears pain and separation from parents (4) Begins to fear disfigurement v) Keys to Successful Interaction (1) Explain actions using simple terms (2) Tell what will happen next, and if something will hurt (3) Respect modesty (4) Head-to-toe exam b) Normal Vital Signs i) Blood Pressure >70 + (2 X (age in years))mmHg ii) Heart Rate 100-120beats/min 5) School Age (6-12 Years) a) Normal Development Characteristics i) Muscle tone and Body Position (1) Physical skills are well developed (2) Risk taking behavior increases ii) Mental Status and Social Interaction (1) Clearly defined social skills (2) Feels very modest about undressing iii) Verbal Abilities (1) Uses language to communicate and learn iv) Cognitive (1) Understands past, present, and some future (2) Relative thinking develops (e.g., may hurt a little or a lot) 101 15 NOV 2008 Revision V (3) Can reliably report where pain is (4) Fears pain, disfigurement, loss of function, and begins to understand death v) Keys to Successful Interaction (1) Respect modesty (2) Let child make treatment choices when applicable (3) Allow child to participate in exam process (4) Head-to-toe exam b) Normal Vital Signs i) Blood Pressure >70 + (2 X (age in years))mmHg ii) Heart Rate 100-120beats/min

102 15 NOV 2008 Revision V Pediatric Airway Management

Pediatric Obstructed Airway If patient can breathe, cough, cry or speak (color pale or pale-pink): 1) Routine BLS medical care and general pediatric respiratory distress protocol. 2) Oxygen 100% by face mask held adjacent to face 3) Transport with parent, keeping child warm 4) If patient is conscious, but totally obstructed perform BLS airway clearing maneuvers appropriate to age a) <1yr back blows and chest thrusts b) >1yr abdominal thrusts

In an unconscious patient, if there is a strong suspicion for epiglottitis and if the patient is unable to be ventilated with a BVM and if an enlarged epiglottis is visualized, one attempt at intubation is allowed if the airway can be visualized. Consider using a smaller size tube than you normally would. If patient is unconscious or unable to ventilate and/or cyanotic with inadequate air exchange: 1) Initiate CPR 2) ALS Intervention - Open airway, attempt direct visualization with laryngoscope, and attempt removal of foreign body using Magill forceps as needed 3) If unsuccessful, transport keeping the child warm, continuing BLS airway clearing maneuvers, trying to ventilate with high pressure.

Establish Online Medical Oversight Possible Physician Orders: 1) Needle cricothyroidotomy a) Needle size is dependent upon the age/size of the child.

103 15 NOV 2008 Revision V Pediatric Respiratory Distress

Respiratory distress can be a life-threatening emergency. It may require immediate assessment and management. Although the etiology of respiratory distress in the pediatric patient may vary, the clinical manifestations are similar. The smaller tracheal diameter contributes to an easily compromised airway. Respiratory distress may occur as a result of upper airway obstruction (croup, foreign body, epiglottitis, congenital anomalies, edema, and allergic reactions) or from lower respiratory airway obstruction (asthma, pneumonia).

Rapid assessment is essential. Do this by checking the patency of the airway: properly position the airway, provide positive pressure ventilation using a BVM with 100% oxygen. Immediately institute ventilatory support for cases of severe respiratory distress or failure. Endotracheal intubation is indicated only if there is an inability to secure a patent airway and ventilate the patient adequately by BVM. Most children can be managed with BVM ventilation. Base the decision to intubate on the response to limited ventilatory support and the distance from the destination hospital.

Upper Airway Obstruction

Stridor and hoarseness are signs of upper airway distress. Croup and foreign body aspirations are the most frequent causes. Rarely, epiglottitis may occur. Epiglottitis usually occurs in a two to six year old child. The onset is usually abrupt and is associated with stridor, severe dysphagia, high fever, and a toxic appearance. Epiglottitis also can occur in an infant or an adolescent. Croup (laryngotracheal bronchitis) usually occurs in the infant or toddler. Its onset is more gradual and is associated with low-grade fever, a barking cough, rapid respiratory rate, and stridor. Foreign-body obstruction may present as stridor, dysphagia or respiratory arrest.

Lower Airway Obstruction

Wheezing is the hallmark of lower airway obstruction. Decreased, unequal, or absent breath sounds also can occur. The respiratory rate is generally rapid (although when expiration becomes prolonged, the rate may fall, an ominous sign). Bronchiolitis, asthma, and foreign-body obstruction should be considered.

Respiratory distress patients, regardless of etiology, must be treated under these general guidelines and other protocols as appropriate. 1) Primary Pediatric Assessment and Care 2) If airway is obstructed follow ECC Foreign Body Airway Obstruction Protocol 3) Assess for sign of respiratory distress (use of accessory muscles, stridor, retractions, nasal flaring or noisy respirations) 4) Administer oxygen in the least irritating manner possible 5) Allow the child to assume the most comfortable position for themselves as practical and safe during transport 6) See protocols for Croup/Epiglottitis or Asthma if indicated 7) If patient requires ventilatory assistance, remember: a) Do not over-extend the neck b) Ventilate with a BVM first c) Follow airway algorithm d) Early transport of the pediatric patient is critical

104 15 NOV 2008 Revision V Pediatric Asthma

1) Primary Pediatric Assessment and Care 2) Albuterol 2.5mg in 3ml normal saline nebulizer treatment a) May repeat X 1

Establish Online Medical Oversight Possible Physician Orders: 1) Repeat Nebulizer treatment 2) Epinephrine 0.01ml/kg/dose SQ (1:1,000)

If no improvement is noted, follow Pediatric Airway Management Guideline

105 15 NOV 2008 Revision V Suspected Croup or Epiglottitis

1) Obtain history and assess respiratory status to include: a) Presence of stridor b) Respiratory rate and effort c) Drooling or mouth breathing d) Degree of cyanosis e) Increased skin temperature 2) Primary Pediatric Assessment and Care 3) Allow child to achieve position of comfort as possible a) Do not look in the mouth. It is important to keep the patient calm and upright. 4) If respiratory status warrants, attempt to administer 100% oxygen via mask held by primary caregiver 4in in front of child’s face, but only if well tolerated by child. 5) Do not attempt to establish an IV. 6) Initiate transport immediately.

Establish Online Medical Oversight

If respiratory arrest occurs from complete airway obstruction: 1) Rapid initial transport is imperative 2) Attempt ventilation with pediatric BVM 3) If ineffective, may use adult BVM to attain higher inspiratory pressure. Use caution not to overinflate the lungs. 4) If still ineffective, endotracheal intubation may be indicated. In an unconscious patient, if there is strong suspicion for epiglottitis and if the patient is unable to be ventilated with a BVM and if an enlarged epiglottis is visualized, one attempt at intubation is allowed if the airway can be visualized. Consider using a smaller size tube than you normally would.

Establish Online Medical Oversight Possible physician orders: 1) Needle cricothyrotomy

106 15 NOV 2008 Revision V Pediatric Allergic Reaction

Stable Hemodynamics - no problem with ventilation, oxygenation or perfusion, minor to moderate skin manifestations and/or respiratory distress. No stridor. 1) Primary Pediatric Assessment and Care 2) If mild to moderate respiratory distress: a) Epinephrine 1:1,000 0.01mg/kg to a maximum total dose of 0.3mg SQ b) Albuterol nebulizer treatment c) Establish IV Normal saline only if patient condition indicates d) Diphenhydramine 1mg/kg IM or IV (over one minute) to a maximum total dose of 50mg

Establish Online Medical Oversight Possible Physician orders: 1) Repeat doses of Epinephrine (1:1,000) 0.01mg/kg SQ

107 15 NOV 2008 Revision V Pediatric Anaphylaxis

Unstable Hemodynamics - hypotensive patient according to normal values for age and weight, pending upper airway obstruction with wheezing and/or stridor, or severe obstruction with wheezing and/or stridor, or severe respiratory distress. 1) Epinephrine 1:1,000 0.01mg/kg SQ 2) Albuterol nebulized treatment for bronchospasm 3) Establish IV/IO access 4) Diphenhydramine 1mg/kg SIVP, or IM if no IV access. Max dose 50mg. 5) Fluid bolus 20ml/kg normal saline

Establish Online Medical Oversight Possible Physician orders: 1) Epinephrine 1:10,000 0.01mg/kg SIVP 2) Epinephrine infusion 0.1-0.3mcg/kg/min increasing to 1mcg/kg/min as necessary 3) Methylprednisolone 2mg/kg infusion over 15min

108 15 NOV 2008 Revision V Pediatric Pulseless Arrest

109 15 NOV 2008 Revision V Pediatric Bradycardia

110 15 NOV 2008 Revision V Pediatric Tachycardia

111 15 NOV 2008 Revision V Pediatric Altered Mental Status / Hypoglycemia / Coma

1) Primary Pediatric Assessment and Care 2) Consider/investigate etiology (trauma, hypoglycemia, overdose, seizure, hypoxemia, etc.) 3) Treat according to appropriate protocol 4) Support airway per Pediatric Airway Management Guideline 5) If blood glucose level <60mg/dl, if blood glucose level measurement is not available and patient is known diabetic, or patient presents with a history consistent with hypoglycemia, administer: a) Dextrose 25% 2ml/kg IV push b) If no IV available glucagon 0.02mg/kg up to 1mg IM 6) If a narcotic overdose is suspected or unknown and respiratory insufficiency is present: a) Administer Naloxone 0.4mg IV or IM i) May repeat to a maximum dose of 2mg

Establish Online Medical Oversight Possible Physician orders: 1) IO in child <6yr if no IV access 2) Repeat Dextrose 25% 3) Repeat Naloxone 4) Transport destination decision

112 15 NOV 2008 Revision V Pediatric Seizures / Status Epilepticus

Initiate treatment based on history and clinical presentation. It is essential to make the distinction between focal motor, general motor seizures, and status epilepticus. Most seizures do not require emergent intervention. Attempt to determine the etiology (i.e. whether the patient has a history of diabetes, seizure disorder, narcotic use, head trauma, poisoning or fever). If post-traumatic; transport to an appropriate facility with in-line cervical and full spinal immobilization as appropriate while maintaining airway. 1) Primary Pediatric Assessment and Care 2) If blood glucose level <60mg/dl administer: a) Dextrose 25% 2ml/kg 3) If the duration of the seizure is >10min, this is considered status epilepticus. Administer one of the following: a) Diazepam 0.25mg/kg (up to 3mg) IV b) Midazolam 0.1mg/kg (up to 2mg) IM c) Lorazepam 0.1mg/kg (up to 2mg) IV/IM 4) If the seizure is controlled by benzodiazepines, continuous assessment of respiratory status is critical as respiratory arrest can occur with use of these medications

Establish Online Medical Oversight Possible Physician Orders: 1) Repeat Dextrose 25% 2) Diazepam per rectum (see Pediatric Rectal Diazepam Administration protocol)

113 15 NOV 2008 Revision V Pediatric Rectal Diazepam Administration

Permission for administering diazepam does not constitute medical direction for administering per rectum. Administering medication per rectum requires specific medical control.

Procedure: 1) Draw up contents of the vial into 2 1ml syringes. Each syringe will contain 5mg in 1ml. 2) Remove the needle from the syringe and lubricate the tip. 3) Gently insert the syringe into the patient’s rectum. This may be facilitated by using a finger. 4) Administer diazepam 0.5mg/kg (0.1ml/kg) with a maximum dose of 10mg. No repeat doses may be administered. 5) Remove the syringe and squeeze the patient’s buttocks together for 5min to ensure medication does not leak out. 6) Monitor the patient’s respiratory status and vital signs, watching carefully for any signs of respiratory depression or hypotension.

114 15 NOV 2008 Revision V Pediatric Trauma Injured Patient Triage Protocol1

When transport to a Level I or II Trauma facility is indicated, but the ground transport time to that hospital is judged to be greater than twenty (20) minutes, determination of destination hospital shall be in accordance with medical control.

Severely injured patients <13yr should be taken to a Level I or II facility with pediatric resources including pediatric ICU.

All EMS providers transporting trauma patients to hospitals shall provide receiving hospital with a complete OEMS approved patient care form prior to departing from the hospital. 1) Measure vital signs and level of consciousness. If: a) Glasgow Coma Scale 12 or less, or b) Systolic blood pressure <90mmHg, or c) Respiratory rate <10breaths/min or >29breaths/min Then transport to Level I or II Trauma Center. 2) Assess anatomy of injury. If: a) Gunshot wound to chest, head, neck, abdomen or groin, or b) Third degree burns >15% BSA, or third degree burns of face, or airway involvement, or c) Evidence of spinal cord injury, or d) Amputation other than digits, or e) Two or more obvious proximal long bone fractures Then transport to Level I or II Trauma Center. 3) Assess mechanism of injury and other factors. If: a) Fall >20feet, or b) Apparent high-speed impact, or c) Ejection of patient from vehicle, or d) Death of same car occupant, or e) Pedestrian hit by car >20MPH, or f) Rollover, or g) Significant vehicle deformity- especially steering wheel, or h) Age <5yr, or i) Known cardiac disease or respiratory distress, or j) Penetrating injury to thorax, abdomen, neck or groin (other than gunshot wounds) Then Contact Online Medical Oversight for direction and transport decision. 4) If the patient is negative for the above, evaluate as per usual protocol.

When in doubt, consult with Online Medical Oversight.

1State of Connecticut Regulation of Department of Public Health and Addiction Services Concerning Statewide Trauma System: Sections 19a-177-5. 115 15 NOV 2008 Revision V Assessment and Management of the Pediatric Trauma Patient3

1) Primary Survey a) Airway and Cervical Spine Control i) Maintain in-line cervical immobilization, children <8yrs have larger occiputs and require elevation of the upper torso to achieve appropriate in-line cervical spine immobilization. ii) Manual (1) Jaw Thrust iii) Mechanical (1) Suction (2) Oropharyngeal Airway (3) Nasopharyngeal Airway (4) Pocket Mask (5) Orotracheal tube with in-line immobilization (6) Nasotracheal tube with in-line immobilization (7) Transtracheal Airway with in-line immobilization b) Breathing: Hypoxia is common in the trauma patient and correcting it is of the highest priority. A spinal injury may be present and the airway should be managed as if C-spine instability exists. Concern about a spinal injury must not delay institution of adequate ventilation and oxygenation. The neck should be maintained in a neutral position. If an endotracheal tube is required, neutral stabilization of the spine must be maintained throughout its insertion, so that the mandible and tongue are moved forward and the head is not tilted backwards. i) Note degree of respiratory distress: increased respiratory rate, skin color change, accessory muscle usage or noisy respirations ii) Ventilation (1) Mouth to mask (2) Bag-valve-mask (a) Age specific rates: (i) <3yrs: 30breaths/min (ii) 3-6yrs : 25breaths/min (iii) >6yrs: 20breaths/min iii) Flail Chest (1) Airway management iv) Open Pneumothorax (1) Partially occlusive dressing (3-sided) (2) Assist ventilations as needed with supplemental O2 v) Tension Pneumothorax (1) Decompression (a) Large bore needle with plastic catheter (angiocath) (b) Second intercostal space (ICS) in Midclavicular Line, superior aspect of the third rib (c) Fifth ICS in Midaxillary Line c) Circulation and Bleeding Control: Pale skin color and pulse characteristics are accurate parameters used in assessing the status of tissue perfusion. Blood pressure is obtained later in the patient’s assessment. Hemorrhage control in the primary survey is used only for massive bleeding. Minor bleeding takes a lesser priority. For patients with an unstable femur fracture, application of a traction splint is the most important field technique for control of this type of hemorrhage. Patients with “open book” pelvic fracture will benefit from stabilization and “direct pressure” from the PASG, in the pediatric patient correct sizing is critical. i) Evaluation (1) Pulse (a) Rate (b) Strength (c) Location 116 15 NOV 2008 Revision V (2) Skin (a) Color (b) Moisture (c) Temperature ii) Cardiac compressions as indicated iii) Hemorrhage control (1) Direct pressure on wound and/or pack wound with sterile gauze (2) Pressure points (usually not required) (3) Tourniquet (seldom, if ever, indicated) (4) Traction splint d) Disability: Changes in neurologic status can be of significance to the trauma surgeon or to the neurosurgeon. Significant alteration can change the outcome for the patient. GCS <9 consider advanced airway management. i) Glasgow Coma Scale (1) Infant (a) Eye Opening (i) 4 - Opens spontaneously (ii) 3 - Opens to speech (iii) 2 - Opens to pain (iv) 1 – None (b) Verbal Response (i) 5 - Coos and babbles (ii) 4 - Irritable cry (iii) 3 - Cries in pain (iv) 2 - Moans in pain (v) 1 – None (c) Motor Response (i) 6 - Spontaneous movement (ii) 5 - Withdraws to touch (iii) 4 - Withdraws to pain (iv) 3 - Flexion (pain) (v) 2 - Extension (pain) (vi) 1 – None (2) Child (a) Eye Opening (i) 4 - Opens spontaneously (ii) 3 - Opens to speech (iii) 2 - Opens to pain (iv) 1 – None (b) Verbal Response (i) 5 - Oriented (ii) 4 - Confused (iii) 3 - Inappropriate words (iv) 2 - Incomprehensible words (v) 1 - None (c) Motor Response (i) 6 - Obeys commands (ii) 5 - Localizes pain (iii) 4 - Withdrawal to pain (iv) 3 - Flexion (pain) (v) 2 - Extension (pain) (vi) 1 - None e) Exposure of the body for examination: It may be necessary to partially or completely expose the body to control hemorrhage and perform lifesaving procedures. It is important to consider modesty and to respect the individual’s needs. Nothing should be done to delay transport of the critically injured patient. f) Resuscitation 117 15 NOV 2008 Revision V i) Supplemental oxygen should be delivered @100% for all multisystem trauma patients. ii) Volume replacement: Excess time should not be spent in the field attempting to establish and IV. Critically injured patients should be transported to the trauma center and IV started enroute. Fluid resuscitation is only indicated for patients with signs and symptoms of shock. (1) Blood pressure should be monitored (a) Systolic/diastolic (b) Pulse pressure (2) Venous access (a) Peripheral IV (IO indicated in child<6yrs with symptomatic shock) (i) Large bore catheters (ii) Two sites preferred (3) Fluid Normal Saline or Lactated Ringers 20ml/kg bolus (a) Repeat bolus per Medical Control (b) Buretrol / volutrol should be used for children <25kg. 2) Secondary Survey: a systematic evaluation of the patient beginning at the head and proceeding to the neck, thorax, abdomen, and extremities should be completed. Unnecessary delay in order to carry out diagnostic procedures that do not produce information concerning direct treatment in the pre-hospital phase should not be attempted. Rapidly identify those patients who, because of the critical nature of their situation, require rapid transport to an appropriate facility. These patients should be stabilized and transported immediately. a) Head: most injuries to the face and head require hospital treatment - therefore delay in evaluation other than hemorrhage control is usually not necessary. Lacerations of the scalp may have a fracture beneath; therefore, unnecessary pressure is to be avoided. Use only enough pressure to control hemorrhage. Transportation to the hospital should not be delayed other than to correct life threatening airway problems. i) Airway (1) Reevaluate (2) Correct problems ii) Open Wounds (1) Control hemorrhage with direct pressure (2) Apply clean dressings to all wounds iii) Eyes (1) Protect from further injury (2) Irrigate to remove contaminants and debris) (3) Do not remove foreign bodies iv) Nose and ears (1) Pre-hospital evaluation for fluid (blood, CSF) (2) Treatment usually not required b) Neck: for small children, an appropriate size collar may not be available. In the event that collars available are too large, maintain cervical spine immobilization with an appropriate pediatric immobilization board with head immobilizers or an appropriately padded KED may be employed according to PEPP Guidelines i) Spinal immobilization indications (1) Any blunt injury above the clavicle (2) Unconscious patient (3) Multiple traumas (4) High speed crash (5) Neck pain (6) Complaints of extremity numbness/tingling (7) Gunshot wound involving the torso ii) Wounds (1) Leave foreign bodies in place, but stabilized (2) Use direct pressure to control hemorrhage c) Thorax i) Ventilation 118 15 NOV 2008 Revision V (1) Assure adequacy of ventilation (2) Reevaluate injuries identified and managed in the primary survey ii) Myocardial contusion (1) EKG monitoring (2) Treat dysrhythmias according to PALS and Online Medical Oversight iii) Chest wall injuries (1) Simple isolated rib fractures, no pre-hospital management necessary iv) Flail chest (1) Airway/ventilation management as necessary v) Hemothorax (1) Fluid replacement to treat shock (2) Ventilatory support as necessary vi) Open pneumothorax (1) Three-sided dressing vii) Tension pneumothorax (1) Needle decompression viii) Cardiac tamponade (1) Fluid bolus d) Abdomen i) Evisceration (1) Clean, moist dressing ii) Foreign body (1) Do not remove except by direct order of medical oversight (2) Stabilize foreign body to prevent further injury during transport iii) Intra-abdominal hemorrhage (1) Intravenous fluids iv) Pelvic fracture (1) Long backboard immobilization (2) Consider PASG stabilization e) Extremities i) Examine for swelling and deformity ii) Check for neurovascular function iii) Apply direct pressure to control bleeding iv) Splint-reassess neurovascular status after splinting v) Consider PASG for multiple lower extremity fractures f) Neurologic - Head, spinal cord, and peripheral nerve trauma i) Suspect associated C-spine injury and treat accordingly ii) All unconscious patients should be considered to have an inadequate respiratory status and should have aggressive airway management with C-spine control. iii) If GCS <9 consider ventilation with B-V-M. Intubation (refer to airway algorithm) iv) Serial GCS determinations at least every 10min v) Pupillary evaluation (1) Reactivity (2) Equality (3) Size vi) Reassess motor and sensory function vii) IV fluids should be restricted unless shock is present viii) If shock is present, look for other causes of blood loss, as brain injury alone is usually not the cause. 3) Transportation: it is impossible to fully stabilize the unstable patient in the pre-hospital setting. There must be a balance of lifesaving skills (such as endotracheal intubation) with minimizing scene time (<10min) and rapid transport in order to reduce the time from injury to definitive surgical treatment. Early “trauma” notification to the receiving hospital is essential to ensure the immediate availability of an appropriate in-hospital response. See Adult Trauma Alert Protocol for patching guidelines. 3Based on Committee on Trauma; American College of Surgeons; Resources for Optimal Care of the Injured Patient. 119 15 NOV 2008 Revision V Pediatric Burn Management

The approach to the pediatric burn patient should be similar in your approach to any burn patient, assuring your safety, the patient’s safety, stopping the burning process, and airway management all remains paramount. These protocols will deal with specific fluid resuscitation measures and special considerations. Please refer to the Adult Trauma - Burn section of these protocols for your “systems” approach to patient care, and the pediatric “Rule of Nines”. Be suspicious for burn patterns that may indicate child abuse, i.e. “stocking” or “glove” pattern burns. 1) Primary Pediatric Assessment and Care 2) IV normal saline 3) IO is indicated in the patient <6yrs who needs fluid replacement and an IV cannot be established. As with adults, IV or IO sites should not be through a burn site unless no other site exists. 4) Administer 20ml/kg bolus

Establish Online Medical Oversight Possible Physician orders: 1) Repeat bolus of fluid 2) Morphine 0.05-0.1mg/kg for pain management

120 15 NOV 2008 Revision V Chapter 13 Pharmacology

121 15 NOV 2008 Revision V Activated Charcoal

Class: Absorbent

Action: Absorbs many drugs and poisons in the GI tract

Indication: Toxic ingestions - not caustics or pure petroleums

Contraindication: None for emergency use

Dose: 50-100g Pedi dose: 1-2g/kg

Route: PO

122 15 NOV 2008 Revision V Adenosine

Class: Endogenous nucleoside

Action: Stimulates adenosine receptors; decreases conduction through the AV node

Indication: PSVT

Contraindication: Patients taking Persantin or Tegretol.

Precaution: Short half-life must administer rapid normal saline bolus immediately after administration of drug. Use IV port closest to IV site.

Side effect: Arrhythmias, chest pain, dyspnea and/or bronchospasm (rare)

Dose: 6mg IV over 1-2sec; may repeat 12mg twice at 2min intervals. Pedi Dose: 0.1mg/kg, may repeat twice at 0.2mg/kg

Route: IV

123 15 NOV 2008 Revision V

Albuterol

Class: ß2 Agonist Synthetic sympathomimetic Bronchodilator

Action: Stimulates ß2 receptors in the smooth muscle of the bronchial tree.

Indication: Relief of bronchospasm.

Contraindication: None for field use.

Precaution: Patient with tachycardia.

Side effect: Tachycardia

Dose: 2.5mg (0.5ml of the 0.5% solution) diluted to 3ml NS for nebulized updraft. May repeat in 10-20min

Route: Inhaled as a mist via nebulizer.

Pediatric Dose: 1.25mg (0.3ml of 0.5% solution) to 2.5mg diluted to 3ml NS for nebulized updraft. May repeat in 10-20min

124 15 NOV 2008 Revision V Amiodarone

Class: Antiarrhythmic

Action: Prolongs refractory period and prolongs repolarization.

Indication: Pulseless Ventricular Tachycardia and Ventricular Fibrillation

Contraindication: Bradycardia, 2nd and 3rd degree AV Blocks

Dose: 300mg, may be followed with 150mg ONCE

Route: SIVP

Infusion: 1mg/min (300mg in 250ml D5W with a 60gtt/ml dripset set at 50gtt/min)

Note: Must be mixed with D5W

125 15 NOV 2008 Revision V Aspirin

Class: Antiplatelet

Action: Inhibitor of platelet aggregation

Effects: Decrease clotting time

Indication: Chest pain of cardiac origin

Dose: 325mg tab or 4-baby aspirin (81mg per tab)

Route: PO

Side Effects: None with field use

Contraindication: Allergy to aspirin.

Note: GI upset is not a true allergy.

126 15 NOV 2008 Revision V Atropine

Class: Antimuscarinic Parasympathetic blocker Anticholinergic

Action: Blocks acetylcholine (ACh) at muscarinic sites

Indication: Symptomatic bradydysrhythmias Cholinergic poisonings Asystole

Contraindication: None in emergency situations

Side effects: Tachydysrhythmias Exacerbation of glaucoma Precipitation of myocardial ischemia

Dose: Bradydysrhythmias- 0.5-1mg IV q3-5min Asystole- 1mg IV q3-5min (total max. dose 3mg) Organophosphate poisonings- 1-2mg IV prn Pedi dose: 0.02mg/kg IV

Route: IV

127 15 NOV 2008 Revision V Calcium Chloride

Class: Electrolyte

Action: Facilitates the actin myosin interaction in the heart muscle.

Indication: Hypocalcemia Hyperkalemia Calcium channel blocker intoxication

Contraindication: Not to be mixed with any other medication - precipitates easily.

Precaution: Patients receiving calcium need cardiac monitoring

Side effect: Cardiac arrhythmias Precipitation of digitalis toxicity

Dose: Usual dose is 5-10ml of 10% Calcium Chloride in 10ml Pedi Dose: 0.2ml/kg of 10% concentration

Route: IV

128 15 NOV 2008 Revision V Dextrose

Class: Carbohydrate

Action: Raises the blood sugar

Indication: Diabetic patients with low blood sugar level Altered mental states Seizure

Contraindication: None for field emergency use

Precaution: Tissue necrosis if infiltration occurs

Side effects: As above-infiltration Intracerebral hemorrhages in neonates with undiluted D50

Dose: 25g SIVP, may repeat Pedi Dose: 1ml/kg of D50 SIVP. Dilute 1:4 in those less than 1wk and 1:2 in those 1wk to 1yr.

Route: SIVP, confirm IV placement prior to and during administration

129 15 NOV 2008 Revision V Diazepam

Class: Benzodiazepine

Action: Decreases cerebral irritability Calms CNS

Indication: Major motor seizures Acute anxiety states Pre-cardioversion

Contraindication: None for emergency field use

Dose: 2-20mg to control seizure activity 2-5mg for anxiety or pre-cardioversion Pedi dose: 0.5mg/min to control seizure. Total dose 0.5mg/kg

Route: SIVP

130 15 NOV 2008 Revision V Diltiazem

Class: Calcium channel blocker

Action: Partial blockade of AV node conduction

Indication: Atrial fibrillation, atrial flutter, narrow complex tachycardia

Contraindication: Hypotension Hypersensivity to drug Wide complex tachycardia Known history of Wolf Parkinson White (WPW) 2° or 3° AV block

Caution: Already on Digoxin and Beta Blocker

Side effect: May induce VF if given to patient with wide complex tachycardia that is due to WPW. May cause hypotension.

Dose: 0.25mg/kg. Average dose 25mg Pedi dose: 0.25mg/kg

Route: SIVP (over 2min)

Note: If patient becomes hypotensive secondary to drug administration: - If bradycardic, give atropine - If not in, give fluids - If acute pulmonary edema ensues or worsens, administer dopamine infusion

131 15 NOV 2008 Revision V Diphenhydramine

Class: Antihistamine H1 blocker

Action: Blocks histamine receptor sites

Indication: Systemic allergic reactions Drug induced extrapyramidal reactions

Contraindication: None with emergency use

Caution: Asthma

Side effect: Sedation Hypotension

Dose: 25-50mg Pedi Dose: 1mg/kg

Route: IV/IM

132 15 NOV 2008 Revision V

Dopamine

Class: Naturally occurring catecholamine, adrenergic agents

Action: Stimulates , 1 and dopaminergic receptors

Effects: 0.5-2μg/kg/min - Renal and mesenteric vasodilation. 2-10μg/kg/min - Renal and mesenteric vasodilation persists and increased force of contraction (FOC). 10-20μg/kg/min - Peripheral vasoconstriction and increased FOC (HR may increase). 20μg/kg/min or greater - marked peripheral vasoconstriction (HR may increase).

Indication: Shock - Cardiogenic - Septic - Anaphylactic

Contraindication: Pre-existing tachydysrhythmias or ventricular dysrhythmias.

Caution: Infuse in large vein only Use lowest possible dose to achieve desired hemodynamic effects, because of potential for side effects. Do not D/C abruptly; effects of dopamine may last up to 10min after IVI is stopped. Do not mix with NaHCO3, as alkaline solutions will inactivate dopamine.

Side effect: Tachydysrhythmias Ventricular ectopic complexes Undesirable degree of vasoconstriction Hypertension relate to high doses Nausea and vomiting Anginal pain

Dose: 2-20mcg/kg/min titrated to desired effect Pedi dose: same as adult dose - titrate to effect

Route: IVI

133 15 NOV 2008 Revision V Dopamine Infusion Chart 400mg Dopamine in 250ml Normal Saline using a 60gtt/ml Drip set

Find patient’s weight in left column, and desired dose in the top row- intersection is gtt/min.

5 10 15 20 Patient Weight mcg/kg/min mcg/kg/min mcg/kg/min mcg/kg/min 88lbs 40kg 8 15 23 30 110lbs 50kg 9 19 28 38 132lbs 60kg 11 23 34 45 154lbs 70kg 13 26 39 53 176lbs 80kg 15 30 45 60 198lbs 90kg 17 34 51 68 220lbs 100kg 19 38 56 75 242lbs 110kg 21 41 62 83 264lbs 120kg 23 45 68 90 286lbs 130kg 24 49 73 98 308lbs 140kg 26 53 79 105 330lbs 150kg 28 56 84 113 352lbs 160kg 30 60 90 120 374lbs 170kg 32 64 96 128 396lbs 180kg 34 68 101 135 418lbs 190kg 36 71 107 143 440lbs 200kg 38 75 113 150

134 15 NOV 2008 Revision V Epinephrine

Epinephrine 1:10,000 and Drip

Class: Natural catecholamine, adrenergic

Action: Stimulates both alpha (a) and beta (ß1 and ß2) receptors.

Indication: Cardiac arrest Severe anaphylaxis with shock

Contraindication: Use in pregnant women should be conservative Pre-existing tachydysrhythmias

Side effects: Tachydysrhythmias Hypertension May induce early labor in pregnancy Headache, nervousness, decreased level of consciousness

Dose: 0.5-1mg (usual) 2-10mcg/min IV infusion Pedi Dose: 0.01mg/kg 0.1-1mcg/kg/min IV infusion Route: IV/IO/ET (if given ET, the dose should be doubled)

Adult Infusion Table: 1mg in 250ml Normal Saline using 60gtt/ml Drip Set

mcg/min 2 3 4 5 6 7 8 9 10 gtt/min 30 45 60 75 90 105 120 135 150

Epinephrine 1:1,000

Class: Same as Epi 1:10,000

Action: Same as Epi 1:10,000

Indication: Severe allergic reaction Angioneurotic edema Bronchial edema

Contraindication: Use with caution in the presence of: Pre-existing tachydysrhythmias Hypertension Significant cardiac history Pregnancy

Side effect: Same as Epi 1:10,000

Dose: 0.3mg Pedi dose: 0.01mg/kg to a max. 0.3mg

Route: SQ

135 15 NOV 2008 Revision V Etomidate

Class: Non-Narcotic, Non-Barbituate sedative hypnotic agent.

Mechanism: Etomidate produces deep hypnosis and sedation with an onset of 10-15sec and duration of 5-15min. It may lower intra-ocular and intra-cerebral pressure, and decrease cerebral oxygen demand.

Dosage: 0.3mg/kg IV over 30-60sec

Route: IV (antecubital site preferred)

Indications: Conscious Sedation to facilitate intubation

Contraindications: Known Hypersensitivity <12yr

Precautions: Hypoventilation and possible apnea in overdosage. Myoclonus, or diffuse muscle contraction, which can be painful once the patient awakens. This can be limited with the use of a benzodiazepine as premedication.

Side Effects: Pain at injection site, Hypotension, apnea, tachycardia, nausea/vomiting.

Note: Etomidate does not cause analgesia; therefore, reflex sympathetic hypertension and tachycardia may be anticipated.

136 15 NOV 2008 Revision V

Furosemide

Class: Loop diuretic

Action: Blocks active reabsorption of chloride in the kidney, results in diuresis Mild venodilation results in decreased preload

Indication: Pulmonary edema

Contraindication: Allergy to sulfa drugs Children under 12yrs Pregnancy

Precaution: Furosemide bolus should be given over 1min Lung sounds should be noted before and after administration of Furosemide Patients already taking diuretics may require a high dosage

Side effect: Dehydration Decreased circulating plasma volume Decreased cardiac output Loss of electrolytes K+ and Mg++ Transient hypotension

Dose: 0.5-1mg/kg (usual dose 40mg)

Route: SIVP

137 15 NOV 2008 Revision V

Glucagon Class: Pancreatic hormone

Action: Increases blood glucose level by converting liver glycogen to glucose

Indication: Hypoglycemic patient who does not have IV access Beta-blocker or calcium channel blocker overdose Food bolus impaction in the esophagus

Contraindication: Known hypersensivity Pheochromocytoma / insulinoma

Caution: Mix with own dilutent - do not mix with saline

Side effect: Nausea / vomiting Hyperglycemia

Dose: 1mg (1unit) Pedi dose: 0.5-1mg

Route: IM

138 15 NOV 2008 Revision V Haloperidol

Class: Antipsychotic, neuroleptic

Action: Depresses cerebral cortex, limbic system, and hypothalamus, which control activity and aggression

Indication: Psychiatric emergencies with violent patients

Contraindications: Brain damage, bone marrow depression, alcohol and barbiturate withdrawl states, Parkinson’s disease, angina, epilepsy

Side effect: laryngospasm, respiratory depression, seizures

Dose: 5mg

Route: IM

Note: May be administered IM with lorazepam in the same syringe

139 15 NOV 2008 Revision V Ipratroprium Bromide

Class: Anticholinergic Bronchodilator

Action: Relaxes bronchial smooth muscle

Effect: Bronchodilation

Indication: For use in severe COPD and asthma cases after albuterol

Dose: 0.5mg nebulizer

Route: Nebulized updraft

Side effects: Tachycardia, palpitations and/or headache (most common)

Note: If patient has a know sensitivity to peanuts, soybeans do not give them Ipratroprium Bromide. This could cause an anaphylactic reaction.

140 15 NOV 2008 Revision V Lidocaine

Class: Antiarrhythmic

Action: Decreases ventricular irritability Elevates fibrillation threshold

Indication: Intractable ventricular fibrillation Ventricular ectopy consisting of wide complex tachycardia including VT After successful defibrillation to prevent the reoccurrence of VF

Contraindication: AV blocks Sensitivity to medication Idioventricular rhythms Sinus bradycardias, SA arrest or block Ventricular conduction defects Not used to treat occasional PVCs

Caution: Reduce dose in patients with CHF, renal or hepatic diseases

Side effect: Early: Anxiety, apprehension, decreases LOC, tinnitus, visual disturbances, euphoria, combativeness, nausea, twitching, numbness, difficulty breathing or swallowing, decreased heart rate. Late: Seizure, hypotension, coma, widening QRS complex, prolongation of the P-R interval, hearing loss, hallucinations.

Dose: 1-1.5mg/kg, may repeat 3-5min 2-4mg/min infusion Pedi dose: 1mg/kg total maximum pedi dose 3mg/kg

Route: IV/IO/ET (if given ET, the dose should be doubled)

Adult Infusion Table: 1g in 250ml Normal Saline using 60gtt/ml Drip Set

1g/250ml NS 2mg/min 3mg/min 4mg/min Drip Rate 30gtt/min 45gtt/min 60gtt/min

141 15 NOV 2008 Revision V Lorazepam

Class: Benzodiazepine

Action: Decreases cerebral irritability; produces sedation

Effect: Stops Grand Mal seizures; produces sedation

Indications: Status epilepticus; sedation for painful procedures

Route: IV/IM

Side Effects: CNS and respiratory depression

Dose: 1-2mg may be repeated with direct physician order Pedi dose: 0.1mg/kg (up to 2mg) may be repeated with direct physician order

Notes: Lorazepam is very temperature sensitive and may be stored at room temperature for no longer than 60dy. After 60dy, the medication must be returned to pharmacy for replacement. At no time may this medication exceed ambient temperature greater then 90˚F; this will immediately render the medication useless. Every precaution must be taken to ensure this temperature is not reached. When receiving this medication please note the return to pharmacy date on the paperwork.

142 15 NOV 2008 Revision V Magnesium Sulfate

Class: Electrolyte

Action: Facilitates the proper function of many enzyme systems in the body Facilitates the Na-K magnesium dependent ATPase pump Blocks calcium non-selectively

Indication: Torsades de pointes Refractory or recurrent VF or pulseless VT Refractory seizures Digitalis-induced cardiac arrhythmias Pre-eclampsia Documented hypomagnesemia

Contraindication: None for field emergency use

Caution: Use with caution or not at all in the presence of renal insufficiency or high degree AV block.

Side effect: Hypotension - mild but common Heart block - uncommon Muscular paralysis, CNS and respiratory depression - toxic effects

Dose: Torsades, refractory seizures, Digitalis, hypomagnesemia - 2g over 1-2min

Pre-eclampsia - 4g IVI over 30min - If actively seizing as above

VF/VT - 2g IV

Route: IV/IVI

143 15 NOV 2008 Revision V Methylprednisolone

Class: Steroid Glucocorticoid Anti-inflammatory

Action: Thought to stabilize cellular and intracellular membranes

Indication: Reactive airway disease Anaphylactic reaction Spinal cord injury

Contraindication: None for emergency field use

Dose: 40-125mg Pedi dose: 2-4mg/kg

Route: SIVP

144 15 NOV 2008 Revision V Metoclopramide

Class: Cholinergic, antiemetic

Action: Enhances response to acetylcholine of tissue in upper GI tract, which causes contraction of gastric muscle; increases peristalsis without increasing secretions.

Indication: Nausea and/or vomiting refractory to oxygen administration

Contraindications: Hypersensitivity to metoclopramide, procaine, or procainamide, seizure disorders, pheochromocytoma, prolactin dependant breast cancer, GI obstruction

Dose: 10mg

Route: Deep, dorsogluteal IM

145 15 NOV 2008 Revision V Metoprolol

Class: ß Adrenergic Blocker

Action: Blocks stimulation of ß adrenergic receptors resulting in decreased chronotropy and inotropy.

Indication: Narrow complex tachycardia in patients currently prescribed ß adrenergic blockers

Contraindication: SBP <110mmHg HR <60beats/min Active COPD Acute Pulmonary Edema

Side effect: Hypotension Headache and facial flushing Dizziness, decreased LOC

Dose: 5mg

Route: IV

146 15 NOV 2008 Revision V Midazolam

Indications: Status epilepticus; sedation for painful procedures

Contraindications: Sensitivity to midazolam or benzodiazepines, acute narrow angle glaucoma

Action: CNS Depressant

Effect: Sedation and Seizure Control

Onset: 1-3min

Duration: 2-6hr

Adverse Effects: Decreased Tidal Volume, Decreased Respiratory Rate, Respiratory Arrest, Hypotension, Bradycardia, Pain During Injection, Site Tenderness, Hiccups, Nausea and Vomiting, Oversedation, Potentiates Narcotics and dosages of both must be reduced.

Dose: Seizures: 2-4mg IV/IM may repeat as per MD Order. Sedation for Pain and Anxiety: 2-4mg IV/IM may repeat as per MD Order. Sedation to Aid or Post Intubation: 2mg IV may repeat per MD Order. NOTE: You will induce apnea prior to creating a “flaccid” patient. Pedi dose: Seizures: 0.1mg/kg (up to 2mg) SIVP (over 2min)/IM. May be diluted normal saline or D5W for administration control. Neonatal dose: (0-6mo): Seizures: 0.05mg/kg SIVP (over 2min)/IM. May be diluted normal saline or D5W for administration control.

147 15 NOV 2008 Revision V Morphine Sulfate

Class: Narcotic analgesic

Action: Decreases pain perception and anxiety

Indication: AMI Pulmonary Edema Burns Injuries not involving mental status changes

Contraindication: Head injury Undiagnosed abdominal injury Multiple trauma COPD/compromised respirations Hypotension Allergic to Morphine, Codeine, Percodan

Side effect: Respiratory depression or arrest Decreased LOC Hypotension Increased vagal tone (slowed heart rate) Nausea/vomiting Pinpoint pupils Increased cerebral blood flow Urticaria

Dose: 2-15mg - dependent on patient situation. Pedi dose: 0.1mg/kg (usual dose)

Route: SIVP/IO/IM/SQ

148 15 NOV 2008 Revision V Naloxone

Class: Narcotic antagonist

Action: Reverses the effects of narcotics by competing for opiate receptor sites. Will reverse respiratory depression cause by narcotics

Indications: Suspected overdose with depression of respiration Diagnostic tool in coma of unknown origin

Contraindication: None for emergency field use

Side effect: Narcotic withdrawal

Dose: 0.4-2mg - titrate to respiratory effort Pedi dose: 0.01mg/kg

Route: IV/IM/IN

149 15 NOV 2008 Revision V Neo-Synepherine

Class: Topical vasoconstrictor

Action: Stimulates alpha receptors in blood vessels of the nasal mucosa causing vasoconstriction. Decreases risk and amount of nasal bleeding.

Indication: Facilitation of nasotracheal intubation

Contraindication: None for emergency field use

Precaution: Administer prior to setting up equipment to allow medication a chance to take effect.

Side effect: Hypertension Palpitations

Dose: 2-4sprays each nostril

Route: IN

150 15 NOV 2008 Revision V Nitroglycerine

Class: Vascular smooth muscle relaxant

Action: Systemic vasodilator which decreases myocardial workload and oxygen consumption.

Indication: Angina Pectoris Pulmonary edema

Contraindication: Hypotension <12yr

Side effect: Hypotension Headache and facial flushing Dizziness, decreased LOC

Dose: SL: 0.4mg may repeat q3-5min, titrate to pain, effect and blood pressure Paste: 1-2in as per protocol

Route: SL/TD

151 15 NOV 2008 Revision V Ondanasetron

Class: 5-HT3 Receptor Antagonist (Antiemetic)

Action: Blocks stimulation of the 5-HT3 receptors by serotonin, which decreases the neural stimulation that causes vomiting.

Indication: Nausea and/or vomiting refractory to oxygen administration

Contraindications: Allergy to 5-HT3 antagonists

Side effect: Constipation, hypokalemia (rare)

Dose: 4mg

Route: IV

152 15 NOV 2008 Revision V Prochlorperazine

Class: Phenothiazine, antiemetic

Action: Blocks stimulation of the chemoreceptor zones which cause vomiting.

Indication: Nausea and/or vomiting refractory to oxygen administration

Contraindications: Hypersensitivity to phenothiazines, coma, seizure, encephalopathy, bone marrow depression

Dose: 5-10mg

Route: Deep, dorsogluteal IM

153 15 NOV 2008 Revision V Sodium Bicarbonate

Class: Alkalotic agent

Action: Neutralizes acid in the blood. May help pH return to normal limits.

Indication: Combat metabolic acidosis Tricyclic medication overdose after hyperventilation

Contraindication: Respiratory acidosis Not to be used routinely in cardiac arrest

Side effect: Metabolic alkalosis Lowers K+, increases cardiac irritability Worsens respiratory acidosis if ventilation is inadequate

Dose: 1meq/kg, may repeat if indicated at ½ initial dose

Route: IV

154 15 NOV 2008 Revision V Sodium Chloride

Class: Isotonic electrolyte

Action: Fluid and sodium replacement

Indications: IV access in emergency situations Fluid replacement in hypovolemic states Used as a dilutent for IVI medications

Contraindications: None for field use

Precaution: Fluid overload

Side Effect: Rare

Dose: Dependent upon patient condition and situation, TKO, fluid bolus, “wide open” Pedi dose: TKO or 20ml/kg bolus

Route: IVI

155 15 NOV 2008 Revision V Thiamine

Class: Vitamin

Action: Essential for normal metabolism of carbohydrates (glucose)

Indication: Suspected malnourished or alcoholic patients receiving dextrose

Contraindication: none for emergency field use

Dose: 100mg

Route: SIVP (over 1min)/IM

156 15 NOV 2008 Revision V Vasopressin

Indications: Pulseless arrest as an alternative to Epinephrine as 1st or 2nd dose

Contraindications: Not recommended for responsive patients with coronary disease

Action: Potent peripheral vasoconstrictor

Effect: Peripheral vasoconstriction during cardiac arrest

Dose: 40units

Route: IV/IO

157 15 NOV 2008 Revision V Revision V Notes

The 2006 Region V Paramedic Protocols have undergone extensive changes in this fifth revision. Some procedures have been added, and some have been modified. There has also been a major stylistic revision. For these reasons, please review the entire protocol, from start to finish, as if this was the first time that you have seen it.

158 15 NOV 2008 Revision V