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Altered Mental Status Universal Patient Care Bring all necessary equipment to patient Scene YES Demonstrate professionalism and courtesy Required VS: Safe Mass assembly consider WMD Blood pressure NO Palpated pulse rate Utilize appropriate PPE Respiratory rate Pulse ox if available Consider Airborne or Droplet Isolation Call for help / additional if indicated resources If Indicated: Stage until scene safe Initial assessment Glucose BLS maneuvers 12 Lead ECG Temperature Initiate oxygen if indicated Pain scale Adult Assessment Procedure CO Monitoring Pediatric Assessment Procedure Use Broselow-Luten tape Trauma Medical Patient Patient Evaluate Mechanism of Injury (MOI) Mental Status General Section Protocols Consider Spinal Immobilization Exam If indicated Unresponsive Responsive Significant MOI No Significant MOI Primary and Chief Complaint secondary Obtain assessment SAMPLE Primary and Primary and Secondary Secondary trauma trauma assessment assessment Obtain history of Primary and Focused assessment present illness from Secondary on specific injury available sources / assessment Obtain VS scene survey Focused assessment Obtain SAMPLE on specific complaint Obtain SAMPLE Obtain VS Repeat assessment while preparing for transport Exit to Continue on-going assessment Exit to Appropriate Protocol Repeat initial VS Appropriate Protocol Evaluate interventions / procedures Transfer Patient hand-off includes patient information, personal property and summary of care and Patient does not Patient does not response to care fit specific fit specific protocol protocol Notify Destination or Contact Medical Control Revised Protocol 1 10/3/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Universal Patient Care General Section Protocols Pearls · Recommended Exam: Minimal exam if not noted on the specific protocol is vital signs, mental status with GCS, and location of injury or complaint. · Any patient contact which does not result in an EMS transport must have a completed disposition form. · A pediatric patient is defined by fitting on the Broselow-Luten tape, Age ≤ 15, weight ≤ 49 kg. · Pediatric Airway Protocols are defined by patients ≤ 11 years of age. · Timing of transport should be based on patient's clinical condition and the transport policy. · Never hesitate to contact medical control for patient who refuses transport. · Blood Pressure is defined as a Systolic / Diastolic reading. A palpated Systolic reading may be necessary at times. · SAMPLE: Signs / Symptoms; Allergies; Medications; PMH; Last oral intake; Events leading to illness / injury Revised Protocol 1 10/3/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Airway Supplemental oxygen Assess Respiratory Rate, Effort, Protocols 1, 2 and 3 should be Goal oxygen saturation Oxygenation utilized together (even if ≥ 90% Is Airway / Breathing Adequate? YES agency is not using RSI) as they contain very useful information for airway NO Exit to management. Appropriate Protocol Basic Maneuvers First -open airway chin lift / jaw thrust -nasal or oral airway -Bag-valve mask (BVM) Adult / Pediatric Respiratory Distress With Spinal Immobilization Procedure a Tracheostomy Tube if indicated Protocol if indicated Consider AMS Protocol Airway Foreign Body NO Obstruction Procedure Airway Patent? Adult General Section Protocols Direct I Laryngoscopy YES Breathing / Oxygenation Supplemental oxygen Complete Obstruction? NO YES Support needed? BVM Consider Airway NO I CPAP Procedure YES Monitor / Reassess Supplemental Oxygen if indicated Airway Cricothyrotomy P Surgical Procedure Exit to appropriate protocol Unable to Ventilate and Oxygenate ≥ 90% during or after one (1) BVM / CPAP or more unsuccessful B Airway BIAD Procedure NO intubation attempts . Effective? Oral / Nasotracheal I Anatomy inconsistent Intubation Procedure YES with continued Consider RSI Protocol attempts. P if available Three (3) unsuccessful attempts by most Consider Sedation experienced EMT-P/I. If BIAD or ETT in place P Exit to Adult Failed Airway Protocol Notify Destination or Contact Medical Control Revised Protocol 2 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult Airway Adult General Section Protocols Pearls · This protocol is only for use in patients with an Age ≥ 12 or patients longer than the Broselow-Luten Tape. · Capnometry (Color) or capnography is mandatory with all methods of intubation. Document results. · Continuous capnography (EtCO2) is strongly recommended for the monitoring of all patients with a BIAD or endotracheal tube. · If an effective airway is being maintained by BVM with continuous pulse oximetry values of ≥ 90%, it is acceptable to continue with basic airway measures instead of using a BIAD or Intubation. · For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation. · An Intubation Attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal passage. · Ventilatory rate should be 8-10 per minute to maintain a EtCO2 of 35-45. Avoid hyperventilation. · It is strongly encouraged to complete an Airway Evaluation Form with any BIAD or Intubation procedure. · Intermediates and Paramedics should use a BIAD if oral-tracheal intubation is unsuccessful. · Maintain C-spine immobilization for patients with suspected spinal injury. · Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag. · Cricoid pressure and BURP maneuver may be used to assist with difficult intubations. They may worsen view in some cases. · Hyperventilation in deteriorating head trauma should only be done to maintain a EtCO2 of 30-35. · Gastric tube placement should be considered in all intubated patients if available or time allows. · It is important to secure the endotracheal tube well and consider c-collar (in absence of trauma) to better maintain ETT placement. Manual stabilization of endotracheal tube should be used during all patient moves / transfers. Revised Protocol 2 8/13/2012 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult, Failed Airway Unable to Ventilate and Oxygenate ≥ 90% during or after one (1) or more unsuccessful intubation attempts . Protocols 1, 2 and 3 should be Anatomy inconsistent with continued attempts. utilized together (even if agency is not using RSI) as Three (3) unsuccessful attempts by they contain very useful most experienced EMT-P/I. information for airway management. Each attempt should include change in approach or equipment NO MORE THAN THREE (3) ATTEMPTS TOTAL Call for additional Failed Airway resources if available Adult General Section Protocols BVM Adjunctive Airway YES Maintains SpO2 ≥ 90 % Continue BVM Supplemental Oxygen NO Exit to Appropriate Protocol Significant Facial Airway Cricothyrotomy YES Trauma / Swelling / P Surgical Procedure Distortion Continue Ventilation / NO P Oxygenation Maintain SpO2 ≥ 90 % B Airway BIAD Procedure NO BIAD Successful YES Continue Ventilation / Oxygenation Maintain SpO2 ≥ 90 % EtCO2 35 – 45 Ventilate 8 – 10 breaths / minute Notify Destination or Contact Medical Control Protocol 3 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Adult, Failed Airway Adult General Section Protocols Pearls · If first intubation attempt fails, make an adjustment and then consider: · Different laryngoscope blade / Video or other optical laryngoscopy devices · Gum Elastic Bougie · Different ETT size · Change cricoid pressure. Cricoid pressure no longer routinely recommended and may worsen view. · Apply BURP maneuver (Push trachea Back [posterior], Up, and to patient's Right) · Change head positioning · Continuous pulse oximetry should be utilized in all patients with an inadequate respiratory function. · Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways. · Notify Medical Control AS EARLY AS POSSIBLE about the patient's difficult / failed airway. Protocol 3 Any local EMS System changes to this document must follow the NC OEMS Protocol Change Policy and be approved by OEMS 2012 Airway, Rapid Sequence Intubation (OPTIONAL) Indications for RSI Preoxygenate 100% O2 IV Procedure Failure to protect the airway IO Procedure I (preferably 2 sites) P Protocols 1, 2 and 3 should be Unable to oxygenate Assemble Airway Equipment utilized together (even if P Suction equipment agency is not using RSI) as Unable to ventilate Alternative Airway Device they contain very useful information for airway Impending airway management. compromise Evidence of Head Injury / CVA or NO Reactive Airway Disease? Age ≥ 12 / Length > Broselow- Luten Tape YES P Etomidate 0.3 mg/kg IV / IO Or Procedure will remove Ketamine 1.5 - 2 mg/kg IV / IO Adult General Section Protocols patient’s protective Succinylcholine 1.5 mg / kg IV/ IO airway reflexes and Or ability to ventilate. P Rocuronium 1 mg / kg IV / IO If indicated (if Succinylcholine contraindicated) You must be sure of your ability to intubate Intubate trachea before beginning this procedure. Placement Verified Continuous Capnography NO May Repeat Must have two (2) Sequence x1 EMT-P on scene Consider Restraints Physical Procedure Confirm appropriate drug doses P Consider Gastric Tube Insertion
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