Adult Treatment Protocols for Cole County Emergency Medical Services Reviewed and Approved By

Adult Treatment Protocols for Cole County Emergency Medical Services Reviewed and Approved By:

Charles Ludy, DO Matthew Lindewirth, MSEMS, NRP Medical Director, Cole County EMS Chief, Cole County EMS

EFFECTIVE DATE: 7 AUGUST 2020 This Page Intentionally Left Blank

2020 Version Cole County EMS Treatment Protocols line medical control MUST be contacted - Introduction Preface Acknowledgments Cole County EMS Treatment Protocols Treatment EMS County Cole s s chief complaint, treatment, or condition falls outside the standards established within ’ EMS provide the citizens within Cole County the best care possible. best provide within thecare County citizens Cole EMS the based practice, as the foundation for treatment of a variety of patient encounters and include both -

2020 Version 1 Version

Without all of the work of Dr. Ludy, Chief Kampeter and Chief Schmitz this would not havebeen this workKampeter all SchmitzChief Chief possible. and of the would not WithoutLudy, of Dr. hard work in making these protocols, formulary, procedures.formulary, and protocols, in hard these making work Also, a special thanks to Chief of Training Jessica Kampeter and Training Chief Nathan Schmitz for all the for tireless all Schmitz the Training andNathan Chief Jessica Kampeter of Training Chief a to Also,thanks special On behalf of Cole County EMS, we would like to thank Dr. County Colehelp Charles Ludy for dedicating his time and effort to emergency medical care. medical emergency under the direct supervision of Cole County EMS Medical Director. Please note that items subject in to this continuous review manualto are ensure that EMS personnel are providing their patients with the most current Treatment protocols are predetermined, written medical care guidelines and may include standing orders these Protocols. the CCEMS Drug Formulary on all patient encounters. As always, on whenever a patient and and clinical judgement. This protocol book is to be used in conjunction with the CCEMS Procedures Book and adult and pediatric patients. While we are unable to encompass every patients, these possible protocols disease provide a and/or foundation for injury high quality care of when our coupled with education, experience, evidence This This document serves as the method in medical which direction Cole of County doctor Charles EMS Ludy, personnel DO. provide patient These protocols care integrate under both, the proven medical practice and This Page Intentionally Left Blank

2020 Version Cole County EMS Treatment Protocols

a situation wherein, in competent in situation wherein,medical competent a

s s healthpersonal information. We respect the privacy ’ parent - Rights of a Patient a Rights of Cole County EMS Treatment Protocols Treatment EMS County Cole an an individual who sick, injured, wounded, diseased, or otherwise incapacitated or

Foundation ofFoundationPractice ”:

Patient “ s s and treat all healthcare information about our patients with care under strict policies of ’ patient is defined as any individual who is less than 13 years of age AND/OR fits the Handtevy conjunction with CCEMS conjunction the andCCEMSProcedures with Drug Formulary.

patient is defined as any individual outside of those Pediatric parameters. Pediatric of those as is outside individual any defined patient

An emergency under implied consent is definedimplied emergency underis as An consent if there has been no protest or refusal of consent by a person authorized and empowered toof consent refusalperson no consent empowered aauthorized there and has been ifor by protest one isthere andmorbid,no is or affected material ofthethat condition person in the A change Deemed emancipated by the state the byof Missouri state Deemed emancipated Pregnant Mother, father, legalstep father, Mother, or guardian, the isfrom permission parent in of group children of written possession Leader of awho

of of faculties. judgement, the proposed surgical or medical treatment or procedures are immediately areorimmediately treatment or proceduresor imminently thesurgical medical judgement, proposed necessary and any delay occasioned by an attempt obtain to wouldconsent jeopardizereasonably the life, health, or oflimb the person affected, or reasonable would result in disfigurement or impairment immediately available who is authorized, empowered, willing and capacitated to consent. andto empowered, authorized,capacitated willing who is available immediately authorizing emergency medical treatment medical emergency authorizing

- - - - -

- - threatening situations without being able to communicate consent: tocommunicateable being without threatening situations

A patient of any Age falls under implied consent when an emergency exists and one of the following and exists following apply: of theunder when ofan any Age consent one emergency A implied patient falls The The only time a minor may consent or refuse medical treatment without the knowledge theof parent is if he or is: she The following groups may consent for the treatment of a minor:ofatreatmentfor consentthe may The groups following of of age. A patient that is deemed a minor by below. exist as stated unless circumstances special the or treatment transport state of Missouri may not consent to or refuse medical Per Missouri Revised RSMo194.210 Statute minor a is defined as an individual who is under eighteen years ADULT

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• • 1. Minors:1. Situations that require special considerations regarding patient consent: regarding require considerations thatspecial Situations confidentiality that we are committed to following at all time. all committed time. thatfollowing at confidentialityto are we of of our patient Cole committedEMSCounty is to patientour protecting be utilized in be utilized Based Based on above the definitions of pediatric adultand appropriatepatients the Protocol Book Treatment should An A Heel).(Head tape to based length institutions, institutions, home or cemeteries, and individuals declared dead prior to assistance the time an ambulance is called for helpless, or dead, excluding deceased individuals being transported from or between private or public Definition Definition of a Version 1 Cole County EMS Treatment Protocols 2020 should be followed if applicable. As with the first section, not every aspect outlined in this final section will will section final this in outlined aspect every not section,topertain first the with As applicable. if followed be should dosages medication on expand advice is to back meant The page knowledge. commonmedical experience and based on The • • be must system as by phone Director EMS Medical the calling includes also or notification Urgent Director. Medical patientthe notify then shall who Chief the on on effect their notifying crew the adverse should with processstart reporting or The completed. is negative response the once potentially Director Medical the to a reported immediately has that incident Any ahidvda rtcl s aial dvdd no scin. h upr oe wl tpcly nld history, include typically will boxes upper The sections. 3 into divided basically is protocol individual Each calculations. dosing for System Handtevy pediatric for patient. the medication a of guidance the and dosing weight utilizealways but guidance, care utilized for be may protocol adult the protocol, pediatrica of pediatric appropriate an patient guidance the under fall notdoes patient pediatric the pediatric arises and asituation If exists. theif one be utilized should For groupings. special other and trauma, medical, cardiac, airway, universal, including sections,divided into protocolsare CountyEMS Cole Ingeneral, control prior to fromcontrol deviationsanyprotocols outlinedthroughoutthisprior revision. recommendedshould the from deviation ANY for rationale the however, exist; exceptions where instances be always will There described. order the in section, this in suggested care the receive should patient every evidence current on based points care patient important define to tree decision style chart flow a utilizes section middle The pertinentelement your willbeincluded patient to the in patient assessment, evaluation, and that EVERY expected any is documentit but,patient; every on bedocumented symptom suggested sign or to / historicalelement not is expectation The encounter. patient particular their to pertinent elements those complaintandchoose then patient a causes for considerpotential multiple to areminder as informationand signs

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2020 Version Table of Contents

UNIVERSAL PROTOCOL SECTION

Universal Patient Care…………………………………………………………………………………………………….. UP 1 Spinal Motion Restriction……………………………………………………………………………………………….. UP 2 Vascular Access………………………………………………………………………………………………………………. UP 3 Criteria for Death / Withholding Resuscitation……………………………………………………………….. UP 4 Discontinuation of Prehospital Resuscitation………………………………………………………………….. UP 5 Do Not Resuscitate (DNR) and Advanced Directives……………………………………………………….. UP 6 U Patient Without a Protocol…………………………………………………………………………………………….. UP 7 U N Physician on Scene…………………………………………………………………………………………………………. UP 8 N I Police Custody………………………………………………………………………………………………………………… UP 9 I V Refusals: AMA / Treatment…………………………………………………………………………………………….. UP 10 V E Safe Place for Newborns…………………………………………………………………………………………………. UP 11 E R Scene Rehabilitation: General…………………………………………………………………………………………. UP 12 R S Service Animal Transport………………………………………………………………………………………………… UP 13 S A Transport: Air Transport Criteria…………………………………………………………………………………….. UP 14 A L Transport: Interfacility Transfers…………………………………………………………………………………….. UP 15 L Transport: Sepsis Criteria………………………………………………………………………………………………… UP 16 Transport: STEMI Criteria.………………………………………………………………………………………………. UP 17 Transport: Stroke Criteria……………………………………………………………………………………………….. UP 18 Transport: Trauma Criteria……………………………………………………………………………………………… UP 19 Transport: Transfer of Care between Agencies / Hospitals……………………………………………… UP 20 MCI: Disasters………………………………………………………………………………………………………………… UP 21 MCI: Triage…………………………………………………………………………………………………………………….. UP 22 EMS Documentation………………………………………………………………………………………………………. UP 23 Citizen Assist………………………………………………………………………………………………………………….. UP 24

A A I I R R W W A A Y AIRWAY / RESPIRATORY PROTOCOL SECTION Y

& Adult Airway…………………………………………………………………………………………………………………… AR 1 & Medication Facilitated Intubation (MFI)…………………………………………………………………………. AR 2 R R E Adult, Failed Airway……………………………………………………………………………………………………….. AR 3 E S Post-Intubation / BIAD Management……………………………………………………………………………… AR 4 S P Ventilator Troubleshooting…………………………………………………………………………………………….. AR 5 P I Adult COPD / Asthma / Respiratory Distress…………………………………………………………………… AR 6 I R Field Ventilator Setup…………………………………………………………………………………………………….. AR 7 R A A T T O O R R Y Y

Table of Contents Table of Contents

ADULT CARDIAC PROTOCOL SECTION

Bradycardia…………………………………………………………………………………………………………………….. AC 1 Chest Pain: Cardiac and STEMI……………………………………………………………………………………….. AC 2 C CHF / Pulmonary Edema…………………………………………………………………………………………………. AC 3 C A Cardiac Arrest…………………………………………………………………………………………………………………. AC 4 A R Cardiac Arrest: Pit Crew CPR…………………………………………………………………………………………… AC 4B R D Cardiac Arrest: Ventricular Fibrillation / Pulseless Ventricular Tachycardia…………………….. AC 5 D I Cardiac Arrest: Asystole / Pulseless Electrical Activity…………………………………………………….. AC 6 I A Cardiac Arrest: ROSC………………………………………………………………………………………………………. AC 7 A C Cardiac Arrest: On – Scene Resuscitation Termination of CPR………………………………………… AC 8 C Emergencies Involving Ventricular Assist Devices (VAD or LVADs)………………………………….. AC 9 Tachycardia: Narrow Complex (<0.11 sec) REGULAR Rhythm…………………………………………. AC 10A Tachycardia: Narrow Complex ( <0.11 sec) IRREGULAR Rhythm……………………………………… AC 10B Tachycardia: Wide Complex (>0.12 sec) REGULAR Rhythm…………………………………………….. AC 11A Tachycardia: Wide Complex (>0.12 sec) IRREGULAR Rhythm………………………………………….. AC 11B

MEDICAL PROTOCOL SECTION

Abdominal Pain / Vomiting and Diarrhea……………………………………………………………………….. AM 1 Allergic Reaction / Anaphylaxis………………………………………………………………………………………. AM 2 Altered Mental Status…………………………………………………………………………………………………….. AM 3 Back Pain………………………………………………………………………………………………………………………… AM 4 M Behavioral………………………………………………………………………………………………………………………. AM 5 M E Dental Problems……………………………………………………………………………………………………………… AM 6 E D Diabetic………………………………………………………………………………………………………………………….. AM 7 D I Dialysis / Renal Failure……………………………………………………………………………………………………. AM 8 I C Central Line Emergencies……………………………………………………………………………………………….. AM 9 C A Epistaxis…………………………………………………………………………………………………………………………. AM 10 A L Hypertension………………………………………………………………………………………………………………….. AM 11 L Hypotension / Shock………………………………………………………………………………………………………. AM 12 Pain Control……………………………………………………………………………………………………………………. AM 13 Seizure……………………………………………………………………………………………………………………………. AM 14 Sepsis……………………………………………………………………………………………………………………………… AM 15 Stroke…………………………………………………………………………………………………………………………….. AM 16 Syncope………………………………………………………………………………………………………………………….. AM 17

T T R TRAUMA AND BURN PROTOCOL SECTION R A A U Blast Injury / Incident……………………………………………………………………………………………………… TB 1 U M Burns……………………………………………………………………………………………………………………………… TB 2 M A Trauma: Crush Syndrome……………………………………………………………………………………………….. TB 3 A Trauma: Extremity………………………………………………………………………………………………………….. TB 4 & Trauma Eye Injury…………………………………………………………………………………………………………… TB 5 & Trauma: Head…………………………………………………………………………………………………………………. TB 6 B Trauma: Lightning Strike…………………………………………………………………………………………………. TB 7 B U Trauma: Multisystem……………………………………………………………………………………………………… TB 8 U R Trauma: Traumatic Arrest………………………………………………………………………………………………. TB 9 R N Radiation Incident………………………………………………………………………………………………………….. TB 10 N S S

Table of Contents Table of Contents

E E N N V ENVIRONMENT / TOXINS PROTOCOL SECTION V I I R R O Bites and Envenomation…………………………………………………………………………………………………. TE 1 O N Carbon Monoxide / Cyanide…………………………………………………………………………………………… TE 2 N M Drowning……………………………………………………………………………………………………………………….. TE 3 M E Hyperthermia…………………………………………………………………………………………………………………. TE 4 E N N T Hypothermia / Frostbite…………………………………………………………………………………………………. TE 5 T Overdose: Beta Blocker…………………………………………………………………………………………………… TE 6 & Overdose: Calcium Channel Blocker………………………………………………………………………………… TE 7 & Overdose: Cholinergic / Organophosphate…………………………………………………………………….. TE 8 T T O Overdose: Cocaine and Sympathomimetic……………………………………………………………………… TE 9 O X Overdose: Opioid……………………………………………………………………………………………………………. TE 10 X I Overdose: Tricyclic Antidepressants……………………………………………………………………………….. TE 11 I N N S S

OB PROTOCOL SECTION

O Childbirth……………………………………………………………………………………………………………………….. OB 1 O B Newly Born…………………………………………………………………………………………………………………….. OB 2 B Post – Delivery Care……………………………………………………………………………………………………….. OB 3 High Risk Childbirth / Labor…………………………………………………………………………………………….. OB 4 Obstetrical Emergencies…………………………………………………………………………………………………. OB 5

S S P P E E C C I I A SPECIAL CONSIDERATIONS PROTOCOL SECTION A L L

C General Infectious Diseases……………………………………………………………………………………………. SC 1 C O Infectious Disease Matrix……………………………………………………………………………………………….. SC 2 O N C-Diff / MRSA…………………………………………………………………………………………………………………. SC 3 N S Coronavirus……………………………………………………………………………………………………………………. SC 4 S I I D Ebola………………………………………………………………………………………………………………………………. SC 5 D E Influenza………………………………………………………………………………………………………………………… SC 6 E R Meningitis………………………………………………………………………………………………………………………. SC 7 R A Tuberculosis……………………………………………………………………………………………………………………. SC 8 A T T I I O O N N S S

A A P P P Approved Medical Abbreviations…………………………………………………………………………………… Appendix A P E Physiologic Effects of Sympathomimetics Agents…………………………………………………………… Appendix B E N Job Aids………………………………………………………………………………………………………………………….. Appendix C N D Blood Gas…………………………………………………………………………………………………………. Appendix C1 D I Capnography……………………………………………………………………………………………………. Appendix C2 I C Ventilator…………………………………………………………………………………………………………. Appendix C3 C E E S S

Table of Contents This Page Intentionally Left Blank

2020 Version Universal Patient Care

Scene Safe? Call for help / additional resources NO Mass assembly consider WMD Stage until scene safe YES MINIMUM REQUIRED EQUIPMENT Notified by dispatch of potential hazmat or infectious for every call: disease exposure risk? • Scene Bag Door jamb survey needed? • Cardiac Monitor Known infectious disease? • Oxygen Don Appropriate PPE R Consider Airborne, Contact, or Droplet Isolation R Reference CCEMS Special Circumstances Protocols / Policy / procedures/ infectious disease primer EXIT to Appropriate As indicated YES Special Circumstances Minimum required PPE subject to change as deemed fit Protocol(s); SC 1 – 8 during fluid situations involving infectious diseases NO EXIT to Appropriate PEDIATRIC PEDIATRIC: < 13 years old AND Protocol(s) [A] < 60 kg OR [B] Fits on Standardized Pediatric Length YES AND reference CCEMS Handtevy Based Tape APP / Book

NO Universal Protocol Section

Bring all necessary equipment to patient’s side. MINIMUM REQUIRED EQUIPMENT Demonstrate professionalism and courtesy. for PEDIATRIC calls: R Primary Assessment R • Handtevy Bag Assessment Procedure • Cardiac Monitor BLS maneuvers • Oxygen Initiate oxygen

Life Threat? YES

Obtain Vital Signs (Temperature must be obtained 1st if suspicion for R infectious disease) R Obtain SAMPLE / OPQRST Assess • Blood Glucose EXIT to B • Pulse Oximetry B Abnormal? YES Appropriate • EtCO2 Waveform Capnography Protocol • Cardiac Monitor / 12 & 15-lead ECG Procedure P Cardiac Monitor / 12 & 15-lead ECG Interpretation P NO

Required Vital Signs on every Patient: 1. Temperature 2. Manual Blood pressure Continue on-going assessment 3. Palpated pulse rate Repeat initial VS 4. Respiratory rate Evaluate interventions / procedures 5. Pulse oximeter

IF Patient refusing care and / or transport Exhausted a Protocol OR EXIT to Refusals: AMA / Treatment M Patient Does Not Fit a Protocol: M Protocol; UP 10 Contact Medical Control

2020 Version 1 UP 1 Version 1 Universal Protocol Section 2020 • • • • • • • • • • •

Disposition: • • • • • • • • Pearls

Patient Refusal: see Refusals: AMA / Treatment Protocol; UP 10 UP Protocol; Treatment / AMA see Refusals: Refusal: Patient PPE FULL don must personnel responding fever, subjective or (38°C) 100.4°F than greater temperature documented has Ifpatient temperature anoral complaint, disease infectious a suspected of contact patient initial Upon minutes 5 every least at patients unstable potentially or unstable for documented be shall sign monitoring Vital less or 15 minutes every patients stable for documented be shall monitoring sign Vital staff. receiving the to completed been has turnover and bedside facility receiving the at until patient to the connected shall remain devices monitoring the medication, any received has that patient 12/15 illness, or injury serious has a that patient any For medication. pain and/or asedative administra any if or signs vital unstable or abnormal trauma, sepsis, intubation), BIAD, orotracheal CPAP, (ex. placed device inadequa any with patients on monitored continuously and applied be will capnography waveform EtCO2 and (SpO2) Oximetry Pulse contact. patient 12/15 completed. interpretation a12 received that patient ANY involvement. neurological or respiratory, cardiac, suspected or <94%) SpO2 or >100, HR <60 <100, (SBP signs vital abnormal if and/or navel and their nose between posteriorly or anteriorly anatomically 12/15 interpret and Acquire required: is (ePCR) Report Care a Patient of Completion OPQRST (Pain assessment): Onset; Provocation; Quality; Radiation; Severity; Time Severity; Radiation; Quality; Provocation; Onset; assessment): (Pain injury OPQRST / to illness leading Events intake; oral Last History; Medical Past Medications; Allergies; Symptoms; / Signs SAMPLE: times. at be necessary may reading Systolic palpated A reading. / Diastolic a Systolic as defined is Pressure Blood transport. refuses who patient for control medical contact to hesitate Never policy. transport the and condition clinical patient's on based be should transport of Timing 10 UP Protocol; / Treatment AMA Refusals: to EXIT refusal, or AMA patient If treatment. Al (ePCR). report care patient electronic a completed have must transport an EMS in notresult does which contact patient Any or complaint. injury of location and GCS, with status mental signs, is vital exam Minimal Exam: Recommended ong with 2 complete sets of vital signs MUST be obtained on any transported patient or any patient that receives receives that patient any or patient transported any on obtained be MUST signs ofvital sets 2 complete with ong R: C: capacity: Assessing to Guide patient the describing assessment status mental a including important is very event the of Documentation signs. vital including an assessment, allow to patient Encourage facility. medical to transport accept to patient Encourage situation. risk high isa refusal Patient - - M: A:

EMS Transport: EMS - - Every patient MUST have their own ePCR completed ePCR own their have MUST patient Every service; for call to a route en goes unit a Anytime -

recognize the significance of the outcome potentially from their decision. their from potentially outcome the of significance the recognize benefits. and risks incapacity. demonstrates consistently choice the express to an inability or choice lead ECG lead Patient should be able to communicate a clear choice: clear a communicate to able be should Patient Limit total on total Limit on total Limit Relevant information is understood: is information Relevant Appreciation of the situation: the of Appreciation describe the logic they are using to come to the decision, though you may not agree with decision. with notagree may you though decision, to the come to using are they logic the describe

Manipulation of information in a rational manner: rational a in information of Manipulation te airway or respiratory function and require aerosol interventions bag interventions aerosol require and function respiratory or airway te ’ s are to be acquired, interpreted by paramedic, AND transmitted to receiving facility within 5 minutes of of minutes 5 within facility receiving to transmitted AND paramedic, by interpreted acquired, be to sare - - scene time to < 20 minutes for all other patients. patients. other for all minutes 20 to < time scene patients for critical minutes 10 to < time scene Universal Patient CareUniversal Patient BLS: ALS:

- Any patient with normal vital signs and are within scope of practice of scope within are signs and vital normal with patient Any Any patient with abnormal vital signs, assessment, has an IV in place, or received ALS intervention intervention ALS received or place, in an IV has assessment, signs, vital abnormal with patient Any lead ECG lead - Lead acquisition and interpretation will be required to have a 15 a to have required will be interpretation and acquisition Lead

Ability to communicate an understanding of the facts of the situation. They should be able to able be should They situation. the of facts the of understanding an communicate to Ability ’ s and apply EtCO2 waveform capnography for patients with a medical complaint complaint medical a with patients for capnography waveform EtCO2 apply sand

Patient should be able to display a factual understanding of the illness, the options and and options the illness, the of understanding factual a display to able be should Patient ’ s capacity to refuse care. to refuse scapacity - UP 1 lead ECG has been acquired, EtCO2 monitoring is being performed or a or performed is being monitoring EtCO2 acquired, been has ECG lead

Demonstrate a rational process to come to a decision. Should be able to able be Should decision. to a come to process rational a Demonstrate

This should remain stable over time. Inability to communicate a communicate to Inability time. over stable remain should This - valve - mask, a nebulized treatments, or airway or airway treatments, a nebulized mask, MUST - Lead acquisition and and acquisition Lead

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Spinal Motion Restriction

Universal Patient Care Protocol; UP1

Patient involved in traumatic event that NO poses ANY potential for spinal injury?

YES

Does the patient meet YES P Major Trauma Criteria with a P BLUNT mechanism of injury?

Does the patient have ANY of the following? • Altered Mental Status (GCS < 15) – associated with trauma – for any reason including possible intoxication from alcohol or drugs. • Complaint of neck and/or spine pain or tenderness, Torticollis for pediatric patients • Weakness, tingling, or numbness of the trunk or extremities at any time since the Universal Protocol Section injury • Deformity of the spine not present prior to the incident • Painful distracting injury or circumstances • Emotional distress or Communication Barrier • High Risk Mechanism of injury associated with unstable spinal injuries that include, but are not limited to: o Axial Load (i.e., diving injury, spearing tackle) o High Speed motorized vehicle crashes ( > 30 mph) OR roll – over o Pedestrian or bicyclist struck/collision NO o Falls > 3 feet/5 steps or patient’s height • Age greater than 65 years OR less than 5 years

YES

Transport Spinal Motion Restriction in R R R R See Below Position of Comfort

Spinal Motion Restriction (SMR) = Appropriately sized rigid cervical collar + Patient remains in position of comfort, assisted movement to prevent extremes of spinal motion.

Notify Destination or M Contact Medical Control M

2020 Version 1 UP 2 Spinal Motion Restriction

Distracting circumstances or injuries result in the patient losing focus on less painful injuries. These injuries could cause the patient to minimize the potential for spinal injury. Such injuries may include, but are not limited to: • Any long-bone fracture • Any suspected injury to the internal organs of the abdomen • Any suspected injury to the internal organs of the chest • Large laceration • Degloving injury • Crush injury • Large burns • Any injury causing acute functional impairment • Any injury thought to have the potential to impair the patient’s ability to appreciate other injuries.

Spinal movement can be minimized by application of an appropriately sized rigid cervical collar and securing the patient to the EMS stretcher.

The combi-carrier, long backboard, and/or KED should be used for patient extrication/movement to the transporting stretcher, as needed. Once movement is completed the patient must be immediately removed from the device unless a life threatening emergen cy to the patient exists. Patients should not be transported on these devices.

Spinal Motion Restriction Procedure (see procedure section) • Apply an appropriately sized rigid cervical collar • For ambulatory patients: Allow the patient to sit on the stretcher then lie flat. “Standing Takedowns” should never be performed. • Lay the patient on the stretcher, secure with ALL straps, and leave the cervical collar in place. Elevate the back of the stretcher to support respiratory function.

• Instruct the patient to avoid moving their head or neck as much as possible. Universal Protocol Section Protocol Universal

Pearls • Required Exam: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Consider Spinal Motion Restriction [SMR] in any patient with arthritis, cancer, or other underlying spinal or bone disease. • Significant mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes. The Spinal motion Restriction process MUST be used in these patients even in the absence of symptoms. • Range of motion should NOT be assessed if patient has midline spinal tenderness. Patient's range of motion should not be assisted. The patient should touch their chin to their chest, extend their neck (look up), and turn their head from side to side (shoulder to shoulder) without spinal process pain. • The acronym "NSAIDS" should be used to remember the steps in this protocol. o "N" = Neurologic exam. Look for focal deficits such as tingling, reduced strength, on numbness in an extremity. o "S" = Significant mechanism or extremes of age. o "A" = Alertness. Is patient oriented to person, place, time, and situation? Any change to alertness with this incident? o "I" = Intoxication. Is there any indication that the person is intoxicated (impaired decision making ability)? o "D" = Distracting injury. Is there any other injury which is capable of producing significant pain in this patient? o "S" = Spinal exam. Look for point tenderness in any spinal process or spinal process tenderness with range of motion. • Any bowel or bladder incontinence is a significant finding which requires immediate medical evaluation.

2020 Version 1 UP 2 Vascular Access

Universal Patient Care Protocol; UP1

Assess need for Vascular Access. Emergent or Potentially emergent

medical or trauma condition Universal Protocol Section • Peripheral IV • External Jugular IV P o Not for use in Pediatric Patients P EXCEPT in Life Threatening Event • IO (Pediatric or Adult device) for Life Threatening Event

Successful Unsuccessful (MAXIMUM 3 attempts total with ANY method)

Monitor Saline-Lock

Notify Destination or P Monitor Non-Medicated Infusion P M Contact Medical Control M

Monitor Medicated Infusion

2020 Version 1 UP 3 Vascular Access

All attempts at vascular access should be performed utilizing an aseptic technique to minimize risk of infection.

PEDIATRIC PATIENTS: All other CCEMS approved routes of medication administration should be considered prior to initiation of vascular access in a non-life threatening emergency.

Intraosseous access is a rapid method of accessing the central circulation by insertion of a cannula into the medullary space . Intraosseous access allows administration of all medication and IV fluids utilized in the prehospital environment.

DO NOT establish IO access in the targeted bone if the patient has received an IO within the previous 48 hours to the targete d bone.

Intraosseous access may be obtained in the following settings: • Consider IO access early in the cardiac arrest patient regardless of age, if concern for patient care delay exists • Critically ill or injured patients with no IV access readily available • Unable to obtain IV access within 3 attempts or 90 seconds in the seriously ill or injured patient

Intraosseous insertion sites permitted by Cole County EMS are: • Adult proximal humeral head • Adult proximal tibia • Pediatric proximal tibia (only approved site for IO placement in Pediatric patients).

If time allows treat with Lidocaine: • Prime the connection extension set with approximately 1 mL of 2% Lidocaine • Slowly infuse Lidocaine IO over 120 seconds o ADULT: 40 mg o PEDIATRIC: 0.5 mg / kg (MAX 40mg) • Allow Lidocaine to dwell in IO space for 60 seconds • Flush with 5 mL of Normal Saline • May repeat prn with ½ the initial dose given over 60 seconds

Refer to Pain Protocol; AM 13 for patients not responding to IO Lidocaine. Universal Protocol Section Protocol Universal

Pearls • All patients with vascular access will be attended by a paramedic • Any prehospital fluids or medications approved for IV use, may be given through an intraosseous line. • All IV rates should be at KVO (minimal rate to keep vein open) unless administering fluid bolus. • External jugular lines can be attempted initially in life-threatening events where no obvious peripheral site is noted. • Any venous catheter which has already been accessed prior to EMS arrival may be used. • Upper extremity IV sites are preferable to lower extremity sites. • Lower extremity IV sites are discouraged in patients with vascular disease or diabetes. • In post-mastectomy patients, avoid (if possible) IV, blood draw, injection, or blood pressure in arm on affected side.

2020 Version 1 UP 3 Criteria for Death / Withholding Resuscitation • CPR and ALS Treatment are to be withheld only if that patient is obviously dead as defined below OR has a Valid Out -of-Hospital DNR form. • A valid DNR means that the patient and the patient’s physician have signed the document. • The Out-of-hospital DNR form must be present and verified by Cole County EMS Paramedic at time of patient contact. • The purpose of this protocol is to honor those who have obviously died prior to EMS arrival

Universal Patient Care Protocol; UP 1

Confirmed Patient in Cardiac Arrest?

YES EXIT to Traumatic Arrest in origin? YES Traumatic Arrest Protocol, TB 9 / PTB 9 NO

1. Does the patient meet one or

more of the criteria below? Universal Protocol Section

• Cardiac Arrest for greater than 15 minutes without CPR AND patient in asystole that has been confirmed in 2 leads • Body decomposition • Rigor mortis Do not start CPR or • Dependent lividity YES ALS Therapy • Injury not compatible with life (i.e., decapitation, burned beyond recognition, massive open or penetrating trauma to the head or chest with obvious organ destruction)

Have bystanders or first responders initiated CPR or automated The Paramedic may defibrillation prior to an EMS paramedic’s arrival and any of the YES discontinue CPR and above criteria (signs of obvious death) are present? ALS Therapy

If doubt exists, start resuscitation immediately. Once resuscitation is initiated, continue resuscitation efforts until either:

a. Resuscitation efforts meet the criteria for implementing the discontinuation of prehospital resuscitation Protocol; UP 5

b. ROSC obtained and Patient care responsibilities are transferred to the destination hospital staff

NO Law enforcement should be notified of the patient’s death if in the prehospital environment, and if not M Contact Medical Control M already on scene.

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2020 Version Discontinuation of Prehospital Resuscitation Unsuccessful Cardiopulmonary Resuscitation (CPR) and other advanced life support (ALS) interventions may be discontinued prior to transport when adequate and appropriate ALS Therapy have been performed as stated below.

1. Discontinuation of CPR and ALS intervention may be implemented prior to contact with Medical Control if ALL of the following criteria have been met: q Patient must be 18 years of age or older, or family of a minor is agreeable after consultation with on-line medical control. q Adequate CPR has been administered q Airway has been successfully managed with verification of device placement. - Acceptable management techniques include orotracheal intubation, nasotracheal intubation, blind insertion airway device (BIAD) placement, or cricothyrotomy. q IV / IO access has been achieved q Rhythm appropriate medications and defibrillation have been administered according to protocol q Persistent asystole or agonal rhythm is present and no reversible causes are identified after a minimum of 25 minutes of resuscitation. q Failure to establish sustained palpable pulses or to establish persistent / recurring ventricular fibrillation / tachycardia or lack of any continued neurological activity such as eye opening or motor response.

q End Tidal CO2 remains < 10 with adequate CPR Universal Protocol Section q All EMS paramedic personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate.

2. If ALL of the above criteria are NOT met and discontinuation of pre-hospital resuscitation is possibly indicated or desired, on-line medical control MUST be contacted prior to termination of CPR and ALS therapy.

3. Deceased subject q Document all patient care and interactions with the patient’s family, personal physician, medical examiner, law enforcement, and / or medical control in the EMS patient care report (PCR). q Rhythm strip confirming asystole in 2 or more leads should be obtained and documented. q Maintain respect for the deceased and family q If law enforcement not on scene contact dispatch for a law enforcement officer to respond.

2020 Version 1 UP 5 This Page Intentionally Left Blank

2020 Version Universal Protocol Section or he limiting - scene - s ons ’ limiting illness - arrest. Hospital Do Not Resuscitate - of - s guardian,s or the patient ’ Hospital DNR - of - line medical control. If there is no obvious life - OR YES YES s history.s If the patient an has obvious life UP 6 UP ’ present? Therapies from Cardiac Arrest Protocol(s) Hospital DNR confirmed VALID?

- of - Do not initiate CPR or ALS Therapy If CPRIf initiated by bystander or First ENTER Out Responder, discontinue CPR all and ALS Does patient have a Out Advanced Directives Advanced request and withhold CPR and ALS therapy: s family.s ’ resuscitate order has been executed, it shall maintained be as the first page of patient's a - NO resuscitate order shall be transferred with the patient when the patient transferredis from - not facility unless otherwise specified in the health care facility's policies and procedures. - Do Not Resuscitate (DNR) andResuscitate Do (DNR) Not not - 55

–– PCPC 22 99 / /

–– to to to AppropriateAppropriate

ACAC 44 EXITEXIT CardiacCardiac ArrestArrest Protocol(s)Protocol(s) When confronted with cardiac a arrest patient, the following conditions must be present order in honor to the DNR line medical control and the patient ermine relationship their to the patient and the patient - 5. Living wills or other documents indicating the patients desire withhold to CPR may be honored ONLY in consultationon with (terminal cancer, advanced neurological disease, etc.), contact on illness, begin resuscitation based on appropriate protocol(s). 4. If family members are present and ask that resuscitative efforts withheld be in the absence of an advanced directive,det to to the patient patient's or representative. 3. A DNR request may overridden be by the request of the patient, the patient physician. 2. An outside the hospital do one health care facility to another health care facility. If the patient transferred is outside of hospital, a the outside t hospital DNR form beshall provided any to other facility, person, or agency responsible thefor medical care of the patient 1. If an outside the hospital do medical record in a health care

2020 To honor the terminal wishes of the patient and prevent to the initiation of unwanted resuscitation Any patient presenting any to component of the EMS system with completed a Missouri Out (DNR) form have shall the form honored and CPR and ALS therapy withheld in the event of cardiac

Version 1 Version

• • PEARLS This Page Intentionally Left Blank

2020 Version Patient Without a Protocol

Is there a patient?

A protocol should be initiated for all patient encounters

When confronted with an emergency or situation that does not fit into an existing Cole County EMS Patient Care protocol, the patient should be treated by the

Universal Patient Care Protocol, UP 1 Universal Protocol Section The Patient’s care may continue using only the Universal Patient Care Protocol or may divert into a more appropriate protocol for the patient’s condition.

Universal Patient Care Protocol; UP 1

If needed, Contact Medical Control for further instruction at any point during patient care. M M This interaction must be documented in the patient care report.

PEARLS • Anyone requesting EMS services will receive a professional evaluation, treatment, and transportation (if needed) in a systematic, orderly fashion regardless of the patient’s problem or condition. • Every patient regardless of the patient’s chief complaint or condition shall receive appropriate medical care.

2020 Version 1 UP 7 This Page Intentionally Left Blank

2020 Version Universal Protocol Section s s directions ’ hospital carehospital - scene scene physician - UP 8 UP All care should be provided within the rules regulations theand of care provided be Allrules should within

s credential level. level. s credential ’ hospital care hospital at scene isof the an responsibilitythe emergency of those most - Physician on Scene onPhysician or medication fallsoroutsideof the medication of credentials,practice scope and / physician or the control physicianoffers control aEMSassistance to attendedisto or apatientbeing by

- s s licensure. ’

physician directionofpatient assumesphysician care. A paramedic MUST attend the patient at all times and document the patient care report, even if theif evenreport, all patient MUST patient times attend the care document A the and paramedicat scope of practice and/or credential, as per CCEMS Medical Director and the state of Missouri Bureau of the and of Missouri Bureau state Medical credential, per Director CCEMS ofpracticeand/or as scope If proceduretheEMS. medication themselves. administer the the or perform procedure required be to will or Medical Control for provider Control a or Medical outsidethatmedications give procedures personnel no their performare shall Under or circumstances Orders received from an accompanying physician may be followed, even if they conflict with existing conflict evenphysician withlocal an they fromaccompanyingbe followed, receivedif Orders may Medicalby ais medications Director CCEMS both approved orders and/or forprovided protocols, skill the the orders do not conform with the current CCEMS protocols, Medical Control must be contacted tobecontacted Medicalprotocols, priorconformwith mustcurrent orders doControl CCEMS thethe not order. the initiating Cole County EMS medical director should be contacted if physician unknown to confirm to credentials confirm unknown physician contacted director be if EMS Countyshould medical Cole If protocol guidelines. toconform thecurrent ifby orders physician orders given the follow Personnel may fact that the physician is assuming care care patient. isthat of the physicianfact assuming the The physician MUST accompany EMS to the hospital in the EMS ambulancethe in the MUST The to physician hospital accompany that to factreportunder the patient signatures the sectiondocument the the care MUST The physician sign The name and physicians specialty must be documented in the patient care report patient in care themust physiciansdocumented be and specialty The name Both EMS personnel on the transporting unit are willing to follow the follow physician are willing transportingto theunit personnel onBoth EMS The EMS paramedic recognizes the licensed physician or is provided documented verification of the documented or physicianis of thethe verification paramedic provided The recognizes licensed EMS person To identify a chain of command to allow field personnel to adequately care for the care patient for adequately personnel allow to chain field of command to a To identify thebenefitreceives pre patient To maximum from assure the wellanysystemon EMSas as liability To of the minimize the The medical directionofpre The medical care. in such providing trained appropriately state the of Missouri. 2020

Version 1 Version

q q

physician theynotwith physician have the an dorelationship, whom continue care ongoing patient the may physician if met: following are criteria When a When non medical a

• • • This protocol was established for the following reasons: protocolwas established the for This • This Page Intentionally Left Blank

2020 Version Universal Protocol Section YES R P facility closest closest appropriate appropriate Transport toTransport to to

Utilize as indicated as Protocol(s) Exit Exit NO Taser Probe Taser Removal Face Neck Spine Groin Groin - if indicated if Procedure Age Appropriate Appropriate Age as indicated as Genitals Agitated Agitated Delirium to Secondary Psychiatric Illness Agitated Delirium to SubstanceSecondary Abuse Traumatic Injury InjuryClosed Head Asthma Exacerbation Cardiac Dysrhythmia Protocol(s) AR 6; PA 6; 4 Protocol(s) AR

Wound Procedure(s) Care Behavioral Protocol;Behavioral AM 5 Differential • • • • • • Normal Saline or Sterile Water Saline Normal or Remove contaminated clothing Remove contaminated Wound Care Irrigate face and eyes copiously eyescopiously andwithface Irrigate Age Appropriate Respiratory Distress Distress Appropriate Respiratory Age Taser Barbs embedded in ANY of theANY in Taser Barbs embedded following high risk / sensitive location: high/ sensitive followingrisk R P YES YES YES YES M UP 9 UP NO NO NO NO External signs of traumaExternal signs of Palpitations breathShortness of Wheezing Altered Mental Status Intoxication/Substance Abuse Use of Use of Weapon?

• • • • • • Signs and Symptoms Protocol; Protocol; UP 1 Notify Destination or or Destination Destination Notify Notify Police CustodyPolice Chemical Spray? Contact Medical Control Control Medical Medical Contact Contact Universal Patient Care Patient Care Universal Conducted Electrical Evidence of Traumatic Injury or Medical Illness? Excited Delirium Syndrome? MM EXCITED EXCITED DELIRIUM

resisting arrest. resisting arrest. Cardiac Cardiac History Asthma History of History Psychiatric Traumatic InjuryTraumatic Abuse Drug

2020

a person for police for a person Version 1 Version be administeredbe for

custody only to custody stop only Ketamine isnot Ketamine to be

Ketamine should only should Ketamine only patients with with patients • • • • • History administered to subdue administered to subdue Police Custody

Pearls • Patient does not have to be in police custody or under arrest to utilize this protocol. • Patients restrained by law enforcement devices must be transported accompanied by a law enforcement officer in the patient

Universal Protocol Section Protocol Universal compartment who is capable of removing the devices. However when rescuers have utilized restraints in accordance with Restraint Procedure, the law enforcement agent may follow behind the ambulance during transport. • All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival. • If an asthmatic patient is exposed to pepper spray and released to law enforcement, all parties should be advised to immediately contact EMS if wheezing/difficulty breathing occurs. • All patients with decision-making capacity in police custody retain the right to participate in decision making regarding their care and may request care or refuse care of EMS. • If extremity / chemical / law enforcement restraints are applied, follow Restraint Procedure. • Excited Delirium Syndrome: - Medical emergency: Combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent / bizarre behavior, insensitivity to pain, hyperthermia and increased strength. Potentially lifethreatening and associated with use of physical control measures, including physical restraints and Tasers. Most commonly seen in male subjects with a history of serious mental illness and/or acute or chronic drug abuse, particularly stimulant drugs such as cocaine, crack cocaine, methamphetamine, amphetamines or similar agents. Alcohol withdrawal or head trauma may also contribute to the condition. - If patient suspected of Excited Delirium Syndrome suffers cardiac arrest, consider a fluid bolus and sodium bicarbonate early. • Do not position or transport any restrained patient in such a way that could impact the patients respiratory or circulatory status. • Patients exposed to chemical spray, with or without history of respiratory disease, may develop respiratory complaints up to 20 minutes post exposure.

2020 Version 1 UP 9 Universal Protocol Section s ’ NO YES illness, injury? or YES Is parent, responsible party, or legal guardian drug / alcohol intoxication, judgement impaired due to M

present closetcloset NO YES Control Control to to to appropriateappropriate AND/ORAND/OR

protocol(s)protocol(s) contact contact contact lawlaw enforcement enforcement Patient < 18 Patient < years of age?ofyears of the minor? of minor? the Contact MedicalMedical ContactContact andand TransportTransport toto document accordingly appropriateappropriate facilityfacility EXITEXIT to onrefuse to carebehalf or legal orguardian Parent, Parent, responsible party, MM Obtain all required signatures for refusal NO UP 10 UP NO If patient refusing specific treatment, obtain appropriate signature and YES legally emancipated?

YES YES OR 1 if needed later - 1 - Refusals: AMA / / AMA Refusals: Treatment Determine Patient Capacity UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP Any specific treatments and/or interventions Primary ALS Assessment Initial Set of vital signs Patient verbalizes consent to obtain:

▪ ▪ ▪ Altered LOC Known suspected or acute head trauma Severe shortness of breath Slurred speech Unsteady gait Abnormal glucose Abnormal pupils Abnormal SpO2

due the to fact that EMS personnel notare physicians and are not qualified authorizedor make to diagnosis a that or their care is not substitute a for that of a physician There may delays be in receiving appropriate care by choosing alternate means of transportation Recommendation by staff transport to patient was made transportation Condition may worsen without seeking medical attention and they can call 9 Knowledge of risk and/or benefit of ANY intervention or alcohol / drug use? The patient NOT is experiencing any of the following: actions by refusing evaluation, treatment, and/or transportation? There is NO evidence of disorientation, and/or evidence of Patient > years 18 of age Patient NOTis a significant threat to self or others? They CAN understand the nature and consequences of their

2020

Version 1 Version

Patient has been informed of theALL of following information: ▪ ▪ ▪ ▪

▪ ▪ ▪ ▪ ▪ Version Universal Protocol Section 2020 Guide to Assessing capacity: Assessing to Guide •

• • • • • • • • Pearls

Patient Refusal Patient If ALS intervention performed during assessment, ePCR MUST be completed by attending paramedic on scene. scene. on paramedic attending by be completed MUST ePCR assessment, during performed intervention IfALS ePCR in related documented all and information refused treatments for obtained be MUST signature a treatment, or interventions specific refusing Ifpatient section comp Notification complete MUST present, guardian or legal representative, parent, and age) of 18years (< minor Ifa Patient refu transportation, without evaluation care refused Patient (AMA), advice medical against released / treated patient selected: are dispositions following the of if one obtained be should Refusal met: be ALL must criteria 3 following the care refuse to be able to patient a For M: A: R: C: patient the describing assessment status mental a including important is very event the of Documentation signs. vital including an assessment, allow to patient Encourage facility. medical to transport accept to patient Encourage situation. risk high isa refusal Patient sed care evaluation with transportation with evaluation care sed 3. Informed Refusal Informed 3. Capacity Decisional 2. Competence 1.

choice or an inability to express the choice consistently demonstrates incapacity. demonstrates consistently choice the express to inability an or choice letely in ePCR. in letely Patient should be able to communicate a clear choice: clear a communicate to able be should Patient Relevant information isunderstood: information Relevant Appreciation of the situation: the of Appreciation to describe the logic they are using to come to the decision, though you may not agree with decision. with agree not may you though decision, the to to come are using they logic the describe to decision. their from potentially outcome the of significance the recognize to benefits. and risks and

Manipulation of information in a rational manner: rational a in information of Manipulation Refusals: AMA / TreatmentRefusals: AMA / proposed treatment and the risks associated with refusing evaluation, treatment, and/or transportation. transportation. and/or treatment, evaluation, refusing with associated risks the and treatment proposed the with associated benefits and risks the condition, medical / her his about informed be fully MUST Patients transportation. and/or treatment, evaluation, refusing by actions their of consequences and nature the understand to ability the AND situation) and time, place, (person, 4 x oriented and alert, awake, whois patient Any or children child minor the of behalf on care whorefuses guardian legal or parent A emancipated legally or age of 18 years > must Patient

Ability to communicate an understanding of the facts of the situation. They should be able able be should They situation. the of facts the of understanding an communicate to Ability

Patient should be able to display a factual understanding of the illness, the options options the illness, the of understanding factual a display to able be should Patient ’ s capacity to refuse care. to refuse scapacity UP 10

Demonstrate a rational process to come to a decision. Should be able able be Should decision. to a come to process rational a Demonstrate

This should remain stable over time. Inability to communicate a communicate to Inability time. over stable remain should This

Patient treated / transported by private vehicle, vehicle, private by transported / treated Patient

Universal Protocol Section s s behalf) ’ UP 11 UP UP NO NO NO CCEMS protocol? UP 11 11 UP Assessment reveals areveals Assessment life Universal Patient Care Protocol; Protocol; Protocol; Care Care Patient Patient Universal Universal child to the nearest nearest hospital. thechild to Concern for abuse / neglect?abuse Concern for / threat requiredthreat or undercare YES Notify Destination and IMMEDIATELY transport transport the IMMEDIATELYand Notify Destination s Safe Place for Newborns Law. for Place Newborns s Safe ’ When a parent arrives with an infant, you need to:need infant, an you a with arrives parent When YES Safe for Safe Newborns Place protocol protocol

to appropriate appropriate toto

Make sure they are aware their parental rights will be terminated and the is rights decision awaretheir be terminated sure the parentaland will they Make are permanent rights has the parent knowparent other Let the Confirm they are the parents (or acting onparent acting thearethe (or parents they Confirm year oneis infant old less than the Confirm EXIT EXIT s Safe Place for Newborns Law allows a parent to permanently give up a newborn up to 45 days up45 days upgive newbornto apermanentlya Lawto parent for Placeallows Newborns s Safe ’

• • • • Pregnancy center center staff Pregnancy pregnancy center hospital, or maternity ahome A volunteer at a or maternity home care while healthin off at hospital, provider duty position Anya staff Emergency Medical Technician (EMT) or or Technician Paramedic(EMT) Emergency Medical Staff Hospital Maternity staff home Law enforcement Law officer Firefighter

pregnancy pregnancy center ------

2020 one year of age is brought to a Cole County EMS employee or station and the proper steps in caring for thecaringandthattoEMSCounty ofage yearColeis or steps proper for employee a in one brought station with accordanceMissouri child in The following protocol provides guidance for Cole County EMS personnel in the event that a child child less athan event personnel in that the EMSfor County Cole provides guidance The protocol following Missouri law safely. astoand done according it as is long without prosecution, old professionals: following with may of the any newbornleft be thisa Underlaw,

Version 1 Version

•

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2020 Version Scene Rehabilitation: General

History: Signs and Symptoms Differential • Firefighting / Rescue Duties • Level of Consciousness • Heat Exhaustion / Stroke • 2 SCBA bottles used • Respiratory Effort • Hyperthermia • 40 minutes of intense work without SCBA • Vital Signs (temperature) • Cramps • Hypothermia • Other Conditions (protocols)

Firefighter enters recycle / rehab area VITAL SIGN CAVEATS Sign In Blood Pressure R R • Prone to inaccuracy on scenes Obtain Full Set of Vital Signs • Must be interpreted in context Significant Injury? Move to Rehab • Firefighters have elevated Cardiac Complaint: Signs / Symptoms? YES area blood pressure due to physical Respiratory Complaint: Serious Signs / Symptoms? exertion and is not typically pathologic NO EXIT to Appropriate Mandatory 10 minute rest Protocol

period and 8 oz fluid PO Universal Protocol Section

Respiratory Rate < 8 or > 40 R Systolic > 160 / Diastolic > 100 R Heart Rate > 100 bpm

NO YES Additional 10 minute rest Temperature > 100.4 R R R period and 8 oz fluid PO R

NO YES

Active Cooling Measures: Cold Towels- Use by applying to Vital Signs meet return Criteria? face, neck, arms as deemed Remove protective clothing and initiate appropriate. • Pulse < 100 active cooling measures as available and Misters- Best used for • Systolic < 160 appropriate for environmental conditions, moderate ambient temp and • Diastolic < 100 additional rest for total 30 minutes low humidity • Orthostatics Negative Fans- only use when ambient • Respiratory Rate 12 – 20 temp is less than 99 degrees • Pulse Ox ≥ 95 % Forearm submersion- • Carboxyhemoglobin (if available) submerge forearms in tepid < 5 dL / mg for nonsmokers water for ten minutes. There • < 10 dL / mg for smokers should not be any pain NO YES associated with submersion.

Firefighters with Systolic BP ≥ 160 or Consult IC, Move to Diastolic Recycle area BP ≥ 100 may need extended recycle time. However this does not necessarily prevent EXIT to them from returning to duty; consult with incident command as needed. Universal Patient Care Protocol; UP 1 Hyperthermia Protocol; TE 4 Sign out of recycle sector and Return to full activities Temperature Hypothermia Protocol; TE 5 Firefighters may have increased Hypotension / Shock Protocol; AM 12 temperature during rehabilitation; consider in context of condition of fire fighter

2020 Version 1 UP 12 Version 1 Universal Protocol Section 2020 • • • • • • • • • • Pearls

The rehab area should be established in a location that that a location in established be should personnel area rehab / rehab The recycle from input with Commander Incident by approved until duty active to return not should Personnel scene the from transport needs a patient event the in to triage assigned be should ambulances Additional possible if replacemen fluid, electrolyte strength ½ be should fluid time, Remaining only. be water should fluid activity, of hour first During fluids cold drinking after minutes 10 performed be should measurement temperature Oral heat and cold for stress risk increased are at stimulants or diuretics, medication, pressure blood antihistamines, taking Responders must member team Each area recycle the of out and into checked be must personnel All area rehab rule; minute communi 45 / bottle two the using area recycle the through cycled be should scene at the operating personnel All scenes training and EMS rescue, enforcement, law fire, on responders adult with be utilized May 4) has ready means of access and egress for transport vehicles, food, and water. water. and food, vehicles, transport for egress and access of means has ready 4) fumes exhaust and smoke of clear is 3) activity the of sight of out is but access hasdirect 2) activity the from distance a safe maintains 1) personnel recycle by performed assessment sign vital have 3) PO fluid oz least8 at to take be able 2) minutes 10 of minimum a Rest 1) Scene Rehabilitation: General Rehabilitation: Scene cation with Incident commander should occur if a responder needs additional recycle time or needs to be moved to to moved to be needs time or recycle additional needs a if responder occur should commander Incident with cation UP 12 t

Service Animal Transport

History Glossary Reasons to consider alternative transport for service dog • The American with Disabilities ACT • Service Animal = any dog that is requires that all entities must individually trained to do work or • Patient is unconscious or is unable to allow service animals to perform tasks for the benefit of an care for the service dog accompany people with individual with a disability, including • Service dog is demonstrating aggressive disabilities in all areas of the a physical, sensory, psychiatric, or destructive behavior facility where the public is intellectual or other mental • If space in the ambulance is crowded normally allowed to go disability. and/or the dog’s presence would • The ADA only recognizes dogs and • Work or Tasks = specific actions interfere with the ability to treat the miniature horses as service when needed to assist the person patient animals with a disability • If the handler does not have the dog under control of a harness, leash or tether and one is not available.

Service Dog

Encounter Universal Protocol Section

Patient is alert and NO YES oriented?

Do any of the reasons to consider alternative transport for service dog exist? Contact EMS Supervisor for alternative YES NO transportation for Contact EMS Transport the service dog Supervisor for service dog and alternative provide notification transportation for to the receiving service dog hospital

Pearls • When you are unsure if the dog is a service animal, you may ask two questions: (1) is the dog a service animal required because of a disability, and (2) what work or task has the dog been trained to perform. We cannot ask about the person’s disability, require medical documentation, require a special identification card or training documentation for the dog, or ask that the dog demonstrate its ability to perform the work or task. • EMS crews must document disposition of the service animal in patient care report • Regardless of who transports the dog, the owner and the service animal should arrive at the hospital at the same time • Ambulances are only required to accommodate service dogs, and ambulance crews can legally deny transporting all other types of animals • The decision to allow the patient and animal to remain together ultimately rests with the crew, and is based on the patient's need and ability to control the animal, as well as the crew's ability to transport the dog safely. • Alternative mechanisms of transporting the service dog are police, animal control, EMS Supervisor, a friend, family member, or neighbor • If transporting the service dog, the dog should be tethered to a stationary object in the ambulance, i.e. the stretcher, benc h seat seatbelt, etc. • Cover sharp object in perforated running boards to ensure dogs paws are not injured • If a care provider or family member of the patient has a service dog and requests to ride with a patient, use the same considerations as above to make decisions regarding transport. • For further information please review: www.ADA.gov UP 13 This Page Intentionally Left Blank

2020 Version Transport Criteria: Air Transport

Call for service, indicates anticipated, Request Air Medical Transport be but not yet confirmed, need for an air YES placed on air standby medical transport service?

Does patient meet any of the Patient requires transport to a YES below criteria for air designated Trauma or Burn Center transport?

Patient requires transport to a YES designated STEMI, or Stroke facility

Air transport should be considered if any of the following criteria apply:

• High priority patient with > 20 minute transport time Universal Protocol Section • Entrapped patients with > 10 minute estimated extrication time • Multiple casualty incident with red/yellow tag patients • Multi-trauma or medical patient requiring life-saving YES treatment not available in prehospital • environment (i.e., blood transfusion, invasive procedure, operative intervention) • Time dependent medical conditions such as acute ST-elevation myocardial infarctions (STEMI) or acute Stroke that could benefit from the resources at a specialty center.

YES

Limit scene time to less that 10 MUST take into account launch time, minutes and transport patient via flight time to scene, time on scene, NO ground ambulance to closest and flight time to hospital when appropriate facility. considering transferring patient via air.

YES

Patient transportation via ground ambulance will not be delayed to wait for helicopter transportation. Provide patient care and ready patient for air Total helicopter time should be significantly less than medical transport. ground transport time in order to be clinically beneficial to the patient.

If scene conditions or patient situation improves after activation or air transport determined not to be necessary, paramedic may cancel the request for air transport

2020 Version 1 UP 14 Transport Criteria: Air Transport

10 mile radius from the medical center As a general rule, patients within a 10 mile radius from the medical center will not benefit clinically from air transport.

15 mile radius from the medical center Except under extreme circumstances, transports within the 15 mile radius will rarely exceed 25 minutes.

20 mile radius from the medical center Transports between the 15 mile and 20 mile radius are most likely to be impacted by poor driving conditions and difficult access to highway systems that can result in extended transport times.

Patients outside of the 20 mile radius are most likely to benefit from air transport. Universal Protocol Section Protocol Universal

Pearls • Utilization of air transport should not be a common practice. • Remember to cancel standby as soon as possible if determined air transport not needed.

2020 Version 1 UP 14 Universal Protocol Section M - s name,s destination, ’ to transport of transport. the facility MUST go with patient. CCEMS ProtocolsProtocolsCCEMSCCEMS Notify SendingSending or or Notify Notify facility facility contains appropriate signatures. Must have CCEMS Interfacility Medication

transfer ifif patient patient transferissue transferissue of of care care outside outside with with Contact Medical Control at any point during during during any any pointpointMedicalMedical ContactContact Control Control at at Intubation BIAD Management Protocol; AR 4 Refer to CCEMS Restraint Procedure and Post and department patient is being transferred to Do not leave facility without proper paperwork Ensure document is filled out appropriately and Request adequate sedation while controlledin a STOP! Must don appropriate PPE prior to patient contact specific drug patient being transferred trained on, a Order form completed for EACH drug not in CCEMS completed, accepting physician Notify patient appropriately and complete ABN form staff member from protocols with transferring physician signature prior order received for sedation medication and adequate amount of sedation medication available for duration IF ParamedicIF not has received training from CCEMS on environment at the hospital prior transport. to Ensure MM UP 15 UP NO NO NO YES YES YES M 19 - NO NO NO YES YES YES YES Transport: Interfacility Transfers Interfacility Transport: Protocol book? truck phonephoneradioradio truck truck oror and completed? ABN form Indicated Notify Sending facility viaviafacility facility Notify Notify Sending Sending obtained and filled out cannot confirm negative? restrained appropriately? Patient Paperwork and all appropriately for transfer? EMS Personnel dispatched interfacilityfor an transfer from a hospital appropriate documentation that is not within CCEMS Field Patient readyfor transport patient, presumed positive, or Patient intubated, sedated, and UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP Patient receiving any medication Medical Necessity form Indicated Is this patient a positive COVID MM 2020 Version 1 Version Version Universal Protocol Section 2020 considerations). balloonpostmonitoring,pump, are who aspat or to stabilized deteriorate, beis such transferring likely thedeterioratingwho facility, cannot at Any who patient Unstable illness/injury.specific whose initially stabilized,patients has of has condition on based been assessmentlikelihood or but deterioration, knowledge medication multiplevasoactive (a ventilator,drips patients secured, intubated, on advanced on airway but Patients requiring deteriorationofwith Stablehigh risk 3 ofdeteriorationwithStable mediumrisk care). interpretation and need assessment for oximetry, increased IV medications, pulse IV, pain medications including Running some deteriorationof withStablelowrisk emergency care). vital lock, salinemedical basic of signs,Oxygen, monitoring risk withStable no for deterioration Acuity ofPatient Level paramedic care, or a medicine,care, cardiovascular respiratory emergency nursing, or example,critical care emergency for a when beneficiary of scopetheservice a of services, andnecessary EMT the beyond level of at supplies provision theincluding medically Services(CMS) Medicaid & CentersMedicarethe for As by defined CareTransport (SCT): Specialty - • • • • • Pearls lead EKG monitoring, basic cardiac medications, e.g., heparin ornitroglycerine e.g., medications,heparin basiccardiac monitoring, lead EKG

member from the transferring facility MUST go with patient on on withtransfer. patient go MUST transferringfacility the member from an patient, a with receivedtransferredappropriately EMS,a has training drug if being of a on not Bureau Per theparamedic perProcedure.CCEMSRestraintrestrainedpatientbe andsedated hospital, must If by intubated patient guidance. for inform supervisor available, aircraftand should flown be on transport notify and for or resourcespersonnel consider additional patient, acuityIf high response urgent and s and with notlights respond hospital, do ifresponding a to service, afor call 911 as Transfershould treated be Emergency facility. andtoa stabilization, care initial health from any transfer includes assessment and after Interfacility Transfer hospital tolong hospital torehabilitation hospital clinic to hospital tohospital Hospital Transport:Interfacility Transfers ’ s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area appropriate an specialty inprofessionalsone musthealth or furnished bethatmore by s requires care ongoing condition - term term care - resuscitation, orhavetrauma who resuscitation, sustained care (critical multiple with or time available crew

UP 15 —

is IFT injuredaisa IFT ambulance or of ground critically by ill beneficiary vehicle - duty battalionIf dutypatient thatconcern chief. - Paramedic. isParamedic. necessary SCT ients who invasiveients require who with training with additional

These include: These

dvanced care +),care dvanced of providerof regarding skills (advancedskills irens but irens maintain trained staff , Universal Protocol Section

” s) s) ’ SEPSIS SEPSIS ALERT OR “

AND UP 16 UP degrees F OR < 96.6 degrees F degrees < 96.6 OR F degrees SSM Health (St. Mary Sepsis Sepsis Patient: Systolic BP < 90 mmHg after fluid resuscitation after fluid mmHg < 90 BP Systolic

Heart Rate > 90 / min / >90 Rate Heart >20 Rate Respiratory Capital Region Medical Center Systolic BP < 90 mmHg < 90 BP Systolic Notify closest appropriate appropriate Notify closest OR ≥ 100.4 ≥ 100.4 facility with facility with SEPSIS Patient Identified based Identified SEPSIS on Patient 2505 Mission Dr. Jefferson City, MO 65109 CCEMS Sepsis Protocol; AM 15 / PM Protocol; CCEMSAM 13 Sepsis 1125 Madison Street, Jefferson City, MO 65101 New onset Altered Mental Status (GCS < 15) < (GCS Status Mental Altered onset New Temperature Temperature Obvious or suspected infection AND any of the following SIRS criteria: SIRS following the of any AND infection suspected or Obvious Limit scene time to < 10 minutes, if unable to, document delays in ePCR delays to,document unable if minutes, < 10 to time scene Limit End tidal CO2 < 26 mmHg 26 mmHg < CO2 tidal End Transport: Sepsis Criteria Sepsis Transport: All of the above mentioned criteria should be documented and time stamped in the ePCR the in time stamped and documented be should criteria mentioned above theof All 2020 Version 1 Version Version Universal Protocol Section 2020 • • • Pearls

If concern for Sepsis or patient meets sepsis SIRS criteria at any point, notify receiving facility of a of facility receiving notify point, any at criteria SIRS sepsis meets patient or Sepsis for Ifconcern 13 PM 15/ AM Protocol; Sepsis aged appropriate the follow should care patient All this protocol in guidelines the considering transported and triaged be should patients Sepsis Transport: Sepsis Criteria UP 16 “ SEPSIS Alert SEPSIS ” Universal Protocol Section medical contact to medical contact

Lead is obtained or obtained is Lead

– FIRST of Identification of STEMI criteria. criteria. ofSTEMI of Identification

Level Level 1 of patient contact. of patient

within 10 minutes 10 within University of Missouri ofMissouri Hospital University ” 1 Hospital Dr. Columbia, 1 MO Hospital Columbia, Dr. 65212 of patient contact of patient s s preference)

’

Lead on ALL STEMI patientson STEMILeadALL UP 17 UP

– STEMI ALERT STEMI “ STEMI PatientSTEMI Lead ECG FindingsSTEMIECG Lead =

Lead ECG criteria of 1 mm ST ST of1 criteriammECG Lead

– – within 10 minutes 10 within s) s) ’ Lead ECGs to the receiving facility at the time the 12 / 15 15 / 12 the time the at facility receiving the to ECGs Lead

– (ST Elevation MyocardiaInfarction) (ST Elevation 12 12 / 15 Lead ECG within the first 10 minutes 10 first the within ECG Lead (with respect torespect patient (with

12 12 / 15 Active Symptoms of Cardiac Chest Painof Cardiac Chest Active Symptoms elevation elevation 2 or contiguousleads in more – PCI, consider Air Transport to PCI capable considerPCI hospital PCI,tocapable Transport Air OR OR 65101 Level 2 Level 2 Level Lead and 15 15 and Lead AND of12 AND transmission/ 15

– The following guidelines should be completed on all STEMI onall patients: beSTEMI should completed guidelinesfollowing The Transport: STEMI Criteria STEMI Transport: Notify receiving hospital of a of hospital receiving Notify Early STEMI notification / activation of closest PCI capable Hospital PCIHospital / capable of closestactivation notification Early STEMI STEMI patients in the field field the in patients STEMI

SSM SSM Health Mary(St. Lead ECG and a 15 15 a and ECG Lead

All of the above mentioned criteria should be documented and time stamped in the ePCR the in stamped time and documented be should criteria mentioned above the of All – Capital Region Medical Center Medical Capital Region Transport andtransportTransport time 90isIf minutes location: than greater from

both the 12 the 12 both

identify 1125 Madison Street, Jefferson City, JeffersonMO Street, Madison 1125 2505 Mission Dr. Jefferson City, JeffersonDr.MO 65109 Mission 2505

2020

If STEMI identified, identified, STEMI If Transmit Obtain a 12 12 a Obtain Administer a total of 324 mg aspirin to CP patient (if not contraindicated) within 10 minutes of patient contact ofpatient minutes 10 within contraindicated) not (if patient CP to aspirin mg of324 total a Administer Version 1 Version Limit scene time to less than 10 minutes, if unable to, documentation of reason should be included in the the ePCR in be included should reason of documentation to, unable if minutes, 10 than less to time scene Limit

Rapidly Rapidly

CONSIDER

6. 5. within 10 minutes of patient contact patient of minutes 10 within 4. 3. 3.

2. 1. Version Universal Protocol Section 2020 information. information. 12 transmitted on based Alert STEMI about via phone physician Room Emergency with CONSULT Consider • • • Pearls

If concern for STEMI in the setting of any of the following: following: the of any of setting the in STEMI for Ifconcern 2 AC Protocol; STEMI / PAIN CHEST the follow should care patient All protocol this in guidelines the considering transported and triaged be should patients STEMI Post Cardiac Arrest ROSC, but no obvious STEMI identified STEMI obvious no but ROSC, Arrest Cardiac Post pacemaker of Presence Hypertrophy Ventricular Left of Presence old or be new to unknown if (LBBB) Block Branch Bundle Left Transport: STEMI Criteria UP 17 –

Lead and 15 15 and Lead –

Lead Lead Universal Protocol Section OR OR Level 1 Level Level 1 Level contact Boone Hospital Center Hospital Boone University of Missouri Hospital ofMissouri University 1 Hospital Dr. Columbia, MO 65212 MO Columbia, Dr. 1 Hospital Last well 6 known hours > of patient 1600 E Broadway, Columbia, MO 65201 MO Columbia, E Broadway, 1600 of patient contact based on Cincinnati Stroke Scale and and Scale Stroke Cincinnati on based contact of patient

UP 18 UP Stroke Scale within 10 minutes 10 within within 10 minutes of patient contact. contact. patient of minutes 10 within ” Last known well Last Identified known See StrokeSee 14 16 / Protocol; AM PM s) s) ’ Stroke Patient identified based on Cincinnati on based identified Stroke Cincinnati Patient CODE STROKE CODE OR OR “ Level 2 Level 2 Level The following guidelines should be completed on all STEMI onall patients: beSTEMI should completed guidelinesfollowing The patient contactpatient STROKE patients in the field field the in patients STROKE Transport: STROKECriteria Transport: SSM Health (St. Mary (St. Health SSM

Transport andtimeTransport time lastwellIf identification from location: STROKEwithknown to first

Capital Region Medical Center Medical Region Capital Last known well < 6 6 wellhours of Last < known All of the above mentioned criteria should be documented and time stamped in the ePCR the in stamped time and documented be should criteria mentioned above the of All medical contact is greater 4 PCI medical is hours; thanCONSIDER toTransport hospital contact Air capable identify 2505 Mission Dr. Jefferson City, MO 65109 MO City, Jefferson Dr. Mission 2505

1125 Madison Street, Jefferson City, MO 65101 MO City, Jefferson Street, Madison 1125 CONSIDER

2020

Obtain a LAST KNOWN WELL KNOWN LAST a Obtain Rapidly Rapidly Version 1 Version

5. Limit scene time to less than 10 minutes, if unable to, documentation of reason should be included in the ePCR inthe included be should of reason documentation to, unable if minutes, 10 than less to time scene Limit 5.

4. Notify receiving facility of facility receiving Notify 4. 3. Obtain a blood glucose, if abnormal fix it based on Diabetic Protocol; AM 7 / PM 8 PM 7 / AM Protocol; Diabetic on based fix it abnormal if glucose, blood a Obtain 3. 2. 2. RACE Score RACE 1. Version Universal Protocol Section 2020 • • • • • Pearls

Time of Symptom Onset (Last known well): Last witnessed time the patient was symptom free symptom was patient the time witnessed Last well): known (Last Onset Symptom of Time personnel CCEMS by identified as stroke acute an of symptoms with patient A Patient: Stroke a of facility receiving notify point, any at Stroke for Ifconcern 14 PM 16/ AM Protocol; Stroke aged appropriate the follow should care patient All protocol this in guidelines the considering transported and be triaged should patients Stroke Wake up stroke (time of symptom onset / last known well): last time patient was awake and known to be symptom free symptom to be known and awake was patient time last well): known last / onset symptom of (time stroke up Wake Transport: Stroke Criteria Transport: Stroke UP 18 “ Code Stroke Code ” Transport Criteria: Trauma

Cole County EMS Closest Appropriate Designated Trauma Centers:

LEVEL 1 University of Missouri Healthcare, One Hospital Drive Columbia, MO 65212; ER Number: 573-882-8091

LEVEL 2 SSM Health DePaul Hospital – St. Louis, 12303 DePaul Drive, Bridgeton, MO 63044; ER Number: SSM Health St. Joseph Hospital – St. Charles, 300 First Capital Dr., St. Charles, MO 63301; Mercy Hospital South (previously known as- St. Anthony Medical Center) – 10010 Kennerly Rd., St. Louis, MO 63128;

LEVEL 3 Lake Regional Health System, 54 Health Drive, Osage Beach, MO 65065 SSM Health St. Joseph Hospital-Lake St. Louis, 100 Medical Plaza, Lake St. Louis, MO 63367;

Cole County EMS Closest Appropriate PEDIATRIC Designated Trauma Centers:

LEVEL 1 SSM Cardinal Glennon Children’s Medical Center, 1465 S. Grand, St. Louis, MO 63104

St. Louis Children’s Hospital, One Children’s Place, St. Louis, MO 63110 Universal Protocol Section Is this a Trauma Patient?

YES

Assess Life Threatening Conditions: Transport to the closest hospital Serious Airway or Respiratory Compromise or YES emergency department capable of impending arrest that cannot be managed in the field? managing condition

Assess Level of Consciousness and Vital Signs GCS < 14 adult and pediatrics Adults • Systolic Blood Pressure < 90 • Respiratory Rate < 10 or > 29 Transport to closest level trauma center • Heart Rate > 120 within 30 minutes transport time via air or ground according to regional plan. YES Pediatrics Age SBP RR HR Pediatric suspected brain injury to pediatric • 0 – 12 Months < 70 > 60 > 160 trauma center. • 1 – 5 years < 80 > 44 > 130 • 6 – 12 years < 90 > 30 > 115 • > 13 years < 90 > 22 > 100

And / OR Clinical Signs of Shock

GO to UP 19B

2020 Version 1 UP 19A Version 1 Universal Protocol Section 2020 • • • • • • • • • • • • • • • • • • • • • • • • • • •

injury PEDIATRICSother: BURNS: application Activeor uncontrolled hemorrhage, tourniquet injury orspinalParalysisorcranial of cord signs nerve skullOpen or depressed fractures Pelvicfractures limbanyAmputationpartof of of trauma Extremity with distal pulsesloss more Two long or proximal scene hemo chest, Airway or obstruction, flail compromise short and t boxer tohead,neck, All penetratinginjuries torso, Falls PEDIATRICS: PEDIATRICS: with abdominal Pregnancy acute and traumatic pain mechanism Non injuries Penetrating distal to T (nonAll open bone longFemur (vs Fractureproximal fx) 1 degloved Crush, or mangled extremity Motorcyclecrash or withmph20or ATV rider = > orof separation rollover. thrown, significant Auto run Pedestrian/bicyclist mph or vs.20or impact with = over, > High consistent or highVehicle data highway injury telemetry of with speedsrisk passengersameDeathcompartment in oror(partialEjectionautomobilecomplete) rollover from 12 > Intrusion:any site; occupantinsite inches inches18 High Assess Biomechanics of Injury and Evidence of High of Evidence and Injury of Biomechanics Assess - - inhalation of injury PEDIATRICS: inhalation of signs injury ADULTS - - -

- Seat belt signSeat unrestrained child ofage or years 8 younger - Major burns withtrauma associated burns Major - autoriskcrash: DirectorDiscretion Medical extremity fractures Twoor more

risk Pedestrian, cycle,ATVPedestrian,risk Crash or pneumothorax, patients intubated on or pneumothorax, Pediatrics > Pediatrics ft 10 Adults > 20 > (One = Adults ft ft) story 20 10 Assess Anatomy of Injury of Anatomy Assess ENTER Transport Criteria:Transport Trauma - shirt coverageareas shirt : Major burns > Major: burns % 20or BSAany - long bone)long fracture

from Page UP UP from 19APage

burns > 10 %10burns > anyBSA or

Maxillo - - facial upperfacial airway or bone fractures bone - shirt and boxer areas to wristandtoboxer ankle shirt areas to and NO GO GO 19C to UP NO signs signs UP 19B - Energy Impact Energy YES IF > 30 minutes transport time via air air time via transport minutes 30 IF> alternate designated trauma center. trauma designated alternate trauma center within 30 minutes 30 minutes within center trauma Transport to closest appropriate appropriate to closest Transport or ground, consider transport to to transport consider ground, or transport time via air or ground ground or air via time transport according to regional plan. plan. to regional according YES Level I, II, or III II, I, Leveltrauma or Transport Transport to closest Pediatric Patient Pediatric to Pediatric capable capable Pediatric Center. center Transport Criteria: Trauma

ENTER from Page UP 19B

Assess other risk factors / special patient or system considerations • Age: Older adults: > age 55 Pediatrics: < 15 years with potential for admission to pediatric capable center • Falls: Adult 5 – 20 ft Pediatrics < 10 ft • Lower-risk crash • MVC < 40 MPH or unknown speed Contact medical • Auto vs. Pedestrian / bicyclist < 20 mph impact • Motorcycle or ATV Crash < 20 mph with separation of rider or rollover Control; consider • Medical Co-morbidity YES transport to trauma • Anticoagulation and bleeding disorder center based on • End-stage renal disease requiring dialysis • All pregnant patients involved in traumatic event injury • BURNS:

non-major burns without other trauma mechanism: triage to burn facility Universal Protocol Section PEDIATRICS: burns < 10 % • Penetrating injury distal to wrist or ankle • Assault without loss of consciousness • Suspected child or elder abuse • Near drowning or near hanging • EMS Provider judgement

Transport to closest appropriate non-trauma designated center

2020 Version 1 UP 19C

Transport Criteria: Trauma Universal Protocol Section Protocol Universal

South of Route D along Highway 54 transport times to Lake Regional are less than to the University of Missouri

CONSIDER: Drive time when transporting trauma patients.

PEARLS • Transport to closest appropriate trauma center is determined by drive time. • From scene to destination, if drive time is greater than 30 minutes via air or ground the closest appropriate trauma center m ay be a level 2 or 3 versus a level 1. • For CCEMS area of coverage, if you are south of the intersection at Route D and Highway 54, the closest appropriate trauma center is LAKE REGIONAL HOSPITAL, this includes patients that are determined to be a class 1 trauma on-scene. • A “TRAUMA ALERT” should be activated via truck phone or radio when leaving scene to allow adequate time for trauma team to arrive. • Special Considerations should be taken on holiday weekends or weekends during peak rush hour time when considering transports of trauma patients to either Lake Regional Hospital or University Hospital. - Peak travel times include Friday evenings between 1600 – 1900 and Sunday / Monday afternoons

2020 Version 1 UP 19D Universal Protocol Section IMMEDIATE Secondary Triage Evaluate Infants FIRST FIRST Infants Evaluate Repeating Triage Process Triage Repeating DELAYED IMMEDIATE IMMEDIATE IMMEDIATE YES NO YES Minor YES Adult DECEASED NO NO UP 22 UP NO Triage NO Adult: 8 30 minute/ PED: 15 < or45 > / minute Adult: Obeys Commands PED: No Palpable Pulse Adult: Cap Refill > Sec 2 PED: Appropriate to AVPU Reposition Upper Airway Serious Hemorrhage Results Spontaneous in Breathing YES YES Pulse Pediatric Breathing YES IMMEDIATE 5 Rescue Breaths NO NO YES Rate Walk Status Mental Able Able to Perfusion Breathing Respiratory Adult: < / 30 minute 2020 PED: 15 > 45 or < / minute Version 1 Version Version Universal Protocol Section 2020 Step 3: Individual assessments: 3: Individual Step RPM. by remembered be can which criteria objective three the using encounter you patient first the 2: Assess STEP sorting: 1: Global Step • • • • • • Pearls

triage decisions. decisions. triage Age temperature. skin including factors many by altered be can refill Capillary Treatment: correct airto only Attempt nextpatient. to on move and TAG RED place stop, category, TAG RED the into falls patient Ifyour allow. resources as section ineach recur should and process a continual is Triage Up: Size Scene limited: are resources where incident casualty multiple a approaching When way problems, treat uncontrolled bleeding, or administer an antidote before moving to next patient. patient. next to moving before an antidote or administer bleeding, treatuncontrolled problems, way - - - - Status Mental M: Perfusion P: Respiratory R: - - -

- - - - incident, of the nature and of patients number the Communicate patients. of number 3.Determine kit. system Triage Take 2. If entering. before safety, scene ensure or Determine ofresponders. being well Assure up. size scene a Conduct 1. - - Administer injector antidotes if indicated if antidotes injector Administer indicated. if Procedure Decompression Chest Needle Perform breaths rescue 5 give child, if and airway Open hemorrhage major Control first. assess threat, life obvious an have or moving not are who involved Those second. them assess and movement purposeful a indicate / wave them have walk, cannot who those For third. assess and area designated a to walk to incident the in involved those to out Call

outcome for the greatest number of patients. of number greatest the for outcome As more help arrives then the triage / treatment process may proceed simultaneously. proceed may process / treatment triage the then arrives help more As head. their over clothing / their shirt pulling by patients deceased also indicate may You place. in remain should TAGs BLACK TAGs. YELLOW by followed first treated / moved are TAGs RED areas. treatment to patients move to need may You begin. can treatment on focus triaged are casualties Once possible best the ensuring to patient individual for an outcome possible best the ensuring from shifts Emphasis information gather time to less with rapidly be made must decisions Triage establish command and establish a medical officer and triage officer if personnel available personnel if officer triage and officer medical a establish and command establish poisoning. CO or WMC HazMat, consider complaints same the with patients several are there Triage UP 22 - appropriate heart rate may also be used in in used also be may rate heart appropriate

Universal Protocol Section e to and

every 5

the and flow

of injury, given to closest appropriate PCI capable ” given to closest appropriate Stroke center ” toe physical exam documented. - to - transports - STEMI Alert “ Stroke Alert transport expectation. If any intervention is performed “ - UP 23 UP notification to closest appropriate facility should be completed. ” critical patients. - Sepsis Alert with a Validation score score aof 100 % with Validation “ sheet, physician orders, drivers license, or transfer forms) - notified to closest appropriate trauma center as as early possible. EMS Documentation ” line medical control should be clearly documented and timed even if orders denied within the PCR. - lead procedure, interpretation, transmitted EKG, and The The following should documented be on every call, when applicable to specific a call: - Trauma Alert A complete Patient Care Report (PCR) must contain at a minimum the following information: “

Last known well, Blood Glucose, Stroke symptoms, and

Fluids should initiated be and 12 / 15

shall beelectronicallyintoshall Patient a a recorded Report (PCR) fashion, in Care timely

s withs extremity injury, documentation of neurovascular status must be documented prior to and immediately after The The documentationcomplete servicedelivery EMS associated carewith patientand ’ SEPSIS: STROKE: within 10 minutes of patient contact TRAUMA: STEMI: hospital within the first 10 minutes of patient contact. Heart Rate Respiratory Rate GCS Pain A full set of vital signs includes: Temperature Blood Pressure

2020 Version 1 Version

15. All appropriate signatures and paperwork must included be in the PCR. 14. All crew members review shall the content of the PCR for accuracy. 12. Any requested orders via on 13. Any wasted medication should have appropriate documentation completed per CCEMS Policy. 11. IV administration: documentation should include catheter size, site, number of attempts, patency, type of fluid infused, rate. splint application 9. A complete list of treatments in chronological andorder patient response to those treatments should be documented. 10. For patient 8. All time critical diagnosed patients MUST have at a minimum the following information transferred the to hospital within appropriate time frame and also documentation of time for each piece documented in the PCR. 7. When medication a intervention performed, is documentation shall include: dosage, route, administration time, and respons medication vital signs. 5. All CAD information should uploaded be into the PCR if available manually or entered if not able upload to information 6. All cardiac monitor information should be uploaded from the monitor the into PCR including applicable all waveform images 4. Only approved medical abbreviations can be used during documentation vital signs must be documented prior to, after, and during transport. At minimum a vital signs should be documented at least minutes on critical patients and every minutes 15 on non 2. An appropriate physical assessment that includes all relevant portions of a head 3. Vital shouldsigns documented be according to either transport or non etc. 1. Clear history of present illness with chief complaint, onset time, associated complaints, pertinent negatives, mechanism 9. Appropriately completed Narrative (recommend using the DRAATT Format) 10. All required documents attached (face 7. All interventions are documented 8. All necessary signatures are obtained 5. 2 Full Sets of Vital signs for any transport or 1 Full set of vital signs for any non 4. A minimum of 2 assessments required are for patients all 2. All insurance information enteredis 3. Chief Complaint 1. Any call for service must have a PCR completed. Version Universal Protocol Section 2020 **First Responders should follow documentation guidance based on First Responder Policy / Procedure / Policy Responder First on based guidance documentation follow should Responders **First Information: Format DRAATT • • • Pearls

If patient refuses a treatment or wants to AMA, follow appropriate refusal protocol(s) and obtain all required signatures. required all obtain and protocol(s) refusal appropriate follow AMA, to or wants a treatment refuses Ifpatient shift. off to going prior completed be MUST paperwork All completed. call of hours 4 within completed be shall (PCR) Report Care Patient EMS The Should include how patient was moved to stretcher for transport, transport mode to destination, and destination and to destination, mode transport for transport, to stretcher moved was patient how include Should Transport T: interventions / treatment of results and Reassessment intervention, / treatment of description procedure, the performed who indications, clinical the a minimum at include Should Treatment T: head threats, life see, you did What Assessment A: size scene the Describe Arrival A: mode Response Response R: dispatch by issued determinants response and dispatch, of time at call the of Nature Exact ZIPCode, call, the for location precise times, include: Should Dispatch D: Reference CADS Course Materials book at headquarters for further guidance as needed as guidance further for headquarters at book Materials Course CADS Reference EMS DocumentationEMS - up, up, “ paint a picture paint - to - toe assessment, etc. etc. assessment, toe ” UP 23 Airway / Respiratory Protocol Section P P B P R NO airway /

ANY Disease: NO to to Special

Protocol If indicatedIf Consider Consider Procedure Direct If If indicated Successful? airway management.airway Place Surgical onMask patient Provider don CONTACT, DROPLET, AIRBORNE PPE prior to breathing procedure EXIT Circumstances Protocol and reference CCEMS Infectious Disease Primer Laryngoscopy Airway Foreign Airway Body be utilized be they together as Surgical Surgical Procedure If suspicious infectious of Airway BIAD Procedure Airway Obstruction Obstruction Procedure contain useful information for information usefulfor contain

Protocols AR 1, 2, and 3 should 1, 2, and 3 Protocols AR Airway CricothyrotomyAirway • • • Oral / Nasotracheal Intubation Intubation Nasotracheal / Oral Medication Facilitated Intubation Intubation Facilitated Medication ≥ 90% ≥ 90% P R YES P P B R NO P R YES NO AND / OR OR / AND OR / AND ≥ 94% to Failed Airway Protocol; AR 3 AR Protocol; Failed Airway to

EXIT YES YES YES intubation attempts . attempts intubation continued with inconsistent Anatomy attempts. most by attempts unsuccessful (3) Three Paramedic experienced Unable to Ventilate and Oxygenate Oxygenate and Ventilate to Unable unsuccessful more (1) or one after or during BVM

• • • Consider Effective? Maintain If If indicated If If indicated BVM /BVM CPAP Successful? AR 1 AR Protocol; UP Protocol; 2 And SpO2 > 94 %) > 94 SpO2 And Basic Maneuvers First Basic Support Support needed? Airway Obstructed Distress Protocol; AR 6 ARProtocol;Distress Supplemental Oxygen Spinal Motion Restriction Motion Spinal Restriction Airway CPAP Procedure open airway chin lift / openjaw thrust lift / chin airway oral adjunctairway nasal or Ventilation / Ventilation/ Oxygenation (Maintain EtCO2 > 35 and < 45 < and > 35 EtCO2 (Maintain - - Oxygen Saturation Adult Respiratory COPDAdult Asthma // Protocol; AR 4 P R YES NO R intubation / BIAD Management - Adult Airway Adult Post MMMM R INADEQUATE? YES NO Effort? Adequacy? inadequate Assess ABCs Assess ADEQUATE? Airway Patent?Airway Protocol; UP 1 Pulse Oximetry? Respiratory Respiratory Rate? Monitor and Reassess andMonitor NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Universal Patient Care ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Airway or Airway breathing becomes R 2020 MMMM Version 1 Version YES Version 1

2020 Airway / Respiratory Protocol Section Inspiratory:Expiratory Ratio(I:E): PeakInspiratory Pressure (PIP) Positive End Oxygenation(FiO2): RespiratoryRate (f): Tidal Volume(Vt): Mode: All ADULT intubated patients will placedbe ventilatoron the (when the ventilator available).is SHORT: Predictorsof DifficultCricothyrotomy: LEMON Predictorsof difficulta Airway: RODS Predictorsof difficultBIAD placement: MOANS Predictorsof difficultBVM: Anticipating the Difficult Airway Airwayand Assessment: • • • • • • •

Disposition • • • • • • • • • • • • • • Pearls

patientstorso andhead to bring the mid earinto alignment withthetop of the shoulder. Inobese patients optimalpatient positioning is achieved byutilizing the " This Innon All intubations utilizing direct laryngoscopymay also include the useof theGum ElasticBougie. capnometry. Confirmation anof Endotracheal tubeincludes: VIDEOLARYNGOSCOPY is mandatory thefor first method intubation.of : : Restrictedmouth opening, Obstruction,Disrupted orDistorted Airway, Stiff lungsor cervicalspine Prior to ANY aerosolizing procedure, crew must don proper PPE prior to procedure. CPAP. PPE includes prior to This proper don procedure. must crewprocedure, to Prior ANY aerosolizing bagrequiresif Untilpatientfurthernotice, any Manual stabilization of endotracheal tube should be used during all patient moves / / transfers. moves tubepatient during all should used be endotracheal stabilization of Manual ETmaintain well endotracheal thetosecureisto better tube important It allows. patients or time inif available intubated shouldconsidered all be tubeplacement Gastric viewglottis. of External Manipulation to improve use attempts Laryngeal During intubation BIAD usingif oral a Consider spinalinjury. suspected patients forwith restriction spinalmotion Maintain injury.headand fracture, skull desaturation. intubation: Nasotracheal DOPE: should8 be rate Ventilatory measures. airway values oximetry of pulse continuous by BVM isbeing with maintained airway effective If an pastteeth the blade passing laryngoscope Attempt the is Intubation An capnography (EtCO2)Continuous airway deterioration. or risk aspiration of and receiving wi airway aventilation the oxygenation is is thisprotocolappropriate of patient when secure the For purposes Assist ControlVolume

: : Look externally, Evaluate3 See Pearls section ARSee 3 protocolsof Pearls and 2 : : Mask seal, Obesity/Obstruction,Aged (over years),55 No teeth, Stiff lungs Surgery(prior), Hematoma (or infection/abscess),Obesity, Radiation (orother tissuedeformity), Tumor "sniffingposition" - - trauma patientsproper head positioning is accomplished by utilizing paddingunder the occiput and shouldersprior employito EMS Transport: Transport: EMS E P O D Tidal Expiratory Pressure(PEEP): quipment quipment failure. neumothorax

isplaced tubeisplaced / tracheostomy ET bstructed tracheostomybstructed ET tube / 6cc/kgIBW 100% with abilityto titrate maintainto SpO2 94 10

Procedure Procedure Contraindicatedcombative,anatomicaldisruptedin airways,increased or severefacial distorted ICP, trauma, basal - 12

greatly enhances the probability firstof passsuccess. –

A/C (V) Alarms:

1:2.5 ALS: All Patients ALS: requiringairway All management -

Procedure requires spontaneous breathing and may require considerable time, exposing patient tocriticalpatient require time,exposing considerable may and breathing Procedure spontaneous requires 3 - 2, Mallampati, Obstruction/Obesity,Neck Mobility - - 10 per minute tomaintainanper 10 minute 35 EtCO2 of tracheal intubation tracheal is unsuccessful. High: –

Orotracheal route is preferred. Orotrachealroute is 1:3

is is 35 3 mandatory - 5cmH2O Low: - Adult Airway Tube - Tube ET 10 . - Tube visualizedpassing the vocal cords,Bilateral breath sounds, Absence gastricof sounds, capnography and - value

with all methods of intubation OR a blind insertion airway ORinsertionofairway blind(BIAD). methods devicea withall intubation - mask [BVM] patient must have advanced airway in place (BIAD or ET Tube)or airway ET must patientin (BIAD place [BVM]advanced mask have - 99%. AR 1 RAMP " procedure" by elevating thehead of the bed and/or placing paddingunder the - 45. Avoid hyperventilation. 45. OR - tube tube placement.

ET - Tubeintoinsertedthenasalpassage.

Initialsettings are: ≥ 94%, ≥ it is acceptable to continue with basicacceptable it with to continueis ng the head tilt maneuver. thout thout undue

Medication Facilitated Intubation

This guideline is only for use in: Patients > than 12 years of age OR greater than 55 kg OR does not fit on a Pediatric Length Based Tape.

Universal Patient Care Protocol; Indications for MFI UP 1 with FULL PPE Procedure will remove • Patient requires advanced airway patient’s protective airway for mechanical ventilation, [BVM] Passive Oxygenation via high flow Nasal reflexes and ability to • Failure to protect the airway B Cannula or Non-Rebreather B ventilate. • Unable to oxygenate • Unable to ventilate You must be sure of your ability to intubate before • Impending airway compromise MUST don CONTACT, DROPLET, AIRBORNE PPE beginning this procedure.

Vascular Access Protocol; UP 3

Assemble: • Airway Equipment P • Suction Equipment P

• Alternative Airway Device Airway Respiratory / ProtocolSection

B Apneic Oxygenation B

Hypertensive? YES NO

Etomidate 0.3 mg/kg via IV/IO AND Ketamine 1 – 2 mg / kg IV / IO P Versed 10 mg via IV/IO P P May repeat x 1 P MAX Dose 10 mg

NO Intubation Successful? YES

Consider: Apply 2-point upper • Change ALS Provider(If available) R extremity Restraints R • Attempt BIAD Consider Gastric Tube • Different laryngoscope blade or ET-Tube P Insertion P size • Change Head Positioning: align external auditory canal with sternal notch/proper positioning. Awakening or Moving After Intubation ? • Consider applying BURP maneuver (Back [posterior], Up, and to patient’s Right). YES NO Ketamine 1 – 2 mg / kg via IV / IO may If Unsuccessful P repeat x1 PRN P in 3 attempts (If SBP <190) Versed 5mg via IV / IO may repeat x1 PRN P P EXIT to Failed Airway (If SBP >190) Protocol; AR 3

P Monitor and Reasses P

Notify Destination or M M Contact Medical Control

2020 Version 1 AR 2 Medication Facilitated Intubation

Minimum Qualifications for MFI Credential: • Current MO Paramedic and a second credentialed/licensed medical provider. • Successfully complete MFI Credentialing approved by the CCEMS Medical Director with the CCEMS Training Division.

MFI Credentialing for CCEMS must be renewed every 12 months to remain in good standing.

PERI-INTUBATION HYPOTENSION (PIH) SHOCK INDEX PIH may be caused by medications used during Medication Facilitated Intubation (MFI), as well as the preload reduction caused by the initiation of positive pressure ventilation. PIH is a common complication of emergent intubation and is associated with increased mortality.

The PIH shock index is calculated (HR divided by Systolic BP). Example: HR 70 / SBP 120 = 0.58 (normal).

A pre-intubation shock index of 0.8 or greater is associated with an increased risk of PIH correlating to the patient condition worsening up to and including sudden death.

“Resuscitate before you intubate”. • Provide adequate fluid resuscitation prior to, and during, MFI procedures. • Consider using a vasopressor agent prior to intubation to increase blood pressure before the administration of an induction agent. • Choose an induction agent that is least likely to exacerbate hypotension (e.g. Ketamine). Etomidate causes adrenal suppression which may be linked to increased mortality in sepsis patients and is unreliable in patients experiencing shock. • Avoid high tidal volumes and dynamic hyperinflation when ventilating, which exacerbates hypotension by decreasing venous return and cardiac output.

It is important to secure the endotracheal tube properly and consider c-collar to better maintain ET-Tube placement – especially during patient movement.

All ADULT intubated patients will be placed on the ventilator (when the ventilator is available). Initial settings are: Mode: Assist Control Volume – A/C (V) Tidal Volume (Vt): 6cc/kg IBW Respiratory Rate (f): 10-12 Oxygenation (FiO2): 100% with ability to titrate to maintain SpO2 94-99%. Positive End-Tidal Expiratory Pressure (PEEP): 3-5 cmH2O Peak Inspiratory Pressure (PIP) Alarms: High: 35 Low: 10 Inspiratory: Expiratory Ratio (I:E): 1:2.5 – 1:3

Pearls • This procedure requires at MINIMUM (1) PARAMEDIC and a second credentialed/licensed medical provider. Divide the

Airway / Respiratory Protocol Section Protocol / Respiratory Airway workload – ventilate, suction, cricoid pressure, drugs, intubation. • This guideline is only for use in ADULT (non-pediatric) patients. (Patients greater than 12 years of age OR greater than 55 kg OR does not fit on a Pediatric Length Based Tape. • Capnography is: • Required for ALL Intubated Patients and Cricothyroidotomy Patients • Required for utilization of any Airway Device (e.g. BIAD) • Attachment of the Capnograph may be delayed until the scene is safe / non-threatening • If First intubation attempt fails, make an adjustment and try again: • Different ET-Tube size • Change head positioning: Align external auditory canal with sternal notch / proper positioning. • Consider applying BURP maneuver (Back [posterior], Up, and to patient’s Right) • Protect the patient from self-extubating when the medications wear off. Longer acting sedatives may be needed post - intubation. Apply upper extremity 2-point restraints per CCEMS Restraint Procedure • MFI not recommended in urban setting (short transport) when able to maintain oxygen saturation ≥ 94 %. • Consider orogastric tube placement in all intubated patients to limit aspiration and decompress stomach if needed.

Disposition EMS Transportation: ALS: All Patients

2020 Version 1 AR 2 Airway / Respiratory Protocol Section R to to

YES Exit Continue BVMContinue Supplemental Oxygen Supplemental Appropriate Appropriate Protocol(s) R YES YES P P B R MMMM R during or after one (1) or more aftermore oror(1) duringone ≥ 94% ≥ ≥ 90% ≥ 90% NO NO YES YES AR 3 AR BVM Attempt Maintains AND /OR AND /OR AND Procedure Procedure Procedure if available if CONFIRM: SUCCESSFUL? SUCCESSFUL? Protocol; 4 Protocol; AR Supplemental oxygenSupplemental BVM with Airway withAdjunctsBVM Airway (Maintain SpO2 and SpO2 EtCO2) and (Maintain NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor intubation BIAD Managementintubation BIAD Oxygen Saturation Oxygen - Adjunctive NP OP Airway / Initiate apneic apneic oxygenation Initiate ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Call foradditional Callresources Blind Insertion Blind Device Airway Airway Cricothyrotomy Surgical Surgical CricothyrotomyAirway unsuccessful intubation attempts. unsuccessful intubation R Post MMMM P B P R Anatomy inconsistent with continued attempts.continued with inconsistent Anatomy NO MORE THAN THREE (3) ATTEMPTS TOTAL ATTEMPTS THREE (3) NO THAN MORE

2. NO Each attempt should include change in approach or in equipment approach includeor should change Each attempt Three (3) unsuccessful attempts by most experienced experienced Paramedic/AEMT. mostunsuccessful (3) Three by attempts Unable to Unable Oxygenate and Ventilate

Adult, Failed Airway Adult, 3. 1. airway / CLOSEST

RESOURCE **EMERGENT TRANSPORT TO ANY Disease: to to Special

and reference CCEMS Infectious Disease Primer breathing procedure EXIT Circumstances Protocol Provider don CONTACT, DROPLET, AIRBORNE PPE prior to Place Surgical onMask patient management. management. together (even if together (even if If suspicious infectiousof agency is not agency using is 3 should be utilized be 3 should

Drug Assisted Drug Airway Assisted Protocols AR 1, 2, 1,2, and Protocols AR as they containthey as useful information for airway for informationairway • • • 2020 Version 1 Version Airway / Respiratory Protocol Section Version 1 DOPE: • • • • the and adjustment an make fails, attempt intubation first If • • • • and Assessment:Anticipating Difficult the Airway Airway 2020

Disposition • • • • • • • Pearls

Difficulty Cricothyrotomy / Surgical Airway (SMART): (SMART): Airway Surgical / Cricothyrotomy Difficulty (RODS): BIAD Difficulty (LEON): Laryngoscopy Difficult (MOANS): Ventilation BVM Difficult Change head positioning head Change size ETT Different Bougie Elastic Gum devices laryngoscopy optical other or Video / blade laryngoscope Different Continuous EtCO2 should be applied to all patients with respiratory failure or to all patients with advanced airways advanced with patients to all or failure respiratory with patients to all applied be should EtCO2 Continuous function. respiratory inadequate with allpatients in be utilized should oximetry pulse Continuous glottis. of view improve to Manipulation Laryngeal External use attempts intubation During oral if BIAD a using Consider measures. airway basic with continue of values oximetry pulse continuous with byBVM maintained being is airway effective ventilation. an and If oxygenation appropriate receiving is patient the when is airway secure a protocol this of purposes the For Notify

T R A M S S D O R N O finger E L S N A O M E P O D ook externally for anatomical problems; problems; anatomical for externally ook urgery scars urgery neck or lungs tiff neck or lungs tiff valuate 3 valuate quipment failure. quipment umor. EMS Transport EMS neumothorax neumothorax adiation treatment to face, treatment adiation opening; mouth estricted ccess or anatomical problems anatomical or ccess ge isplaced tracheostomy tube / ET / tube tracheostomy isplaced airway; or disrupted istorted eck mobility limited. limited. mobility eck teeth; o bstructed tracheostomy tube / ETT, / tube tracheostomy bstructed OB obstruction, bese, OB obstruction, bese, OB obstruction, bese, ass or hematoma or ass trauma); secretions, (hair, difficulty seal ask

Medical Control Medical ≥ 55; 55; ≥ ’ s width, base of chin to thyroid prominence should equal 2 of patients finger patients of 2 equal should prominence to thyroid chin of base swidth, - 3 - 2 (Mouth opening should equal 3 of patients finger patients of 3 equal should opening (Mouth 2 ; : ALS: ALS: PATIENTS ALL , Adult, Airway Failed

AS EARLY AS POSSIBLE concerning POSSIBLE AS EARLY AS – – – -

2d and 3d trimesters; trimesters; 3d and 2d trimesters; 3d and 2d trimesters; 3d and 2d tracheal intubation isunsuccessful. intubation tracheal

neck, or chest; neck, ; - tube, tube,

AR 3 n consider: n

the patient's difficult / failed airway. failed / difficult patient's the ’ s width, mental area to neck should equal 3 of patient of 3 equal should to neck area mental swidth, ’ s width); width); s ≥ 90%, ≥ it is acceptable to to acceptable is it ’ s Airway / Respiratory Protocol Section P P M P 3

– to Airwayto

EXIT Protocol; AR 1 1 ARProtocol; 10 mg 20 mg 100 mcg 200 mcg

Slow / IV push IO 2.5 mg IV / IO

minutes as needed 75 mcg IV / IO 4 mg IV / IO - NO

YES NO NO - OR 5

2 – 50 AND / OR mg / kg NO 2 every 5 minutes needed as

MMMM

Contact MedicalMedicalMedicalMedical Control Control Control Control ContactContactContactContact –

Effective Sedation? every 5 minutes needed as (MAX Dose mg) 10 Effective Sedation? Effective Sedation?

1 Awakening Moving or Morphine MAX Total Dose MAX Single Dose 2 mg MAX Total Dose MAX Single Dose Fentanyl MUSTMUSTMUSTMUST Midazolam after Intubation / BIAD Placement Prior to administrationadministrationadministrationadministration totototoPrior Prior Prior Prior of of of of MidazolamMidazolamMidazolamMidazolam Repeat NO Evidence of Pain / Anxiety / Agitation Repeat every 3 Repeat Ketamine YES YES YES P P P MMMM MedicalMedicalMedicalMedical ControlControlControlControl YES AR 4 AR R P NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact P B Patient Sedated? Device Successful MMMM Tube or Blind Insertion Airway - YES ET 45 ≥ 94% ≥

– breaths / minute breaths / YES YES 10

See PearlsSee – Lead ECG Procedure EtCO2 EtCO2 35 - intubation / BIAD Management BIAD / intubation Lead ECG Interpretation - - Maintain SpO2 Maintain SpO2 May require May rate faster 4 Continue Airway Adjuncts AirwayContinue

– VascularVascular AccessAccess Protocol;Protocol; UPUP 33 12 / 15

Ventilate 8 Ventilate Transport Ventilator Procedure 12 / 15 19, status for -

- be applied

P B Post COVID P R further notice MUST management. Patient + / If unable to determine

done in FULL PPE; until airway in place.

advanced airway must be and secured prior to

point Upper Extremity management patient of with that has an advanced as they contain useful - information for airway of anof advanced airway

2020 2 transporting any patient Version 1 Version Airway Protocols; AR 1 should be utilized together as possible after placement

Restraints This should done be as soon Version 1 Airway / Respiratory Protocol Section 2020 Inspiratory: Expiratory Ratio (I:E): Ratio Expiratory Inspiratory: (PIP) Pressure Inspiratory Peak End Positive (FiO2): Oxygenation (f): Rate Respiratory (Vt): Volume Tidal Mode: is available). ventilator the (when ventilator the on placed be will patients intubated ADULT All Disposition • • • • • • • • • • • • Pearls

DOPE: balloon leak. compliance. Search With abruptclinical deterioration, mechanicallyif ventilated, disconnect fromventilator to assesslung Head bed of should maintainedbe at least 10 Continuous oximetrypulse andcapnography should be maintained during transport monitoring.for should aboutbe mL/kg6 and peak pressuresshould be 30< cmH20. generalIn ventilation with BVM should chestcause rise. mechanicalWith ventilation a reasonabletidal volume Ventilator Ventilation/ strategies willneed to be tailoredto individual patientpresentations. Ketamine alsois a reasonablefirst choice agent. Pain must be addressed first,before anxiety. both are not always reliableindicators of patient Vitalsigns such has tachycardia and hypertension or/ can provide cluesinadequate to sedation, however they Ventilated patients cannot communicate pain anxiety/ and providerspoor are at recognizing pain / anxiety. hospitalization. Unrelieved pain canlead to increased catecholamine release, ischemia,immunosuppression, and prolonged Patients requiring advanced airways ventilationand commonlyexperience painand anxiety. Recommended Exam: Mental Status, HEENT, Heart, Lungs, Neuro Assist Control Volume Volume Control Assist Post EMS Transport: Transport: EMS E P O D quipment failure. neumothorax isplacedtracheostomy tube /ET bstructedtracheostomy tube/ ET -

Tidal Expiratory Pressure (PEEP): (PEEP): Pressure Expiratory Tidal 6cc/kg IBW 6cc/kg 100% with ability to titrate to maintain SpO2 94 SpO2 to maintain to titrate ability with 100% 10 - - 12 intubation / BIADManagement ALS: All patients All ALS: for dislodged ET –

A/C (V) A/C Alarms: Alarms:

1:2.5 1:2.5 High: –

1:3

35 35 - tubeor BIAD, obstruction intubing airway,or pneumothorax, or ET 3 - tube - 5 cmH2O 5 - Low: Low: Tube 10

– Opioidsare typically the first line agents before benzodiazepines.

20 AR 4 ’ s oflack adequatesedation. degreesof elevation when possible to decrease aspiration risk. - 99%.

Initial settings are: settings Initial - tube Airway / Respiratory Protocol Section YES to Appropriate to protocol(s)

Exit P NO Disruption of oxygen source Disruption of tube obstructed tracheostomyDislodged or circuitorventilator Detached disrupted arrestCardiac demand / oxygen Increased requirement Ventilator failure

Differential • • • • • • Other problems R maintain maintain current settings Problem with Circulation / MMMM Transport on patients andonventilatorTransport patients NO P Intubation / BIAD Intubation / - AR 5 AR Correct causeCorrect to Post to

Management Protocol; ARProtocol; Management4 EXIT R EXIT to Adult COPD / Asthma / / EXIT / Asthma COPD Adult to YES Respiratory Distress Protocol; Respiratory 6 ARProtocol; Distress YES Notify Destination orororor Notify Notify Notify Notify DestinationDestinationDestinationDestination Contact MedicalMedicalMedicalMedicalContactContactContactContact Control Control Control Control YES Transport requiring maintenance of a maintenance requiring of Transport a ventilator mechanical failure equipmentor Power at residence YES NO

MMMM • • Signs and Symptoms P mmHg Tube Tube - - 45

Ventilator Ventilator Troubleshooting – Or NO NO NO NO NO YES YES UP 1 ≥ 94%

patient) traumatic brain or spinal cord cord spinal or brain traumatic - Tube / ET Tube / ET Cause corrected ventilate BVM with Removefrom patient EtCO2 35 ventilator and manuallyand ventilator Problem with Airway, baseline saturation for (Ask Caregiver: What is Oxygenation saturation Dislodged Tracheostomy Detached Oxygen Source Obstructed Tracheostomy Detached Ventilator Circuit Ventilation, or Oxygenation Universal Patient Care Protocol; Patient Protocol; Care Universal Patient adequately sedated? P dysplasia, muscular dystrophy) muscular dysplasia, nerve) (post Trauma injury) (bronchopulmonary condition Medical Birth defect (tracheal atresia, atresia, (tracheal defect Birth abnormalities) craniofacial tracheomalacia, to phrenic (damage complications Surgical 2020 Version1

• • • • History Version1 Version1

2020 Airway / Respiratory Protocol Section Disposition: • • • • • • • Pearls

DOPE: alarms: Typical properly. functioning not if even to hospital ventilator patient Take BVM. using ventilate manually and ventilator from patient Remove problem: ventilator to correct Unable transport. and assessment during be utilized must monitoring CO2 tidal end and oximetry pulse Continuous patient use Always patient the using If skills. and knowledge specific have as they / caregivers family to talk always ventilator, a on home is patient If E P O D - - -

quipment failure. quipment neumothorax or circuit. airway / obstructed Plugged Pressure: High depleted. battery Internal Power: Low site. tracheostomy or around circuit in leak circuit, disconnected or Loose / Apnea: Pressure Low isplaced tracheostomy tube / ET / tube tracheostomy isplaced bstructed tracheostomy tube / ET / tube tracheostomy bstructed

Ventilator TroubleshootingVentilator EMS Transport: EMS ’ ’ s equipment if available and functioning properly. functioning and available if sequipment s ventilator bring caregiver knowledgeable in ventilator operation during transport. during operation in ventilator knowledgeable caregiver bring sventilator ALS : All patients All : - Tube - Tube Tube AR 5 ’ s Airway / Respiratory Protocol Section P P mg 5

– mL NS

2.5 2.5 Protocol;Protocol; ACAC 33 AllergicAllergic ReactionReaction / / STRIDOR? CHFCHF / Pulmonary/ Pulmonary EdemaEdema May repeat x 1 May AnaphylaxisAnaphylaxis Protocol;Protocol; AMAM 22 Repeat as neededasRepeat x 3 Epinephrine NebulizerEpinephrine 1 mg (1:1000) / 1 3 (1:1000) mg Albuterol Nebulizer Albuterol Nebulizer Asthma Anaphylaxis Aspiration Bronchitis) COPD (Emphysema, Pleural effusion Pneumonia Pulmonary embolus Pneumothorax Cardiac (MI CHF) or tamponadePericardial Hyperventilation (Carbon monoxide, toxinetc.) Inhaled P P YES YES

Differential • • • • • • • • • • • • P P P P P MMMM minutes 2g IV / / IO IV 2g NO NO

YES AR 6 AR 20 20 Edema?

mg mg IM – anaphylaxis? Airway Patent?Airway NO 0.5 0.5

Signs / Symptoms of Symptoms Signs / – Consider CONSIDER CONSIDER Following Following Assessment if indicated if Improved? mg repeat as neededmg repeat as Rales / Signs of of / Pulmonary RalesSigns 0.3 0.3 5

125 mg IV / IO // 125 mg IVIM IO Epinephrine 1:1000Epinephrine Albuterol Nebulizer Albuterol Nebulizer Methylprednisolone – Shortness of breath Pursed lip breathing Decreased ability to speak Increased respiratory rate and effort Wheezing, rhonchi Use of accessory muscles Fever, cough Tachycardia Airway CPAP Procedure Airway NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Infuse over 10 10 over Infuse UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP Magnesium Sulfate Magnesium ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl 2.5 2.5 VascularVascular AccessAccess Protocol;Protocol; UPUP 33

• • • • • • • • Signs and Symptoms NO P MMMM Respiratory Distress P P P P P Adult COPD / Asthma / / AdultAsthma COPD 4 4

–– chronic bronchitis,

Nebulizer If indicatedindicated IfIf -- WHEEZING? 2.5 mg / 0.5 mg x1 via 2.5 mg /

Medication FacilitatedFacilitatedMedication Medication DUONEB Intubation (MFI) Protocol; AR 22 Intubation Intubation (MFI) (MFI) AR AR Protocol; Protocol; Adult Airway Protocol;Protocol; AirwayAirwayAdult Adult 1 1 AR AR

P Toxic exposure, smoke inhalation Home treatment (oxygen, nebulizer) Medications (theophylline, steroids, inhalers) Asthma; COPD emphysema, congestive heart failure

2020

Version 1 Version

• • • • History Version 1 Airway / Respiratory Protocol Section 2020 Mix 2 grams of Magnesium Sulfate into a 100 mL bag of Normal Saline and infuse over 15 minutes. 15 minutes. over infuse and Saline Normal of bag mL 100 a into Sulfate Magnesium of grams 2 Mix Infusion: Sulfate Magnesium prepare To a nebulizer in Saline Normal of mL 3 with Epinephrine of solution) 1:1,000 a of (1mL 1mg Mix Nebulizer: via Epinephrine administer To 15 A ischemia. cardiac precipitate may Epinephrine 150. > is rate caution Use • • • • • are: CPAP for Contraindications symptoms and signs serious with patients of treatment the in early considered be Should CPAP

Disposition: • • • • • • • • Pearls

Pneumothorax or cough) swallowing (impaired airway protect to Inability face the to or Burns Trauma Arrest Respiratory / Drive Respiratory Poor Volume) (Tidal Vt Low A silent chest in respiratory distress is ais pre distress respiratory in chest silent A Non or CPAP End and oximetry Pulse improvement. no and failure respiratory impending with Sulfate Magnesium Consider Epinephrine: to benefit proven continu no is there once administered be should ipratropium and albuterol containing nebulizers Combination Patien Bronchospasm. or Disease, Airway Reactive Asthma, COPD, distress, respiratory with patients all includes protocol This Neuro Extremities, Abdomen, Lungs, Heart, Neck, Skin, HEENT, Status, Mental Exam: Recommended EMS Transport: EMS - - - - - needed are nebulizers continuous if guidance patient Monitor improvement. until should continue treatments and symptomatic remain if treatments nebulizer Albuterol mg 2.5 3 morethan receive may Patients

Consider removal if SBP remains < 100 mmHg and not responding to other treatments. treatments. to other responding not and mmHg 100 < remains SBP if removal Consider course. treatment in early Consider CHF. and reactions, Allergic Asthma, COPD, with be used May improvement. no and failure respiratory impending with administer suspected, isnot reaction Ifallergic improvement. until repeat and immediately give is suspected, anaphylaxis or reaction Ifallergic

ts may also have wheezing and respiratory distress with viral upper respiratory tract infections and pneumonia. pneumonia. and infections tract respiratory upper viral with distress respiratory and wheezing have also may ts administering epinephrine in patients who are > 50 years of age, have a history of cardiac disease, or if the patient the if or disease, cardiac of a history have age, of years > 50 are who patients in epinephrine administering e use ofipratropium. use e -

Invasive Positive Pressure Ventilation: Ventilation: Pressure Positive Invasive BLS ALS - tidal CO2 should be monitored continuously. monitored be should CO2 tidal : Pulse oximetry > 94%, speaking comfortably and no medications administered medications no and comfortably speaking 94%, > oximetry Pulse : : With a Hx of respiratory distress any patient with stridor and all patients receiving ALS treatment ALS receiving patients all and stridor with patient any distress respiratory of Hx a With : Adult COPDAsthmaAdult / / Respiratory Distress Respiratory - respiratory arrest sign. sign. arrest respiratory ’ s heart rate and if greater than >150 contact medical control for further for further control medical contact >150 than greater if and rate sheart AR 6 - lead ECG should be performed on these patients on performed be should ECG lead ’ s heart heart s Bradycardia

History Signs and Symptoms Differential • Past medical history • HR < 60/min with hypotension, acute altered • Acute myocardial infarction • Medications mental status, chest pain, acute CHF, • Hypoxia / Hypothermia • Beta-Blockers seizures, syncope, or shock secondary to • Pacemaker failure • Calcium channel blockers bradycardia • Sinus bradycardia • Chest pain • Head injury (elevated ICP) or Stroke • Clonidine • Respiratory distress • Spinal cord lesion • Digoxin • Hypotension or Shock • Sick sinus syndrome • Pacemaker • Altered mental status • AV blocks (1°, 2°, or 3°) • Syncope • Overdose

Universal Patient Care Protocol; UP 1

Exit to Heart Rate < 60 / min and Symptomatic: Appropriate Hypotension, Acute AMS, Ischemic Chest Pain, Acute CHF, Seizures, NO Protocol(s) Syncope, Overdose, or Shock secondary to bradycardia Typically HR < 50 / min

YES Adult CardiacProtocol Section B 12-Lead / 15-lead ECG Procedure B Chest Pain: Cardiac Airway Protocol(s); and STEMI P 12-Lead / 15-Lead Interpretation P YES AR 1 – 4 Protocol; AC 2 If indicated NO If indicated

Airway / Respirations NO Adequate? YES Respiratory Distress Exit to appropriate Protocol; AR 6 Overdose? YES Overdose Protocol; If indicated NO TE 6 – 11

UNSTABLE? NO YES 2nd or 3rd AV Block? Vascular Access Protocol; UP 3 Vascular Access Protocol; UP 3 Normal Saline Fluid Bolus 500 mL – 2 L NS IV / IO P P (Unless Acute CHF, CAUTION with fluid) Consider Sedation Midazolam 2.5 mg (MAX Dose 2 L) IV / IO / IM / IN Atropine 0.5 mg IV / IO If SBP > 110; May repeat every 3 – 5 minutes may repeat in 5 minutes x 1 (MAX Dose 3 mg) MAX Dose 5 mg P OR P P Norepinephrine 2 – 10 mcg/min IV / IO P Fentanyl 25 mcg OR IV / IO / IM / IN Dopamine 5 – 20 mcg/kg/min IV / IO May repeat q 5 minutes (Titrate to SBP ≥ 90 mmHg MAX Single Dose 100 mcg Maintain MAP > 65mmHg) MAX Total Dose 200 mcg If SBP > 90

NO Improved? Transcutaneous Pacing Procedure P (Consider earlier in 2nd or 3rd AV-Block) P YES

P Monitor and Reassess P Notify Destination or M Contact Medical Control M

2020 Version 1 AC 1 Bradycardia

NOTE: DO NOT delay pacing to obtain vascular access in unstable patients.

Atropine - Do NOT delay Transcutaneous Pacing to administer Atropine in bradycardia with poor perfusion. - Caution in setting of acute MI. Elevated heart rate can worsen ischemia. - Ineffective and potentially harmful in cardiac transplantation. May cause paradoxical bradycardia.

Transcutaneous Pacing Procedure (TCP) - Utilize TCP early if no response to atropine. If time allows transport to specialty center because transcutaneous pacing is a temporizing measure. Transvenous / permanent pacemaker will probably be needed. - Immediate TCP with high-degree AV block (2nd or 3rd degree) with no IV / IO access.

- Confirm both mechanical and electrical capture Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls • Recommended Exam: Mental Status, Neck, Heart, Lungs, Neuro • Identifying signs and symptoms of poor perfusion caused by bradycardia are paramount. • Rhythm should be interpreted in the context of symptoms and pharmacological treatment given only when symptomatic, otherwise monitor and reassess. • 12-lead and 15-lead ECG’s shall be acquired, transmitted, and have Paramedic interpretation within 10 minutes of patient contact. • Consider hyperkalemia with wide, bizarre appearance of QRS complex and bradycardia. • Hypoxemia is a common cause of bradycardia. Ensure oxygenation and support respiratory effort. • Consider treatable causes for bradycardia (Beta Blocker OD, Calcium Channel Blocker OD, Hyperkalemia, etc.) • If concern for acute fluid overload, restrict fluid and MUST reassess lung sounds between each 500 mL fluid bolus

Disposition: EMS Transport: ALS: All Patients

2020 Version 1 AC 1 Chest Pain: Cardiac and STEMI

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

Procedures to complete in the first 10 Universal Patient Care Protocol; UP 1 minutes of Patient contact

IF no immediate life threat and Aspirin 81 mg x 4 (chewed) Chief Complaint CARDIAC in nature: P MAX 324 mg PO P Adult CardiacProtocol Section • 324 mg PO Aspirin (if not contraindicated) • 12-Lead ECG obtained, interpreted, and transmitted B 12-Lead / 15-lead ECG Procedure B • 15-Lead ECG obtained, interpreted, and transmitted P 12-Lead / 15-Lead Interpretation P

Identified Acute MI / STEMI NO (STEMI = 1 mm ST Segment YES Elevation ≥ 2 Contiguous Leads) Complete within 10 minutes of Vascular Access Protocol; UP 3 CONTROL PAIN Patient contact 1. Total of 324 mg baby aspirin YES 2. Transmit 12 / 15-lead ECG Nitroglycerin 3. Call via phone “STEMI ALERT” 0.4 mg SL every 5 minutes, if SBP >120 (Do this when transmitting ECG) P (MAX 3 doses) P 4. Scene Time to ≤ 10 Minutes Caution: if concern for Posterior or Right sided infarct

Hypotension / Shock Patient becomes hypotensive YES Protocol; AM 12 NO CHF / Pulmonary Edema Pain Improved after Protocol; AC 3 NO Nitroglycerin administration? If indicated

YES Consider Zofran CONSIDER P 4mg IV / IO / IM / ODT P Morphine 2 – 4 mg IV / IO (PRN for Nausea, may repeat x 1) Repeat every 5 minutes as needed MAX Single Dose 10 mg Monitor and reassess Patient MAX Total Dose 20 mg P P P OR P condition q 5 minutes Fentanyl 50 mcg (0.25-1 mcg/kg) IM / IV / IO / IN 25-50 mcg may repeat q 5 mins Notify Destination or M M MAX Single Dose 100 mcg Contact Medical Control MAX Total Dose 200 mcg

Version 1 2020 AC 2 Chest Pain: Cardiac and STEMI

• ANY patient that receives a 12-Lead acquisition and interpretation will be required to have a 15-Lead acquisition and interpretation completed. Both MUST be completed and transmitted to receiving facility within 10 minutes of patient contact • Titrate oxygen administration for an Sp02 between 94 – 99% • STEMI ALERT: Consider Air Medical Activation if ground transport time will be > 30 minutes to the nearest PCI capable hospital AND onset of symptoms to a Cath Lab is expected to be > 90 minutes. STEMI ALERT should be called via truck phone at time of 12/15 – Lead transmission STEMI (ST-Elevation Myocardial Infarction) - Consider placing 2 IV sites in the left arm: Many PTCI centers use the right radial vein for intervention. - Consider placing defibrillator pads on patient as a precaution. - Consider Normal Saline or Lactated Ringers bolus of 250 – 500 mL as pre-cath hydration. • In patients with left bundle branch block (LBBB) or ventricular paced rhythm, infarct diagnosis based on the ECG is difficult . The baseline ST segments and T waves tend to be shifted in a discordant direction (“appropriate discordance”), which can mask or mimic acute myocardial infarction. However, serial ECGs may show dynamic ST segment changes during ischemia. A new LBBB is always pathological and can be a sign of myocardial infarction. Modified Sgarbossa Criteria: - 1 or more leads with ≥1 mm of concordant ST elevation. - 1 or more leads of V1-V3 with ≥ 1 mm of concordant ST depression. - 1 or more leads anywhere with ≥ 1 mm ST elevation and proportionally excessive discordant ST elevation, as

defined by ≥ 25% of the depth of the preceding S-wave. Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls • Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro • Aspirin shall be administered within 10 minutes of patient contact. • 12-lead and 15-lead ECG’s shall be acquired, transmitted, and have Paramedic interpretation within 10 minutes of patient contact. • Avoid Nitroglycerin in any patient who has used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 36 hours due to potential severe hypotension. • If CHF / Cardiogenic shock resulting from inferior MI (II, III, aVF), consider Right Sided ECG (V3 or V4). If ST elevation noted Nitroglycerin and / or opioids may cause hypotension requiring normal saline boluses. • If patient has taken nitroglycerin without relief, consider potency of the medication. • Monitor for hypotension after administration of nitroglycerin and narcotics (Morphine, Fentanyl, or Dilaudid). • Diabetic, geriatric and female patients often have atypical pain, or only generalized complaints. • Document the time of the 12/15 - Lead ECG in the ePCR as a Procedure along with the interpretation (Paramedic). • Document “STEMI ALERT” time and EKG Transmit time in the ePCR.

Disposition: EMS Transport: ALS: All patients

Version 1 2020 AC 2 Adult Cardiac Protocol Section MMMM 44

P -- 4 4

-- ARAR 1 1 if in place in if to to to AppropriateAppropriate As indicated indicated As As bradycardia

hypotension Protocol; AM AM 12 12 Protocol; Protocol; Remove CPAP Remove CPAP CARDIOGENIC SHOCK CARDIOGENIC AirwayAirway Protocol(s);Protocol(s); EXITEXIT Protocol;Protocol; ACAC 22 Notify Destination orororor NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination Tachycardia followed by by followed Tachycardia Adult Hypotension / ShockShockHypotensionHypotension Adult Adult / / Hypertension followed by followed Hypertension Airway Protocol(s); ARARProtocol(s);Protocol(s); AirwayAirway 1 1 Contract MedicalMedicalMedicalMedical Control Control Control Control ContractContractContractContract Respiratory Failure immanent? Failure Respiratory P MMMM ChestChest Pain:Pain: CardiacCardiac andand STEMISTEMI Myocardial infarction Myocardial heart failureCongestive Asthma Anaphylaxis Aspiration COPD Pleural effusion Pneumonia Pulmonary embolus tamponadePericardial Toxic Exposure

Differential • • • • • • • • • • • NO PPP PPPP P R NO YES PPPP B times times 3)

Lead - Lead Lead Lead Lead Lead MAX ---- NO YES 0.4 0.4 mg Sublingual YES YES Procedure

Ventilation Lead / 15 Lead / - CPAPCPAPCPAPCPAP ProcedureProcedureProcedureProcedure

AC 3 AC Improving? Lead / 15 15 15 15 Lead Lead Lead Lead / / / / Elevated Elevated BP 12 ---- InterpretationInterpretationInterpretationInterpretation 12121212 Nitroglycerin PastePastePasteNitroglycerinNitroglycerinNitroglycerin Chest Pain Chest/STEMI? Elevated Heart Elevated Rate Heart (If Systolic BP > 120) BPSystolic(If > Airway patent AND Airway patent AND MODERATE / SEVERE MODERATE / Systolic BP > 100 = 1 = = = inch inch inch 1 1 1 100100100 > > > BP BP BP Systolic Systolic Systolic = = = inch inch inch 2 2 2 200200200 > > > BP BP BP Systolic Systolic Systolic Systolic BP > 150 = 1.5 inch inch inch = = = 1.5 1.5 1.5 150150150 > > > BP BP BP Systolic Systolic Systolic as needed in the absence of of CPAP the absence in needed as Respirations Respirations adequate? Assess Symptom AssessSeverity Assist Ventilations with Bag AssistMask with Ventilations REMOVE if patient hypotensive hypotensive hypotensive patient patient patient if if if REMOVE REMOVE REMOVE ConsiderConsiderConsiderConsider VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Nitroglycerin Repeat q 5 minutes ( 5 qminutesRepeat PPPP UniversalUniversal PatientPatient Protocol;Protocol;Care Care UP UP 11 B PPPP P PPP R Respiratory Respiratory distress, ralesbilateral orthopneaApprehension, vein Jugular distention frothy sputumPink, diaphoresis edema,Peripheral Hypotension, shock pain Chest

• • • • • • • Signs and Symptoms Signs and P PPP R NO Viagra / Viagra / CHF / Edema / CHF Pulmonary <94% times times 3) Consider

YES past myocardial myocardial past 0.4 mg 0.4 Sublingual mg

MILD -- Consider Improving? MAX ( Normal Heart Rate Heart Normal Nitroglycerin PastePastePasteNitroglycerinNitroglycerinNitroglycerin Repeat q 5 5 qminutesRepeat O2 administration SPO2if (If Systolic BP > 120)BP Systolic(If > ) Systolic BP > 100 = 1 inch inch inch = 1 = 1 = 1 100100100 > > > BP BP BP Systolic Systolic Systolic inch inch inch = = = 2 2 2 200200200 > > > BP BP BP Systolic Systolic Systolic Elevated or Normal BP Normal Elevated or Systolic BP > 150 = 1.5 inch inch inch = = = 1.5 1.5 1.5 150150150 > > > BP BP BP Systolic Systolic Systolic REMOVE if patient hypotensive hypotensive hypotensive patient patient patient if if if REMOVE REMOVE REMOVE Nitroglycerin infarction Medications Medications (digoxin, Lasix, Cialis /Levitra/ vardenafil, sildenafil, tadalafil historyCardiac Congestive heart heart failureCongestive medicalhistoryPast

PPP P R 2020

Version 1 Version

•

• • History • Adult Cardiac Protocol Section Version 1 2020 Once CPAP Once Bi /CPAP to 12/15byof Nitroglycerin ofLead administrationrapid Myocardial prior EKG. interpretation Infarction Ventricular this, avoidpressure.Right droprule Toblood out in precipitous which may PRELOAD cause inRightadministrationpatient Myocardial NitroglycerincardiacreducesVentricular with Infarction the Disposition: • • • • • • • • • • Pearls

Even though this historically hasbeen a mainstay of EMS treatment, isit nolonger routinely recommended. Furosemideand Opioids have NOTbeen showntoimprove the outcomes EMSof patients with pulmonary edema. Allowthe patient into be theirposition comfortof to maximize theirbreathing effort. myocardial infarction allinthese patients. Contraindications to opioids includesevere COPD andrespiratory distress. Monitor the patientclosely. If patienthastaken nitroglycerin without relief, consider potency of medication.the elevation no If CHF Cardiogenic/ shock resulting from inferior MI (II, III, aVF),consider Right SidedECG (V3 V4).orIfST Carefullymonitor the level of consciousness, BP, respiratoryand statuswiththe above interventions. Cialis (t AvoidNitroglycerin inany patientwho has used Viagra (sildenafil) Levitraor (vardenafil) in the pasthours 24 or patient contact. 12 Recommended Exam: Mental Status, Skin, Neck, Lung, Heart,Abdomen, Back, Extremities, Neuro Diabetics,geriatric and female patients often have atypical orpainonly generalizedcomplaints; - leadand 15 EMS Transport: EMS adalafil) inthe past36 hours due potentialto severe hypotension. - level is initiated,level is use ofNitroglycerindiscontinue (SL)sublingual tablets and apply Nitro paste. tedNitroglycerin and or/ opioids maycause hypotension requiring normal saline boluses. CHF / PulmonaryCHF / Edema - leadECG ALS: ’ s s shallbe acquired, transmitted, and have Paramedic interpretation within10 minutes of All patients All AC 3 Consider Adult Cardiac Protocol Section COPD Trauma Sepsis P

• • • PrehospitalPrehospital YES ResuscitationResuscitation Protocol;Protocol; UPUP 55 withholdingwithholding ACAC && 1212 11 11 Protocol(s);Protocol(s); ResuscitationResuscitation DiscontinuationDiscontinuation ofof Protocol;Protocol; UPUP 44 CriteriaCriteria forfor DeathDeath AdultAdult TachycardiaTachycardia VFVF / VT/ VT ProtocolProtocol ACAC 55 Decomposition mortis Rigor lividity Dependent Blunt force Massive trauma with Injury incompatible life withExtended downtime asystole

Do not begin resuscitation • • • • • • R Chest Pain / STEMI Pain Chest / Stroke CHF YES YES Cardiac Monitor

Shockable Rhythm? Differential • • • MMMM YES 44

–– seconds) P Tach - NO ≤ 10 inches) ACAC 66 120 / min)

NO NO - ≥ 2 ≥ 2 ROSC? NO YES Criteria for fib /fib Pulseless V AC 4 AC - MedicalMedicalMedicalMedical ControlControlControlControl Discontinuation? AsystoleAsystole // PEAPEA ProtocolProtocol Review DNR AirwayAirway Protocol(s);Protocol(s); ARAR 11 ALS Available? (sooner if fatigued) NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Push Hard ( Push Fast (110 R MMMM Confirmed Pulseless apneic? and UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP Ventilate 1 breath every 6 seconds Criteria for Death No Resuscitation/ Begin Continuous CPR Compressions Change Compressors every 2 minutes Apneic V Asystole PEA / / Pointesde Torsade's Pulseless (Limit changes / pulse checks CardiacArrest

• • • Signs and SignsSymptoms • R NO 30:2 Compression:Ventilation if no Advanced Airway R YES YES R AED AED Procedure R NO if available if 2 2 Minutes Rhythm? Shockable Continue CPRContinue Return of Protocol;Protocol; ACAC 77 AED Procedure ProtocolProtocol to to to appropriateappropriate

Repeat and reassess andRepeat AT ANY TIMEANYAT CardiacCardiac Arrest:Arrest: ROSCROSC EXIT EXIT Spontaneous Circulation R ENSURE SCENE IS SAFE NO R See Reversible Causes back ReversibleonSee Will orDNR Living SAMPLE Estimated downtime

2020

Version 1 Version

• • • • History Cardiac Arrest

• Automatic CPR devices will be applied just prior to moving the patient to the stretcher for transport, never allowing a pause in chest compressions of more than 10 seconds. • Common causes of post-resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and medication reaction to ALS drugs

Criteria for Discontinuation of Resuscitation ***All criteria MUST be met*** 1) Patient must be 18 years of age or older, or family of a minor is agreeable after consultation with a Battalion Chief. 2) Adequate CPR has been administered as evidenced by EtCO2 greater than 10 mm / Hg 3) Airway has been successfully managed with verification of device placement. Acceptable management techniques include orotracheal intubation, Blind Insertion Airway Device (BIAD) placement, or cricothyrotomy. 4) IV or IO access has been established 5) No evidence or suspicion of hypothermia 6) Rhythm appropriate medications and defibrillation have been administered according to CCEMS Protocols 7) Persistent asystole or agonal rhythm is present and no reversible causes are identified after 25 minutes of resuscitation efforts. 8) All CCEMS Paramedic Personnel involved in the patient’s care agree that discontinuation of the resuscitation is appropriate. Reference Discontinuation of Prehospital Resuscitation Protocol; UP 5 IF ALL CRITERIA HAS BEEN MET, contact ONLINE MEDICAL CONTROL for discussion on a pronouncement of death. Document the time given in the ePCR.

Special Considerations - Maternal Arrest - Treat mother per appropriate protocol with immediate notification to Medical Control of incoming arrest and rapid transport preferably to obstetrical center if available. Place mother supine and perform Manual Left Uterine Displacement moving uterus to the patient’s left side. IV/IO access preferably above diaphragm. Defibrillation is safe at all energy levels. - Renal Dialysis / Renal Failure - Reference Dialysis / Renal Failure protocol; AM 8 for caveats when faced with dialysis / renal failure patient experiencing cardiac arrest. - Opioid Overdose - Naloxone cannot be recommended in opioid-associated cardiac arrest. If suspected, attention to airway, oxygenation, and ventilation increase in importance. Naloxone is not associated with improved outcomes in cardiac arrest. - Drowning / Suffocation / Asphyxiation / Hanging / Lightning Strike – Hypoxic associated cardiac arrest. Prompt attention to airway and ventilation is priority followed by continuous high-quality chest compressions and early defibrillation.

End Tidal CO2 (EtCO2) - If EtCO2 is < 10 mmHg, improve chest compressions. - If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC)

CONSIDER H’s and T’s • Hypoxia- Secure airway and ventilate • Tension Pneumothorax- Chest Decompression Procedure • Hypoglycemia- Dextrose 10% (D10) 250 mL IV / IO • Tamponade, Cardiac • Hyperkalemia- Sodium Bicarbonate 50 mEq IV / • Toxins: IO AND Calcium Chloride 1 g IV / IO - Calcium Channel Blocker OD- Calcium Chloride 1 g IV / IO Bolus • Hypothermia- Active Rewarming (Contraindicated if on DIGOXIN / LANOXINE)

Adult Cardiac Protocol Section Protocol Cardiac Adult • Hypomagnesemia / Torsades- Magnesium 2 g IV / - Beta-Blocker OD- Treat Bradycardia IO over 2 minutes - Tricyclic Antidepressant OD- Sodium Bicarbonate 1 mEq / kg IV / IO • Hypovolemia- 500 mL Normal Saline Bolus IV / IO - Narcotic OD- Naloxone 2 mg IV / IO / IN / IM • Hydrogen Ion (Acidosis)- Secure airway and • Thrombosis, Pulmonary ventilate • Thrombosis, Coronary Pearls • Team Focused Approach / Pit-Crew Approach recommended; assign responders to predetermined tasks. Refer Cardiac Arrest: Pit Crew CPR; AC 4B • Efforts should be directed at continuous high-quality compressions with limited interruptions and early defibrillation when indicated. • DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compression to ventilation ratio is 30:2. If advanced airway in place, ventilate 10 breaths per minute with continuous, uninterrupted compressions. • Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. • Reassess and document BIAD and/or endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. • IV / IO access and drug delivery is secondary to high-quality chest compressions and early defibrillation. • Defibrillation: Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. • Transcutaneous Pacing: Pacing is NOT effective in cardiac arrest and pacing in cardiac arrest does NOT increase chance of survival • Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. • Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options. Disposition EMS Transport: ALS: All Patients

2020 Version 1 AC 4 Adult Cardiac Protocol Section P P P ACAC 77 Return of Circulation CardiacCardiac Arrest:Arrest: ROSCROSC Protocol;Protocol; Spontaneous AT ANY TIMEANYAT ALS B B R R R Team LeaderTeam ALS PersonnelALS Establish IV / IVEstablish IO / Establish IVIO EMS ALSEMS Personnel Establish Code Commander Code Establish Responsible for for patient care Responsible Continuous CardiacMonitoringContinuous Administer Appropriate Appropriate MedicationsAdminister Appropriate Medications Administer ContinueContinue CardiacCardiac ArrestArrest Protocol;Protocol; ACAC 44 Initiate Defibrillation InitiateManual Procedure Establish Airway with BIAD if not in place notwithif Establish Airway in BIAD placenotwith Establish ifAirway BIAD in Responsible for briefing / for briefing Responsiblecounseling family Initiate Defibrillation InitiateAutomated Procedure seconds) P P P (if only 1 1 provider (if only

≤ 10≤ inches) 120 / min) 120 /

- OR (≥ 2 2 (≥ NO BLS orBLS ALS AC 4B AC Review DNRReview (sooner fatigued)if(sooner Push Hard Push

First ArrivingFirst Responders Third Arriving Third Responder Arriving Push FastPush (110 Monitor EtCO2 Monitor (if EtCO2 available) B B B R R R Ventilate 1 breath every 1 Ventilate breath 6 seconds Second Arriving BLS / ALS BLS Second Responder Arriving Criteria Death for / No Resuscitation Begin Continuous CompressionsBeginCPR Continuous Change Compressors everyChange 2 minutes UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP (Limit changes / pulse pulse checks/(Limit changes Ventilate at 6 to 8 8 minuteto breaths peratVentilate 6 Initiate Compressions Only CPR Only Initiate Compressions present) Defibrillationsoon as Initiate Automated Procedure available as for additional resourcesCall Assume Compressions Manual Defibrillation / Automated Initiate Procedure BIAD Place for Compressions Interruptmore 10 than NOTDO atpoint seconds any 30:2 Compression: Ventilation if no Advanced Airway noif Advanced Compression: 30:2 Ventilation

• • • • • • • • R R R B B YES BLS EMT quality compressions quality - (Hierarchy) compressions Scene Scene Commander First Arriving First Arriving Responder Rotate CompressorwithRotate Team Lead until ALS arrival Team Lead until Cardiac Arrest: Pit Crew CPRCrew Pit CardiacArrest: Manages SceneBystanders Manages / Establish Establish Scene Commander Take direction from Team Leader from Take Team direction Fire Department or Squad Officer orDepartmentFire Squad withholdingwithholding Ensures high ResuscitationResuscitation Protocol;Protocol; UPUP 44 Ensures frequent Ensures compressorchange frequent ContinueContinue CardiacCardiac ArrestArrest Protocol;Protocol; ACAC 44 Take direction from Scene Commander from Take Scene direction CriteriaCriteria forfor DeathDeath Fire DepartmentFire / First Responder Officer To prevent Fatigue and effect high qualityand high To Fatigue prevent effect Fourth / Subsequent Arriving / Fourth Subsequent Responders with asystolewith Decomposition Rigor mortis Dependentlividity Blunt force trauma Injury incompatible lifewith Extended downtime ENSURE SCENE IS SAFE Responsible for briefing family for priorbriefing arrival ResponsibleALS to

Do not begin resuscitation Do not • • • • • • R R R 2020 B B B Version 1 Version Version 1 Adult Cardiac Protocol Section 2020 • • • • • Pearls

work. Success is based on proper planningand execution. Procedures require space and patient access. Make room to airway in place, ventilate10 breaths per minute with continuous, uninterrupted compressions. DO NOTHYPERVENTILATE: If no advanced airway(BIAD, compressionETT) to ventilation ratiois 30:2. advancedIf defibrillation when indicated. Efforts should directedbe high atquality and continuous compressions with limited interruptions andearly TeamFocused Approach / Pit Do notinterrupt compressions to place endotracheal tube. ConsiderBIAD first to limit interruptions. Cardiac Arrest:Cardiac Pit Crew CPR - Crew Approach recommended;assign responders to predeterminedtasks. AC 4B Cardiac Arrest: Ventricular Fibrillation / Pulseless Ventricular Tachycardia

History Signs and Symptoms Differential • SAMPLE • Pulseless • Chest Pain / STEMI • COPD • Estimated downtime • Apneic • Stroke • Trauma • • See Reversible Causes on back PEA / Asystole / V-fib / Pulseless V-Tach • CHF • Sepsis • DNR or Living Will • Torsade's de Pointes

Cardiac Arrest Protocol; AC 4, 4B

Begin Continuous CPR Compressions Push Hard (≥ 2 inches) Push Fast (110 - 120 / min) Change Compressors every 2 minutes R (sooner if fatigued) R (Limit changes / pulse checks ≤ 10 seconds) Reversible Causes If AED available follow prompts from AED See back At the end of each 2 minute cycle Hypovolemia Check ECG Monitor Hypoxia P If shockable rhythm, deliver shock and immediately P Hydrogen ion (acidosis) continue chest compressions Hypothermia

Hypo / Hyperkalemia P Search for Reversible Causes P Adult CardiacProtocol Section Tension pneumothorax Vascular Access Protocol; UP 3 Tamponade; cardiac Toxins Thrombosis; pulmonary (PE) P Epinephrine (1:10,000) 1 mg IV / IO P Thrombosis; coronary (MI) Repeat every 3 to 5 minutes *SEE BACK* Continue CPR Compressions Push Hard (≥ 2 inches) Push Fast (110 - 120 / min) Change Compressors every 2 minutes (sooner if fatigued) R (Limit changes / pulse checks ≤ 10 seconds) R If Rhythm Refractory Continue CPR up to point where you are ready to defibrillate with device charged. Repeat pattern during resuscitation.

Amiodarone 300 mg IV / IO No Transport until ROSC May repeat if refractory (FIRST DOSE) obtained Amiodarone 150 mg IV / IO (SECOND DOSE) EXCEPTIONS: P Refractory P an unsafe scene Magnesium 2 gm IV / IO OR Traumatic Arrest. History of Dialysis CONSIDER (if traumatic arrest EXIT to Traumatic Calcium Chloride 1 g IV / IO Arrest Protocol; TB 9) Refractory after 2 Defibrillations Attempts P CONSIDER changing location of defibrillation pads P

Airway Protocol(s); AR 1 – 4 AT ANY TIME Return of Criteria for Discontinuation? NO ROSC? YES Spontaneous Circulation Cardiac Arrest: ROSC YES NO Protocol; AC 7 Cardiac Arrest: On-Scene Resuscitation, Notify Destination or Contact Termination of CPR; AC 8 M Medical Control M Discontinuation of Prehospital Resuscitation Protocol; UP 5

2020 Version 1 AC 5 Cardiac Arrest: Ventricular Fibrillation Pulseless Ventricular Tachycardia Consider Correctable Causes of Arrest (H’s and T’s):

q Hypoxia- Secure airway and ventilate q Hypoglycemia- Dextrose 10% (D10) 250 ml IV / IO q Hyperkalemia- Sodium Bicarbonate 50 mEq IV / IO AND Calcium Chloride 1g IV / IO q Hypothermia- Active Rewarming q Hypomagnesemia / Torsades- Magnesium 2g IV / IO over 2 minutes q Hypovolemia- 500 ml NS Bolus IV / IO q Hydrogen Ion (acidosis)- secure airway and ventilate q Tension Pneumothorax- Chest Decompression Procedure q Tamponade, Cardiac q Toxins: - Calcium Channel Blocker OD- Calcium Chloride 1g IV / IO Bolus (contraindicated if on DIGOXIN / LANOXINE) - Beta-Blocker OD- Treat Bradycardia - Tricyclic Antidepressant OD- Sodium Bicarbonate 1 mEq / kg IV / IO - Narcotic OD- Naloxone 2 mg IV / IO / IN / IM q Thrombosis, Pulmonary q Thrombosis, Coronary

End Tidal CO2 (EtCO2) - If EtCO2 is < 10 mmHg, improve chest compressions. - If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC)

Pearls • Recommended Exam: Mental Status, neuro, heart, and lung • Team Focused Approach / Pit-Crew Approach recommended; assigning responders to predetermined tasks. • Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. • Consider early IO placement if available and / or difficult IV access anticipated. • DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT) compression to ventilation ratio is 30:2. If advanced Adult Cardiac Protocol Section Protocol Cardiac Adult airway in place, ventilate 10 breaths per minute with continuous, uninterrupted compressions. • Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. • Reassess and document BIAD and / or endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. • IV / IO access and drug delivery is secondary to high-quality chest compressions and early defibrillation. • Defibrillation: Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. • Magnesium Sulfate is not routinely recommended during cardiac arrest, but may help with Torsades de points, Low Magnesium States (Malnourished / alcoholic), and Suspected Digitalis Toxicity • If no IV / IO, with drugs that can be given down ET tube, double dose and then flush with 5 ml of Normal Saline followed by 5 quick ventilations. IV / IO is the preferred route when available. • Return of spontaneous circulation: Heart rate should be > 60 when initiating anti-arrhythmic infusions. • In patients with chronic kidney disease or end-stage renal disease (dialysis patients), consider 1 g Calcium Chloride via IV/IO.

Disposition: EMS Transport:ALS: All patients

2020 Version 1 AC 5 Cardiac Arrest: Asystole / Pulseless Electrical Activity History Signs and Symptoms Differential • SAMPLE • Pulseless • See Reversible Causes below • Estimated downtime • Apneic • See Reversible Causes below • No electrical activity on ECG • DNR, Living Will • No heart tones on auscultation

Cardiac Arrest Protocol; AC 4, 4B

Criteria for Death / No Resuscitation YES Review DNR • Decomposition NO • Rigor mortis • Dependent lividity Begin Continuous CPR Compressions • Push Hard (≥ 2 inches) Blunt force trauma • Push Fast (110 - 120 / min) Injury incompatible Change Compressors every 2 minutes with life R (sooner if fatigued) R • Extended downtime (Limit changes / pulse checks ≤ 10 seconds) with asystole Reversible Causes

Hypovolemia Ventilate 1 breath every 6 seconds CardiacProtocol Section Hypoxia 30:2 Compression : Ventilation ratio if no Advanced Airway Criteria for Death / Hydrogen ion (acidosis) AED Procedure Withholding Resuscitation; UP 4 Hypothermia R if available R Hypo / Hyperkalemia Search for Reversible Causes / Check Blood glucose / Monitor Tension pneumothorax B EtCO2 B Tamponade; cardiac Toxins Cardiac Monitor Thrombosis; pulmonary P P Consider Chest Decompression Procedure (PE) Thrombosis; coronary (MI) *SEE BACK* Vascular Access Protocol; UP 3

Epinephrine (1:10,000) 1 mg IV / IO Repeat every 3 to 5 minutes

P Normal Saline Bolus 500 mL IV / IO P May repeat as needed to maintain SBP > 90 and lung sounds clear MAX Dose 2 L

Airway Protocol(s); AR 1 – 4 No Transport until ROSC AT ANY TIME obtained Return of ROSC? YES Spontaneous Circulation EXCEPTIONS: Cardiac Arrest: ROSC an unsafe scene NO Protocol; AC 7 OR Traumatic Arrest. Criteria for Discontinuation? (if traumatic arrest EXIT to Traumatic Arrest Protocol; TB 9) YES NO

Discontinuation of Prehospital M Notify Destination or Contact M Resuscitation Protocol; UP 5 Medical Control

2020 Version 1 AC 6 Cardiac Arrest: Asystole / Pulseless Electrical Activity Consider Correctable Causes of Arrest:

Special Considerations: -Maternal Arrest -Treat mother per appropriate protocol with immediate notification to Medical Control and rapid transport preferably to obstetrical center if available. Place mother supine and perform Manual Left Uterine Displacement moving uteru s to the patient’s left side. IV/IO access preferably above diaphragm. Defibrillation is safe at all energy levels. -Renal Dialysis / Renal Failure -1 g Calcium Chloride via IV / IO given to all of these patients. Refer to Dialysis / Renal Failure Protocol; AM 8 caveats when faced with dialysis / renal failure patient experiencing cardiac arrest. -Opioid Overdose- Naloxone 2 mg IM / IV / IO / IN. -Drowning / Suffocation / Asphyxiation / Hanging / Lightening Strike –Hypoxic associated cardiac arrest and prompt attention to airway and ventilation is priority followed by high-quality and continuous chest compressions and early defibrillation.

End Tidal CO2 (EtCO2) - If EtCO2 is < 10 mmHg, improve chest compressions.

- If EtCO2 spikes, typically > 40 mmHg, consider Return of Spontaneous Circulation (ROSC) Cardiac Protocol Section Protocol Cardiac Pearls • Team Focused Approach / Pit-Crew Approach recommended; assigning responders to predetermined tasks. • Efforts should be directed at high quality and continuous compressions with limited interruptions and early defibrillation when indicated. • DO NOT HYPERVENTILATE: If no advanced airway (BIAD, ETT), compression to ventilation ratio is 30:2. If advanced airway in place, ventilate 10 breaths per minute with continuous, uninterrupted compressions. • Do not interrupt compressions to place endotracheal tube. Consider BIAD first to limit interruptions. • Reassess and document BIAD and / or endotracheal tube placement and EtCO2 frequently, after every move, and at transfer of care. • IV / IO access and drug delivery is secondary to high-quality chest compressions and early defibrillation. • Defibrillation: Follow manufacture's recommendations concerning defibrillation / cardioversion energy when specified. • Transcutaneous Pacing: Pacing is NOT effective in cardiac arrest and pacing in cardiac arrest does NOT increase chance of survival • Success is based on proper planning and execution. Procedures require space and patient access. Make room to work. • Discussion with Medical Control can be a valuable tool in developing a differential diagnosis and identifying possible treatment options.

Disposition: EMS Transport: ALS: All Patients

2020 Version 1 AC 6 Adult Cardiac Protocol Section P

YES As indicated As mcg / kg / min / min / kg mcg (Septic) CONSIDER MAX Dose Dose MAX Protocol; AC 2 10 10

Hypovolemic Norepinephrine – 10 mcg / kg / min kg / / mcg 10 via IV / IO on PUMP IO on / IV via Chest Pain and STEMI 1 P MMMM If ArrhythmiaIf Persists follow P Rhythm Appropriate Protocol Arrhythmias are common and usually self limiting after ROSC R R P YES P R P B 6,6, 11,11, 1212

–– YES 4 4

on PUMPon –– Persistent Amiodarone Arrhythmia? MedicalMedicalMedicalMedical ControlControlControlControl over 10 minutes over 10 150 mg via IV / IO /150 mg via IV Monitor and Monitor Reassess and ≥ % 94 P Notify Destination or Contact orororor Contact Contact Contact Contact Notify Notify Notify Notify Destination Destination Destination Destination P P NO YES YES MMMM As indicated indicated As As As indicated indicated As As STEMI? AC 7A AC Lead ECG Procedure Lead ECG

– Lead ECG Interpretation Lead ECG Confirm ROSC

Cardiac Monitor – X2X2 IVIV ifif timetime permitspermits Maintain SpO2 Respiratory Rate 10 / minute DO NOT HYPERVENTILATE 1 1 gm AirwayAirway Protocol(s);Protocol(s); ARAR 11

12 / 15 15 12 / VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Repeat Primary Assessment Optimize Ventilation and Oxygenation • • • YES Monitor Vital Signs / Reassess 12 / 15 15 12 / TXA On On PUMP Via Via IVIO / UniversalUniversal PatientPatient Protocol;Protocol;Care Care UP UP 11 over 10 minutes over 10 to Bleeding? P R Hypovolemic due P B PostPost IntubationIntubation BIADBIAD ManagementManagement ProtocolProtocol ARAR 4 4 AppropriateAppropriate ArrhythmiaArrhythmia Protocol(s);Protocol(s); ACAC 44 P R R P P NO Cardiac Arrest: ROSC CardiacArrest: 6 6

–– Infusion

mcg / kg / / min / kg mcg 20 20

YES YES 10 mcg / kg / min kg / / mcg 10 20 mcg / kg / min min kg / / mcg 20 –

mcg / kg / min / min / kg mcg via IV / IO / IV via 5 CONSIDER

10 10

– via IV / IO on PUMP IO on / IV via 1 administered on PUMP on administered Cardiogenic Shock Norepinephrine Remains Hypotensive? Remains Titrate to maintain SBP >90 SBP tomaintain Titrate MAX Dose MAX MAX Dose MAX Dopamine to to to AppropriateAppropriate CardiacCardiac

Reversible Causes P P ArrestArrest Protocol;Protocol; ACAC 4 4 EXIT EXIT 2020 Version 1 Version (PE) Thrombosis; coronary (MI) Tamponade; cardiac Toxins Thrombosis; pulmonary Hypo / Hyperkalemia Tension pneumothorax Hypoxia Hydrogen ion (acidosis) Hypothermia Hypovolemia Version 1

2020 Adult Cardiac Protocol Section STEMI (Complete within 10 minutes of STEMI identification): STEMI of 10 minutes within (Complete STEMI • • • • • • • • • • • • • • • • • • • POST

Disposition: • • • • • • • • • • • • • Pearls

Inform destination hospital of incoming ROSC patient patient ROSC incoming of hospital destination Inform possible if information; all patient Gather transport for ambulance the of back the in present personnel Appropriate rhythm cardiac and ETCO2, SpO2, sounds, breath pulse, confirm ambulance, in Once ismoved: patient When method egress controlled establishes command Scene ETT placing if cannula nasal with oxygenation passive Use post for Evaluate 60 bpm < bradycardias TREAT and for Assess Pressure Blood Obtain possible if transmit and hospital the to STEMI CODE call evident STEMI if EKG; 12 lead Obtain 94 SaO2 lpm to O2 TITRATE Ox to pulse and supply 02 Check personnel paramedic by rhythm monitor cardiac of visualization Continuous a to try obtain not Do waveform) good with be >20 (should ETCO2 ASSESS Appropriate post Appropriate post of condition The monitored. constantly and pressure) blood good AND pulse the on (ie finger be verified absolutely can capture re pacing. missed of danger the consider heart, ischemic the in indicated be otherwise may pacing transcutaneous While HR. and pressure blood to maintain as necessary together pressors multiple utilizing Consider INFUSION TO PRIOR CONTROL MEDICAL CONTACT MUST infusion Epinephrine Consider services. neurology and service, care intensive catheterization, post the managing of capable to facility transport Consider 65 of (MAP) 90 of SBP maintain to administration vasopressor and resuscitation fluid Titrate assistance. ventilatory will require resuscitation post immediately patients Most achieve. to hyperventilation avoid post immediately be elevated may CO2 tidal End Initial of SpO2 maintain to FiO2 Titrate m and all costs. at phase avoided be resuscitation post the in arrest cardiac of recurrence and hypotension of cause significant a is Hyperventilation post during arrest cardiac of cause potential for search to Continue Neuro Extremities, Abdomen, Heart, Lungs, Skin, Neck, Status, Mental Exam: Recommended - ROSC Adult Cardiac Checklist: ROSC Arrest Cardiac Adult ------

EMS Transport: EMS Transport to closest appropriate primary cardiac catheter facility catheter cardiac primary appropriate closest to Transport EKG Transmit Destination Notify fails airway advanced case in BVM for is available Mask rhythm cardiac of assessment Continuous monitoring ETCO2 Continuous all movement after pulse Check

In general titrate pressor as needed and only attempt pacing if indicated in the post the in indicated if pacing attempt only and as needed pressor titrate Ingeneral –

80 - resuscitation airway placement (e.g. ETT) (e.g. placement airway resuscitation - mmHg. resuscitation management may best be planned in consultation with medical control. medical with consultation in planned be best may management resuscitation

to receiving facility receiving to Cardiac Arrest:Cardiac ROSC “ - -

normal resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. monitoring. close require they and continuously, and rapidly fluctuates patients resuscitation Pressor agent (s) indicated for SBP <90 or MAP <60 MAP or <90 for SBP indicated (s) agent Pressor

***REFERENCE information***REFERENCE Medicationfor on FORMULARYadditional infusions.*** “ STEMI ALERT STEMI ” ETCO2 by increasing respiratory rate respiratory increasing by ETCO2

ALS: in the patient with recurrent episodes of cardiac arrest that respond to Epinephrine injections; injections; Epinephrine to respond that arrest cardiac of episodes recurrent with patient the in ≥ 94%. ≥ ” All patients All AC 7B - resuscitation, but will usually normalize. While goal is 35 is 35 goal While normalize. will usually but resuscitation, - - arrest patient including hypothermia therapy, cardiology / cardiac cardiac / cardiology therapy, hypothermia including patient arrest 99% - resuscitation care. resuscitation

with evidence of STEMI on 12 / 15 12 15 / on STEMI of evidence with –

100 100 mmHg or Mean Arterial Pressure Pressure Arterial Mean or mmHg - ROSC patient if mechanical mechanical if patient ROSC

Lead ECG. ECG. Lead – - arrest while while arrest

45 mmHg mmHg ust ust Cardiac Arrest: ROSC

Medication Administration via IV PUMP Guidance:

Dopamine Infusion Setup: 800mg / 500 mL Calculations valid for a 1600 mcg / mL premixed solution of dopamine MUST use IV PUMP TUBING Administer in: mcg / kg / min. Usual dose: 2 – 10 mcg / kg / min MAX Dose: 20 mcg / kg / min Initiate Drip: at 5 mcg / kg / min titrating by 1 – 5 mcg / kg / min every 15 minutes until blood pressure parameters met. May titrate more frequently if SBP < 70 mmHg or > 180 mmHg.

To set up Dopamine infusion on Pump: Select “Guardrail Drugs” Select “Drug Calc” soft key and enter in the following information: Dose Volume

Norepinephrine (Levophed) Infusion Setup: Common concentration 4 mg / 250 cc D5W = 16 mcg / mL Administered in: mcg / min. (May also be administered in mcg / kg / min with dosing from 0.01 - 0.5 mcg / kg / min) Usual dose is 2-12 mcg / min. Adult CardiacProtocol Section MAX Dose: 30 mcg / min with refractory shock Initiate Drip: 1 - 12 mcg / min. Acute Hypotension related to Cardiac Arrest: Initial dose: 8 – 12 mcg / min adjusting to establish SBP 80 – 100 Maintenance drip: 2 – 4 mcg / min (May use mcg / Kg / min 0.1 – 0.5 titrating to effect) Septic shock Initial Dose: of 0.01 – 3 mcg / Kg / min titrating in 0.02 mcg / Kg / min increments to achieve desired effect. Titrate every 5 minutes by 2 - 4 mcg / min. May titrate up or down more frequently for SBP < 70 or SBP > 180. May be weaned down by titrating by 1 - 2 mcg / min every 15 minutes.

To set up Norepinephrine on Pump: Select “Guardrail Drugs” Select appropriate concentration of Norepinephrine Follow prompts on pump

Pearls • Recommended Exam: Mental Status, Neck, Skin, Lungs, Heart, Abdomen, Extremities, Neuro • Blood Pressure goals Post arrest is to maintain SBP > 90 and a Mean Arterial Pressure (MAP) of > 65 • REFERENCE FORMULARY for further information regarding medications

Disposition: EMS Transport: ALS: All patients

2020 Version 1 AC 7C This Page Intentionally Left Blank

2020 Version Adult Cardiac Protocol Section 7

– – to to

Return Return of Exit Exit Protocol; AC 7 Continue Do not begin resuscitation AT TIME ANY Cardiac Cardiac Arrest Cardiac Arrest Cardiac Cardiac Arrest: ROSC Protocol(s) PC 2 Protocol(s) PC Protocol(s); AC 4 AC Protocol(s); Spontaneous Circulation Spontaneous Protocol(s); AC 4 AC Protocol(s); Pediatric Cardiac Pediatric Arrest Cardiac YES YES MMMM YES YES tube - 15

≥ ≥ 20 ≥ 10 ≥ 20 ≤ 18 NO NO YES YES PEA AC 8 AC Age EtCO2 EtCO2 EtCO2 > minutes30 > minutes45 > minutes20 Downtime MedicalMedicalMedicalMedical ControlControlControlControl If continuing CPR FR / EMS BLS ALS + AED / ECG Monitor No shock indicated minutes with no CPR? FR / EMS BLS ALS + CPR FR / EMS BLS ALS + CPR Change BIAD ET to Initial Rhythm Asystole / NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact NO NO NO NO MMMM Termination of CPRTermination of 7

– Exit to Terminate CPR EffortCPRTerminate Terminate CPR EffortCPRTerminate Terminate CPR EffortCPRTerminate Cardiac Cardiac Arrest Protocol(s); AC 4 AC Protocol(s); Cardiac Arrest: On Scene Resuscitation Scene On Arrest: Resuscitation Cardiac 60 60 Minutes

- 30 30 Minutes 20 20 Minutes TIME FROM BLS or ALS ALS CPR FROM or BLS TIME 45 2020 Version 1 Version Version 1 Adult Cardiac Protocol Section 2020 • Pearls

General approach: Cardiac Resuscitation Arrest: On Scene 5. Obtainhistory a whileresuscitation efforts areongoing. Determine the most legitimateperson on sceneas 4. Remember a living willis not a DNR. 3. theDid patient express to your historian any desiresregarding resuscitation and if so what measures? 2. Is there an OUT 1. Determinea terminalif disease involved?is yourinformation source such a asspouse, child, or siblingor Durable Health CarePower Attorney.of - OF - HOSPITAL DNRForm? Termination ofTerminationCPR AC 8 Adult Cardiac Protocol Section s ’ YES s ’ CALL VAD CAREGIVERS COORDINATOR and DISCUSS PLAN WITH problems baseline, other anybaseline, Problem with circulation, withProblem Stroke Cardiac Arrest from Dysrhythmia patient different baseline Infection patients are (VADBleeding anticoagulated) Dehydration Cardiac Tamponade such problembattery Device low as cabledisconnected or B perfusion, SYMPTOMATIC, SYMPTOMATIC, perfusion, NO dysrhythmia notpatient dysrhythmiaat R

PPPP PPPP R B B PPPP Differential • • • • • • • • MMMM NO - VAD - YES Device s HANDs maintain PUMP to ’ related and related non and Pulsatile Flow Pulsatile - familiar with device familiar with 12 /15 Lead Lead Procedure 12 /15 AC 9 AC from LVADsitefrom ICD and MedicalMedicalMedicalMedical ControlControlControlControl Place patientonPlace Cardiac Monitor 12 / 15 15 15 15 15 Lead Lead Lead Lead 12 12 12 12 InterpretationInterpretationInterpretationInterpretation//// If indicated, place defib pads awayindicated,place Ifdefib pads to to Appropriate Cardiac protocol(s) NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact ConsiderConsiderConsiderConsider 500500500500 mlmlmlml fluidfluidfluidfluid NS NS NS NS BolusBolusBolusBolus Vascular Access Protocol; UP 3

Treat SYMPTOMATICSYMPTOMATICSYMPTOMATICSYMPTOMATICdysrhythmiasdysrhythmiasdysrhythmiasdysrhythmias TreatTreatTreatTreat perfusion OR askOR perfusion family who is member Measure pulse and blood pressure. If no Ifpressure. Measure no pulse blood and use the device pulse or pulse bloodor pressure, providers should Exit R MMMM PPPP PPPP R B B PPPP The The of flow through these many devices is pulsatile,thereforenot THE PATIENT MAY HAVE NOTA BASELINE. PULSE thisAT For reason may pulse readings oximetry also be inaccurate Altered be the Mental only Status may indicator problemof a ConsiderVAD both related problems B YES

VAD related conditions per usual protocol. Transport appropriate to usual Transport per protocol. VAD related conditions • • • Signs and Symptoms - B destination; if at all possible to the hospital where VAD was was placedhospitalthe toat ifwhere destination; VAD possibleall Emergencies Involving CALL VAD and COORDINATOR CALL Treat non Treat DISCUSS PLAN WITHDISCUSS CAREGIVERSPLAN NO STEMI? Universal Patient Protocol;Care UP 1 Determine Type of Device and Assess and of Alarms Determine Device Type any Consider: change device batteries, reconnect cables Consider: batteries, change device if no pump no if sound, YES Device Signs or Symptoms of possible device malfunction failure deviceor of Signs Symptoms possible or implanted pumpimplanted YES - Continuous FlowContinuous of hypoperfusion to to

AC 2 Ventricular Assist Devices (VAD or LVAD) Auscultate chest for for whirring Auscultate chest EXIT mechanical sound. pumpAssessmechanical Protocol; Mental Status, Mental pallor, Status, diaphoresis patient for hypoperfusion: Altered patient Altered for hypoperfusion: Consider NO CPR Consider NO no pulse or blood pressure, and signs and blood pulse pressure, orno Chest Pain / STEMI stage Heart stage Failure Heart B - that assists the action of one both or of action the that assists ventricles may onbefor list or not a Patient may cardiac transplantation End surgically Patient has

2020 Version 1 Version

• • • History Version 1

2020 Adult Cardiac Protocol Section Left Ventricular Assist Devices (LVADs) are surgically implanted pumps that essentially essentially that pumps implanted are surgically (LVADs) Devices Assist Ventricular Left Disposition: • • • • • • • • • Pearls

restoring normal blood flow to the body. These devices accomplish this by sucking in blood from the ventricle via a pump and and pump a via ventricle the from blood in sucking this by accomplish devices These body. to the flow blood normal restoring Unconscious with no respiratory effort and ECG shows ventricular fibrillation / ventricular tachycardia: defibrillation is ap defibrillation tachycardia: ventricular / fibrillation ventricular shows ECG and effort respiratory no with Unconscious or memberscaregivers. asfamily any aswellknowledgeable secondary andbatteries, primary backup handpumps, instructions, any including deviceequipment with ALL Transport patients preloadtodependence. vasodilate due CAUTIONusingwhen medicati BOLUS reversehypoperfusion. often a can that patients preload FLUID VAD dependent. Consider are /and12 15Monitor Cardiac The dysrhythmia, infection. and upbleeding, 25%),to (incidence TIA and Strokeinclude in patients VAD Common complications coordin non with a a is unresponsiv patient a VAD coordinator. If VADand responsive the advance Ideally, patient with in die. decisionthe plan patie the and ableperfusion be maintain towill heart thenot has stopped However, pump if the dislodged. device becomes the chest that compressions Consider difficult.compressions is very chest initiateto when Deciding ASK: TO QUESTIONS plan. theof treatment an integralpart s availableareand 24/7 They device. on listed or the /as patient instructions as family EARLYVAD per COORDINATOR CALL THE knowledgeand specific asskills. have they to family/caregivers talk ALWAYS propriate. EMS Transport: EMS - - -

Can CHEST COMPRESSIONSperformed in Can case failure? CHEST be pumpof be patientdefibrillatedcardiovertedCan if or the needed? ADNR?THEDOESPATIENT HAVE atorandcontrol. medical - functioning pump indicatedaresuscitativefunctioningpreviouslyforContactpump efforts,compressions. desire and has begin theVAD Ventricular Assist DevicesVentricular Assist (VAD LVAD) or ALS: -

Lead EKGLead not theand VADare willaffected by provideimportantinformation All patients All EmergenciesInvolving propelling the blood into the aorta. the into blood the propelling AC 9 LVAD “ take over take MAY CAUSE DEATH CAUSE MAY EXANGUINATION BY DEATH ” the job of the failing left ventricle, ventricle, left failing the of job the e andpulselesse nt will likely ntwill controllers, controllers, hould hould be onsthat

if Tachycardia Narrow Complex (≤ 0.11 sec) REGULAR RHYTHM

Universal Patient Care Protocol; UP 1 Single lead ECG able to diagnose and treat arrhythmia B 12 / 15 Lead Procedure B 12 Lead ECG not necessary to P 12 15 Lead Interpretation P diagnose and treat, but preferred when patient is Exit to stable. Appropriate Confirmed NO Protocol(s) Tachycardia, Narrow, REGULAR Complex YES

Unstable / Serious Signs and Symptoms HR Typically > 150 YES NO Hypotension, Acute AMS, Ischemic Chest Pain, Acute CHF, Seizures, Syncope, or Shock secondary to tachycardia

Vascular Access Protocol; UP 3

Vascular Access Protocol; UP 3 Adult CardiacProtocol Section

CAUTION R Attempt Vagal Maneuvers Procedure R Consider Sedation Prior to Cardioversion (Consider Modified Valsalva Maneuver) Midazolam 2.5 mg IV / IO Adenosine 6 mg IV / IO May repeat in 5 minutes x 1 Rapid push with flush MAX Dose 5 mg P P P P May repeat at 12 mg IV / IO x 1 (If SBP > 100) OR Diltiazem (Cardizem) Ketamine 1-2 mg / kg IV / IO (if identified as irregular rhythm) Slow IV Push 1st Diltiazem Bolus 0.25 mg/kg via IV / IO on Pump P Cardioversion Procedure P Over 2 – 5 minutes (MAX Dose 20 mg) Narrow and Regular: 50 – 100J If No Improvement in 10 minutes P May repeat and increase dose with P P 2nd Diltiazem Bolus 0.35 mg/kg via IV / IO on Pump P subsequent cardioversion attempts Over 2 – 5 minutes (MAX Dose 25 mg)

Initiate Infusion at 7ml / hr May titrate up q 15 minutes by 5 mg (MAX Dose 15 mg)

NO RHYTHM CONVERTS YES

P Monitor and Reassess P B 12 / 15 Lead Procedure B

Unstable? NO P 12 15 Lead Interpretation P

YES YES STEMI? NO

EXIT to Exit to Chest Pain / STEMI Appropriate Protocol; AC 2 Protocol(s) Notify Destination or M Contact Medical Control M

2020 Version 1 AC 10A Tachycardia Narrow Complex (≤ 0.11 sec) REGULAR RHYTHM • Symptomatic condition - Arrhythmia is causing symptoms such as palpitations, lightheadedness, or dyspnea, but cardiac arrest is not imminent. - Symptomatic tachycardia usually occurs at rates ≥ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF.

• Serious Signs / Symptoms: - Hypotension. Acutely altered mental status. Signs of shock / poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.) Acute CHF. - Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. - If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g. Diltiazem), Adenosine, or Beta Blockers. Wolfe Parkinson White (WPW) EKG Features: - Wave: delta wave - PR: Short PR Interval - WIDE: Wide QRS Complex - Typical sinus tachycardia is in the range of 100 to (200 - patient’s age) beats per minute.

• Regular Narrow-Complex Tachycardias: - Vagal maneuvers and adenosine are preferred. Vagal maneuvers may convert up to 25 % of SVT. NO CAROTID MASSAGE - Adenosine should be pushed rapidly via proximal IV site followed by 20 mL Normal Saline rapid flush.

• Irregular Tachycardias: - First line agents for rate control are calcium channel blockers or beta blockers. - Agencies using both calcium channel blockers and beta blockers should choose one primarily. Giving the agents sequentially requires Contact of Medical Control. This may lead to profound bradycardia / hypotension. - Adenosine may not be effective in identifiable atrial fibrillation / flutter, yet is not harmful and may help identify rhythm . - Amiodarone may be given in CHF, risk of rhythm conversion in patients with arrhythmia > 48 hours.

• Synchronized Cardioversion: - Recommended to treat UNSTABLE Atrial Fibrillation, Atrial Flutter and Monomorphic-Regular Tachycardia (VT.) - Monitor for hypotension after administration of Calcium Channel Blockers or Beta Blockers.

- Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls • Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro • 12-lead and 15-lead ECG’s shall be acquired, transmitted, and have Paramedic interpretation within 10 minutes of patient contact. • Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE and SYMPTOMATIC. • Rhythm should be interpreted in the context of symptoms. • Unstable condition Condition which acutely impairs vital organ function and cardiac arrest may be imminent. If at any point patient becomes unstable move to unstable arm in algorithm. Disposition: EMS Transport: ALS: All patients

2020 Version 1 AC 10A Adult Cardiac Protocol Section P R PPPP B to to

Exit NO Protocol(s) Appropriate Appropriate

at 7ml hr at /

minutes minutes when patient is when stable. patient is Single lead ECG able lead toable Single ECG 5 5

– – STEMI? 12 Lead ECG tonot 12 Lead ECG necessary diagnose and treat andarrhythmia treat diagnose RHYTHM diagnose and treat, andbut diagnoserequired treat, CAUTION

0.35 mg/kg via IV / IVPump IO on0.35 mg/kg / via 0.25 0.25 IVmg/kg IO Pump / viaon

YES 12 Lead / 15 Procedure Over 2 2 Over 2 Over (MAX Dose 20mg) (MAX Dose 25mg) (MAX Dose 15mg) (MAX Dose NO Diltiazem Diltiazem (Cardizem) 12121212 LeadLeadLeadLead 15 15 15 15 InterpretationInterpretationInterpretationInterpretation Initiate Infusion Initiate VascularVascular AccessAccess Protocol;Protocol; UPUP 33 If No Improvement in 10 minutes in If Improvement No Attempt Vagal ManeuversAttempt Procedure Vagal May titrate up q 15 minutes by 5 upmg 15 minutes q May titrate YES PPPP B to to Diltiazem Diltiazem Bolus Diltiazem Bolus

PPPP B st nd 1 2 EXIT Protocol; AC 2 AC Protocol; P R Chest Pain / STEMI STEMI / Pain Chest IRREGULAR MMMM sec) YES AC 10B AC LeadLeadLeadLead InterpretationInterpretationInterpretationInterpretation Confirmed

–––– HR Typically > 150 TypicallyHR 12 Lead / 15 Procedure RHYTHM CONVERTS? secondary to secondary tachycardia to P P P (≤ 0.11 (≤ 0.11 NO 12121212 / / / / 15 15 15 15 P UniversalUniversal PatientPatient Care Care Protocol;Protocol; UP UP 11 Acute CHF, Seizures, Syncope, or Shock Seizures, CHF, Syncope, Acute Shock or Tachycardia Unstable / Serious SignsSymptoms / Seriousand Unstable Hypotension, ChestIschemicPain, Acute AMS, Tachycardia, Narrow, IRREGULAR Complex PPPP B NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor 200J

ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl – M YES NO NO 2.5 mg IV / 2.5 mg IVIO

OR 2 mg / kg IV / kg 2 IVIO mg / - 1

Unstable? (If SBP >100) (If SBP Slow IV Push Slow IV (MAX Dose 5 5 (MAX mg)Dose Narrow Complex to to Cardioversion Cardioversion Procedure Monitor and Reassess

Midazolam

May repeat May in x 5 1 minutes Ketamine VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Exit Narrow and 120 Irregular: Narrow May repeat and increaserepeat and May with dose subsequent cardioversion attempts subsequent cardioversion Protocol(s) Appropriate Appropriate P Consider SedationConsiderPriorto Cardioversion YES P P P 2020 Version 1 Version Tachycardia Narrow Complex (≤ 0.11 sec) IRREGULAR RHYTHM • Symptomatic condition - Arrhythmia is causing symptoms such as palpitations, lightheadedness, or dyspnea, but cardiac arrest is not imminent. - Symptomatic tachycardia usually occurs at rates ≥ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF.

• Regular Narrow-Complex Tachycardias: - Vagal maneuvers and adenosine are preferred. Vagal maneuvers may convert up to 25 % of SVT. - Adenosine should be pushed rapidly via proximal IV site followed by 20 mL Normal Saline rapid flush. - Agencies using both calcium channel blockers and beta blockers should choose one primarily. Giving the agents sequentially requires Contact of Medical Control. This may lead to profound bradycardia / hypotension.

• Irregular Tachycardias: - First line agents for rate control are calcium channel blockers or beta blockers. - Adenosine may not be effective in identifiable atrial fibrillation / flutter, yet is not harmful and may help identify rhythm. - Amiodarone may be given in CHF, risk of rhythm conversion in patients with arrhythmia > 48 hours.

- Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention. Adult Cardiac Protocol Section Protocol Cardiac Adult

2020 Version 1 AC 10B Adult Cardiac Protocol Section PPPP B P to to

to to

Exit NO Protocol(s) Exit Appropriate Appropriate Protocol Appropriate

lead ECG Procedure 150 150 mg

- LeadLeadLeadLead InterpretationInterpretationInterpretationInterpretation ---- STEMI? RHYTHM NO

CONSIDER NO Lead / 15 - LeadLeadLeadLead / 15/ 15/ 15/ 15 PPPP B Amiodarone ---- 12 REGULAR RHYTHM and REGULAR RHYTHM in 100 mL of D5W IV / IO in of/ 100 mL D5W IV IO

12121212 Monomorphic QRS Complex Monomorphic QRS

VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Infuse over 10 minutes via 10 PUMP minutesInfuse over via YES YES to to

PPPP B May repeat if wide complex tachycardia widerepeat if May recurs complex EXIT Protocol; AC 2 AC Protocol; P REGULAR Chest Pain / STEMI STEMI / Pain Chest lead ECG Procedure YES YES YES - LeadLeadLeadLead InterpretationInterpretationInterpretationInterpretation ---- sec) sec) Confirmed AC 11A AC P RHYTHM CONVERTS? RHYTHM MMMM HR Typically > 150 TypicallyHR Lead / 15 NO - LeadLeadLeadLead / / / / 15151515 P P P ---- Shock secondary to secondary tachycardiato Shock 12 12121212 UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP

(≥0.12 Pain, orAcute Seizures, CHF, Syncope, Tachycardia Unstable / Serious Signs Symptoms/ Serious Unstableand Hypotension, Acute AMS, Ischemic Chest Ischemic Hypotension, AMS, Acute Tachycardia, Wide, REGULAR Complex P PPPP B NO YES Monitor Monitor and Reassess NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl 2.5 mg IV / 2.5 mg IV IO OR 2 mg / kg IV / kg 2 IVIO mg / - 1 MMMM P (If SBP > (If 100) Unstable? (Synchronized)

MAX Dose 5 mg DoseMAX 5 Wide and Wide 100J Regular: Midazolam Monitor and Reassess Cardioversion Procedure May repeat in 5 minutes x 1 in repeat 5 May minutes Ketamine Wide Complex Wide VascularVascular AccessAccess Protocol;Protocol; UPUP 33 YES May repeat and increaserepeat and May dose with subsequent cardioversion attempts subsequent cardioversion

Consider SedationtoPrior ConsiderCardioversion P arrhythmia 12 Lead ECG not12 Lead ECG P P P diagnose and diagnose treat necessary to necessary diagnoseto when patient is stable. when patient is Single lead Singleable to ECG and treat, but preferredtreat, and but 2020 Version 1 Version Tachycardia Wide Complex (≥0.12 sec) REGULAR RHYTHM • Regular Wide-Complex Tachycardias: Unstable condition: Immediate defibrillation if pulseless and begin CPR; IF pulse present Synchronize cardiovert starting at 100 J Stable condition: - Typically VT or SVT with aberrancy (Patients with RBBB or LBBB). Adenosine may be given if regular and monomorphic. - Giving multiple anti-arrhythmic requires contact of medical control. • Irregular Tachycardias: - Wide-complex, irregular tachycardia: Do not administer calcium channel, beta blockers, or adenosine as this may cause paradoxical increase in ventricular rate. This will usually require cardioversion. Contact medical control. - In patients with concern about WPW, contact Medical Control prior to intervention unless patient requires defibrillation, in which case defibrillation is appropriate treatment • Polymorphic / Irregular Tachycardia: - This situation is usually unstable and immediate defibrillation is warranted. - When associated with prolonged QT this is likely Torsades de pointes: Give 2 gm of Magnesium Sulfate slow IV / IO. Without prolonged QT likely related to ischemia and Magnesium may not be helpful. • Symptomatic condition - Arrhythmia is causing symptoms such as palpitations, lightheadedness, or dyspnea, but cardiac arrest is not imminent. - Symptomatic tachycardia usually occurs at rates ≥ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF. • Serious Signs / Symptoms: - Hypotension. Acutely altered mental status. Signs of shock / poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.) Acute congestive heart failure.

Wolfe Parkinson White (WPW) EKG Characteristics: - Wave: delta wave - PR: Short PR Interval

- WIDE: Wide QRS Complex Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls • Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro • 12-lead and 15-lead ECG’s shall be acquired, transmitted and have Paramedic interpretation within 10 minutes of patient contact. • Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE and SYMPTOMATIC. • Rhythm should be interpreted in the context of symptoms • Unstable condition - Condition which acutely impairs vital organ function and cardiac arrest may be imminent. - If at any point patient becomes unstable move to unstable arm in algorithm. • Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. • If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g. Diltiazem), Adenosine, or Beta Blockers • Typical sinus tachycardia is in the range of 100 to (220 – patients age) beats per minute. • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.

Disposition: EMS Transport: ALS: All patients

2020 Version 1 AC 11A Tachycardia Wide Complex (≥0.12 sec) IRREGULAR RHYTHM

Universal Patient Care Protocol; UP 1

Single lead ECG able to B 12-Lead / 15-lead ECG Procedure B diagnose and treat arrhythmia

P 12-Lead / 15-Lead Interpretation P 12 Lead ECG not necessary to Exit to diagnose and treat, but preferred Appropriate when patient is stable. NO Confirmed Protocol(s) Tachycardia, Wide, Irregular Complex

YES

Unstable / Serious Signs and Symptoms HR Typically > 150 Hypotension, Acute AMS, Ischemic Chest Pain, Acute CHF, Seizures, Syncope, or Shock secondary to tachycardia

Vascular Access Protocol; UP 3 Adult CardiacProtocol Section YES NO

P Cardioversion Procedure P IRREGULAR RHYTHM IRREGULAR RHYTHM and Consider Sedation Prior to and MONOMORPHIC QRS Cardioversion POLYMORPHIC QRS Complex Midazolam 2.5 mg IV / IO Complex May repeat in 5 minutes x 1 P (MAX Dose 5 mg) P (If SBP > 100) Airway Protocol(s); OR AR 1 – 4 Ketamine 1-2 mg / kg IV / IO As indicated Slow IV push Amiodarone 150 mg in 100 mL of D5W Wide and Irregular: P P Pulseless VF / VT via IV / IO Protocol; AC 6 200 – 360J (Defibrillate) Infused over 10 minutes on PUMP P May repeat and increase dose with P As indicated subsequent cardioversion Cardiac Arrest attempts Protocol; AC 4 As Indicated

Consider consultation with medical P control if patient is stable P

NO RHYTHM CONVERTS YES

B 12-Lead / 15-lead ECG Procedure B P 12-Lead / 15-Lead Interpretation P YES Unstable? NO YES STEMI? NO

P Monitor and Reassess P EXIT to Exit to Chest Pain / STEMI Appropriate Notify Destination or M Protocol; AC 2 Protocol(s) Contact Medical Control M

2020 Version 1 AC 11B Tachycardia Wide Complex (≥0.12 sec) IRREGULAR RHYTHM • Regular Wide-Complex Tachycardias: Unstable condition: - Immediate defibrillation if pulseless and begin CPR. Stable condition: - Typically VT or SVT with aberrancy (Patients with RBBB or LBBB). Adenosine may be given if regular and monomorphic. - Giving multiple anti-arrhythmic requires contact of medical control. • Irregular Tachycardias: - Wide-complex, irregular tachycardia: Do not administer calcium channel, beta blockers, or adenosine as this may cause paradoxical increase in ventricular rate. This will usually require cardioversion. Contact medical control. - In patients with concern about WPW, contact Medical Control prior to intervention unless patient requires defibrillation, in which case defibrillation is appropriate treatment • Polymorphic / Irregular Tachycardia: - This situation is usually unstable and immediate defibrillation is warranted. - When associated with prolonged QT this is likely Torsades de pointes: Give 2 gm of Magnesium Sulfate slow IV / IO. Without prolonged QT likely related to ischemia and Magnesium may not be helpful. • Symptomatic condition - Arrhythmia is causing symptoms such as palpitations, lightheadedness, or dyspnea, but cardiac arrest is not imminent. - Symptomatic tachycardia usually occurs at rates ≥ 150 beats per minute. Patients symptomatic with heart rates < 150 likely have impaired cardiac function such as CHF. • Serious Signs / Symptoms: - Hypotension. Acutely altered mental status. Signs of shock / poor perfusion. Chest pain with evidence of ischemia (STEMI, T wave inversions or depressions.) Acute congestive heart failure.

Wolfe Parkinson White (WPW) EKG Characteristics: - Wave: delta wave - PR: Short PR Interval

- WIDE: Wide QRS Complex Adult Cardiac Protocol Section Protocol Cardiac Adult

Pearls • Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro • 12-lead and 15-lead ECG’s shall be acquired, transmitted and have Paramedic interpretation within 10 minutes of patient contact. • Most important goal is to differentiate the type of tachycardia and if STABLE or UNSTABLE and SYMPTOMATIC. • Rhythm should be interpreted in the context of symptoms • Unstable condition - Condition which acutely impairs vital organ function and cardiac arrest may be imminent. - If at any point patient becomes unstable move to unstable arm in algorithm. • Search for underlying cause of tachycardia such as fever, sepsis, dyspnea, etc. • If patient has history or 12 Lead ECG reveals Wolfe Parkinson White (WPW), DO NOT administer a Calcium Channel Blocker (e.g., Diltiazem), Adenosine, or Beta Blockers. • Typical sinus tachycardia is in the range of 100 to (220 – patients age) beats per minute. • Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.

Disposition: EMS Transport: ALS: All patients

2020 Version 1 AC 11B Adult Medical Protocol Section P mmHg 500 mL Bolus ≥ 90 If If If Indicated Indicated MAX Dose L 2 Repeat as needed Protocol;Protocol; AMAM 12 12 HypotensionHypotension / Shock/ Shock Titrate SPB Normal Saline Gyn disease (ovarian cyst, PID, Pregnancy) PID, cyst, disease (ovarian Gyn - NO P CNS (increased stroke,CNSheadache, pressure, lesions, hemorrhage, CNSor trauma vestibular) infarction Myocardial antibiotics, narcotics, (NSAID's,Drugs chemotherapy) orGI disorders Renal Diabetic ketoacidosis OB influenza) (pneumonia, Infections abnormalitiesElectrolyte toxinor Food induced Substance orabuse Medication Psychological

Differential • • • • • • • • • • • YES MMMM YES R AM 1 AM NO NO NO NO > 250? Lead Abnormal?

Pregnant? Protocol; UPUP Protocol; Protocol; 3 3 - Vascular Access Access Access Vascular Vascular MedicalMedicalMedicalMedical ControlControlControlControl Hypotension, poor perfusion, shockperfusion, Nausea / Vomiting? /Nausea Hypotension, poor Blood Glucose < 60 or < 60 or Blood Glucose Monitor and and Monitor Reassess perfusion, shock perfusion,remain? and Diarrhea Serious Signs / SymptomsSigns /Serious 12 / 15 12 / Serious Signs / SymptomsSigns /Serious NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Pain Pain (OPQRST) Distention Constipation Diarrhea Anorexia Radiation UniversalUniversal PatientPatient Care Care Protocol;Protocol; UP1 UP1 R

P • • • • • • Associated symptoms: blurred vision, Fever, headache, cough,myalgias, malaise, weakness, status mentaldysuria, headache, changes, rash Signs and Symptoms MMMM YES NO YES YES YES YES P Abdominal Pain,Abdominal Vomiting, 4 mg IV TKO 55

Improved? –– May Repeat x1 AM AM AM 77 IV / IO / ODT / IM (MAX Dose 8 mg) Ondansetron OB 1 1 OB OB to Appropriate Appropriate to to

Saline Lock

OB Protocols; Protocols; OB OB Diabetic Protocol; Diabetic Diabetic Protocol; Protocol; OR Cardiac Protocol(s) Protocol(s) Cardiac Cardiac

EXITEXIT P Normal Saline P NO Medications (pregnancy) Menstrual history Travel history emesisdiarrhea Bloody/ Other sick Other contacts historymedicalPast historysurgicalPast Last bowel Lastmovement/emesis food orwith Improvementworsening activity or problem Duration of Age Time of last meal

2020 Version 1 Version

• • • • • • • • • • • • History Abdominal Pain, Vomiting, and Diarrhea

Adult Medical Protocol Section Protocol Medical Adult Pearls • Recommended Exam: Mental Status, Skin, HEENT, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Abdominal / back pain in women of childbearing age should be treated as pregnancy related until proven otherwise. • The diagnosis of abdominal aneurysm should be considered with abdominal pain, with or without back and/or lower extremity pain or diminished pulses, especially in patients over 50 and/or patients with shock / poor perfusion. Notify receiving facility early with suspected abdominal aneurysm. • Consider cardiac etiology in patients > 50, diabetics and/or women especially with upper abdominal complaints. • Repeat vital signs after each fluid bolus. • Heart Rate: One of the first clinical signs of dehydration, almost always increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal. • Isolated vomiting may be caused by pyloric stenosis, bowel obstruction, and CNS processes (bleeding, tumors, or increased CSF pressures). • Vomiting and diarrhea are common symptoms, but can be the symptoms of uncommon and serious pathology such as stroke, carbon monoxide poisoning, acute MI, new onset diabetes, diabetic ketoacidosis (DKA), and organophosphate poisoning. Maintain a high index of suspicion. Disposition: EMS Transport: ALS: All patients with potential for cardiac, CNS, renal, traumatic, or diabetic ketoacidosis etiologies. All patients who receive any ALS intervention or medication BLS: No abnormal vitals signs and does not fit criteria above.

2020 Version 1 AM 1 Adult Medical Protocol Section 44 -- P P P M M

0.3 0.3 mg IM If If If indicated indicated If If indicated indicated 500 mL IV / IV IO 500 mL/

ProtocolProtocol AMAM 1212 SEVERE See back See NO HypotensionHypotension / / ShockShock > 90 Bolus 2.5 2.5 mg nebulized AirwayAirway Protocol(s)Protocol(s) 11 AR AR CONSIDER R wheezing Isolated Hypotension

P MAX 2 Liters MAX improvement B OR Epinephrine Drip orders Drip Epinephrine Medical Control contact for contact Control Medical 2 + Body+ hypotension 2 Systems+ Urticaria (rash only) Urticaria (rash effect) Anaphylaxis (systemic (vascular Shockeffect) (drug induced) Angioedema obstruction Airway Aspiration / Vasovagal event COPDorAsthma CHF Epinephrine IM dose needed dose IM Epinephrine Pen, Pen, Albuterol Albuterol - Repeat x 1 in 5 minutes if no x 1 if in Repeat5 minutes Epinephrine 1:1000Epinephrine

Contact Medical Control if additional additional if Control Medical Contact Repeat as needed as x Repeat3 continued if Epi Normal Saline Normal

Differential • • • • • • • • Repeat as neededas SBP Repeatto maintain a 1:1000 IM 1:1000 P P P M M prescribed 0.3 mg 0.3 IM mg improvement administration ABCs adequate? NO Epinephrine Repeat in 5 minutes no in if 5 Repeatminutes may assist self may patient with If patientIf MMMM P P P P B P R YES AM 2 AM See back See MODERATE 2 + Body 2 + Systems X X 1 YES If If wheezing Improved? 50 mg IV / IO // 50 mg IVIM IO

125 mg IV /125 mg IV IO MedicalMedicalMedicalMedical Control Control Control Control - Diphenhydramine Methylprednisolone Methylprednisolone if not already taken PO taken already not if Albuterol Albuterol / Atrovent Monitor and Reassess UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP 25 Itching or hivesItching or distress/ respiratory Coughing or wheezing throatorChest constriction Difficulty swallowing shock Hypotension or Edema N/V 2.5 mg / 0.5 mg Nebulized2.5 mg / Vascular Access Protocol; UPUP Protocol;Protocol;33 Access Access Vascular Vascular Notify Destination or Contact orororor Notify Notify Notify Notify Contact Contact Contact Contact DestinationDestinationDestinationDestination

• • • • • • • Signs and Symptoms P P P P MMMM Assess Symptom Severity / SymptomSuspected Exposure / AssessSeverity Allergen to YES P 50 50 mg

NO - Allergic Reaction / Anaphylaxis / AllergicReaction MILD See back See Consider Skin Skin Only 25 IV / IVIO IM / / Symptoms Worsening? Diphenhydramine Past medicalhistoryPast historyMedication Food /allergy Food exposure / allergyexposure Medication soap, clothing, detergent New history Pastof reactions Onset and Onset location and bite Insect or sting

2020 P Version 1

• • • • • • • • History Version 1 Version Adult Medical Protocol Section 2020 Disposition: • • • • • • • • • • • Pearls

EMR / EMT may assist patient with Epinephrine IM administration viaAuto IM with Epinephrine administration patient assistmayEMT / EMR 15 / 12 paSome Angioedema Hereditary takingmedicationspressure called ACE patients blood Angioedema skin rash/ involvement. and no have symptoms and withonly respiratory gastrointestinal occurmay reactions Allergic Classification:Severity Symptom reaction.thesevere morethe exposure shorter Thefrom to symptoms onset the dosing. forappropriate Control Contact Medical infusion. orpush epinephrin IV by administration epinephrine IMIV ofrequire may epinephrine repeat doses unresponsive to Anaphylaxis administration: Epinephrine allergicreaction. acutelethal multisystem and potentially is Anaphylaxis an Lungs, Abdominal Mental Heart, Exam: RecommendedSkin, Status, Allergic ReactionAllergic / Anaphylaxis EMS Transport: EMS Severe symptoms (PLUS 2 body systems and Hemodynamically unstable): and systems Hemodynamically unstable): (PLUS body Severe 2 symptoms symptoms systems): (PLUS body Moderate 2 symptoms (Skin Mild Only): - - - -

Epinephrine. Diphenhydramine and steroids should NOT delay repeated Epinephrine administration.Epinephrine delay should and NOT repeated steroids Epinephrine.Diphenhydramine IM beinIM administered before priority duringattempts IVor Epinephrine atshould IO access. or choice ofthe Drug anaphylaxisdrug should / FIRSTand be Symptoms.) in administeredthat acute (Moderate Severe In In and Diphenhydramineanaphylaxis Moderate Severe maydecrease mental status. andhave SevereDiphenhydramine /steroids andprovenutility in anaphylaxis Moderate no only may be given – tients are prescribed specificmedications tients toaid prescribed of reversal are in swelling.

lead ECG and leadECG cardiac monitoring Calculations valid for 1 mg (either 1: 1000 or 1: 10000 may be used) Epinephrine mixed into 1000 mL of of mL 1000 into mixed Epinephrine used) be may 1: 10000 or 1: 1000 mg (either 1 for valid Calculations is seen in moderate to severe reactions and is swelling involving the face, lips or airway structures. This can also be also seen This be structures.airwaycan involvingface,lips theor is and swelling moderate in reactions severe to isseen vomiting, abdominalwith isolated vomiting, hypotension/poorpain) hypotension. perfusion or Flushing, itching, hives, dyspnea,erythema (wheezing,PLUS or respiratory gastrointestinalhypoxia) (nausea, symptoms abdominal(nausea, vomiting, with blood pain) normal pressure and perfusion. itching, orFlushing,dyspnea, hives,gastrointestinal (wheezing, hypoxia) PLUS erythema respiratory symptoms Flushing, itching, hives, normal erythema with pressurebloodand perfusion.

involves swelling of airway involves structures, andtoabdominalseveremay extremities,moderate the face, swelling lips, cause pain. ALS: Initiate at 2 2 at Initiate All patients who exhibit abnormal vital signs, facial swelling, and/or receive Epinephrine receive and/or swelling, facial signs, vital abnormal exhibit who patients All – Epinephrine Infusion Rate Rate Infusion Epinephrine

Administer with pump tubing and infuse via IV PUMP IV via infuse and tubing pump with Administer 10 should administrationdelayshould epinephrine. ofNOT mcg / kg / min titrate q 5 minutes until systolic BP improves > 90 improves BP systolic until minutes 5 q titrate min / kg/ mcg (mcg / min) / (mcg 10 9 8 7 6 5 4 3 2 1 - Inhibitors, Inhibitors, Zestril examples include Prinivil / (lisinopril) Concentration = 1 mcg / mL/ mcg =1 Concentration AM 2 Normal Saline. Saline. Normal - 135 gtt / min/ gtt 135 min/ gtt 120 min/ gtt 105 150 gtt / min/ gtt 150 Injector 90 gtt / min / gtt 90 / min gtt 75 min / gtt 60 / min gtt 45 min / gtt 30 min / gtt 15

gtt / min gtt (mL / hr) (mL - typically end typicallyend in after

- il. e

in Adult Medical Protocol Section 44

–– 11

- MMMM 12

to to to to to to to to -

Exit Exit Exit Exit Exit Exit Exit Head trauma Head seizure,tumor,(stroke, CNSinfection) Cardiac (MI, CHF) Hypothermia other) and(CNS Infection / Thyroid (hyperhypo) (septic, Shocktraumatic) metabolic, hypoglycemia) /Diabetes (hyper orToxicological Ingestion /Acidosis Alkalosis exposure Environmental Pulmonary (Hypoxia) abnormality Electrolyte disorder Psychiatric AC 1 AC

Differential • • • • • • • • • • • • • • Sepsis AM Protocol; 15 Head Injury Protocol; TB 6 TB 6 Protocol; Injury Head Stroke AM16 Protocol;Stroke Airway Protocol(s); ARARProtocol(s);Protocol(s); 1 1 AirwayAirway Protocol; TETE Protocol; 6 2, to Diabetic AM to 7 Protocol(s); Seizure Protocol; AM AM 14 Protocol;Seizure

Overdose Toxic Exposure/ Hypothermia Protocol; TE 5 5 TEHypothermia Protocol; Hyperthermia 4 Protocol; TE Trauma: Multisystem Protocol; TB 8 TB Protocol; Multisystem Trauma: Appropriate Cardiac Protocol(s); Exit Hypotension / Shock Protocol; AM 12 AM Protocol; /Shock Hypotension AM 3 AM YES YES YES YES YES YES YES NO Notify Destination or Contact Medical ControlControlControlControl orororor Medical Medical Medical MedicalNotify Notify Notify Notify Contact Contact Contact Contact DestinationDestinationDestinationDestination Decreased mental status or status mental Decreased lethargy status mental baseline in Change behavior Bizarre diaphoretic (cool, Hypoglycemia skin) skin; dry (warm, Hyperglycemia Kussmaul breath; fruity of signs respirations; dehydration) Irritability MMMM

• • • • • • Signs and Symptoms and Signs P R ≥250 AlteredMental Status or NO ≤60 ≤60 Lead Lead ECG - NO NO NO NO NO NO YES YES if indicatedif indicatedif Lead ECG Procedure Lead ECG

Fever / Sepsis Fever / Interpretation - Airway Patent?Airway Traumatic Traumatic Injury 12 / 15 12 / Signs of CVA CVA Or SeizureSigns of Signs of OD /OD Signs Toxicology of Arrhythmia / STEMI / CP / / Arrhythmia STEMI Consider Cardiac Etiology Blood Blood Glucose 12 / 15 12 / Signs of Hypo Hyperthermia Signs of / VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Signs of shock / Poor Poor shock perfusion /Signs of Universal Patient Care Protocol; UPUPPatient Patient Protocol; Protocol; Care Care UniversalUniversal11

P R

habits Change in condition in Change sleep or feeding in Changes Past medical history medical Past Medications trauma of History Drugs, drug paraphernalia paraphernalia drug Drugs, or use drug of illicit Report ingestion toxic Known diabetic, medic alert alert medic diabetic, Known tag

2020

Version 1

• • • • • • •

• History Version 1

2020 Adult Medical Protocol Section Disposition: • • • • • • • • • Pearls

Consider Restraints if necessary for patient's and/or personnel's protection per the Behavioral Protocol; AM 5 and Restraint Restraint 5 procedure AM and Protocol; Behavioral the per protection personnel's and/or for patient's necessary if Restraints Consider injurie unrecognized have may and hypoglycemia develop frequently Alcoholics picture. clinical the confuse Glucagon alcohol or let not Do Dextrose after glucose blood Recheck exists. doubt if hyperglycemia than hypoglycemia assume to safer is It Trauma: / Restriction Motion Spinal health: Behavioral misuse: Substance General: Haz or toxin environmental an of sign a as present may AMS Neuro. Extremities, Back, Abdomen, Lungs, Heart, Skin, HEENT, Status, Mental Exam: Recommended EMS Transport: EMS immobilized. when agitation increased with worsen may AMS with patient The warrants. situation the if immobilization spinal utilize Only disease. underlying patients a of a deterioration precipitates condition trauma or medial underlying an Often etiology. psychiatric underlying an of solely result the is AMS assume NOT DO differential. a forming in challenge a great present may patient health behavioral The cause. the be may conditions trauma and medical underlying serious More a of Misuse AMS. for reasons sole the are alcohol or / and use drug recreational assume NOT DO challenge. a great pose can substances ingesting Patients facility. receiving the to be communicated must scene the at found Information injury. other or ofbruising signs for exam head the to attention careful Pay otherwise. proven until AMS of their cause lifethreatening a has patient the Assume undertaken. be should circumstances the and scene the patient, the of assessment careful A challenges. significant most the of one poses AMS with patient The s. s.

lcohol may lead to hypoglycemia. to lead may lcohol Altered Mental Status Mental Altered ALS: All patients All AM 3 - Mat exposure exposure Mat -

protect personal safety. personal protect Adult Medical Protocol Section P 1111

-- P If If If indicated indicated ≥ 90 Appropriate Appropriate Appropriate Cardiac Cardiac Protocol(s); AC 1 1 AC AC Protocol(s); Protocol(s); Cardiac Monitor UP 33 UP UP IfIf indicatedindicated P MAX Dose L 2 Normal Saline Protocol(s)Protocol(s) AMAM 1212 Vascular Access Protocol; Protocol; Protocol; Access Access Vascular Vascular HypotensionHypotension / Shock/ Shock Titrate to SBP Bolus 500 mL IV / IO YES P Muscle spasm / Muscle strain spasm / discnerve withcompression Herniated Sciatica Spine fracture Kidney stone Pyelonephritis AneurysmAortic Pneumonia Epidural AbscessSpinal CancerMetastatic STEMI /Cardiac

Differential • • • • • • • • • • • YES P R R MMMM Lead - UPUP 11 NO NO YES AM 4 AM if indicated if indicated if Instability Lead ECG Procedure Lead ECG Abnormal? Mechanism

12 / 15 - Lead ECG Interpretation Lead ECG - Injury or Traumatic NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Monitor and Reassess Shock / Hemodynamic Consider Cardiac Etiology ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Universal Patient Care Protocol; Patient Patient Protocol; Protocol; Care Care UniversalUniversal 12 / 15 12 / 12 15 12 / Back Pain R P R MMMM Pain (paraspinous, spinous Pain (paraspinous, process) Swelling motion range Pain of with Extremity weakness Extremity numbness Shooting pain an into extremity bladder Bowel / dysfunction YES

NO R • • • • • • • Signs and Symptoms PainPain ControlControl Protocol;Protocol; AMAM 13 13 YES YES If If If indicated indicated Protocol; UP 22 UP UP Protocol; Protocol; Protocol; 88 TBTBProtocol; Protocol; If If indicated Procedure Trauma: MultisystemMultisystemTrauma:Trauma: Spinal Motion Restriction Restriction Restriction Motion Motion Spinal Spinal Spinal Motion Restriction R NO Improvement or worsening orwithImprovement worsening activity Traumatic mechanism Traumatic of painLocation Fever Past surgicalhistoryPast Medications pain / Onset injury of Previousinjury back Age medicalhistoryPast

2020 Version 1 Version

• • • • • • • • • • History Back Pain

Pearls • Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Neuro, Lower extremity perfusion • Consider pregnancy or ectopic pregnancy with abdominal or back pain in women of childbearing age. • Consider abdominal aortic aneurysm with abdominal pain especially in patients over 50 and/or patients with shock / poor perfusion. Patients may have abdominal pain and/or lower extremity pain with diminished pulses, . Notify receiving facility early with suspected abdominal aneurysm. • Consider cardiac etiology in patients > 50, diabetics and / or women especially with upper abdominal complaints. • Red Flags which may signal more serious process associated with back pain: - Age > 50 or < 18 - Neurological deficit (leg weakness, urinary retention, or bowel incontinence) - IV Drug use - Fever - History of cancer, either current or remote - Night time pain in pediatric patients • Back pain is one of the most common complaints in medicine and effects more than 90 % of adults at some point in their life. Back pain is also common in the pediatric population. Most often it is a benign process but in some circumstances can be life or limb threatening. • Cauda equina syndrome is where the terminal nerves of spinal cord are being compressed (Symptoms include):

Adult Medical Protocol Section Protocol Medical Adult - Saddle anesthesia – loss of sensation in the area of the buttocks, perineum, and inner surfaces of the thigh - Recent onset of bladder and bowel dysfunction. (Urine retention and bowel incontinence) - Severe or progressive neurological deficit in the lower extremity. - Motor weakness of thigh muscles or foot drop • Back pain associated with infection: - Fever / chills. - IV Drug user (consider spinal epidural abscess) - Recent bacterial infection like pneumonia. - Immune suppression such as HIV or patients on chronic steroids like prednisone. - Meningitis. • Spinal motion restriction in patients with underlying spinal deformity should be maintained in their functional position. • Kidney stones typically present with an acute onset of flank pain which radiates around to the groin area.

Disposition: EMS Transport: ALS: Patient with abnormal vital signs, age > 50, any sensory or motor deficit associated with traumatic mechanism. BLS: 12 / 15 – Lead negative. Normal sensory or motor exam associated with traumatic mechanism.

2020 Version 1 AM 4 Behavioral

History Signs and Symptoms Differential • Situational crisis • Anxiety, agitation, confusion • Altered Mental Status differential • Psychiatric illness/medications • Affect change, hallucinations • Alcohol Intoxication • Injury to self or threats to others • Delusional thoughts, bizarre behavior • Toxin / Substance abuse • Medic alert tag • Combative violent • Medication effect / overdose • Substance abuse / overdose • Expression of suicidal / homicidal thoughts • Withdrawal syndromes • Diabetes • Depression • Bipolar (manic-depressive) • Schizophrenia • Anxiety disorders

Scene Safe? NO Call for help / additional resources Stage until scene safe YES Ketamine Universal Patient Care Protocol; UP1 should not be used for patient resisting arrest in the absence of EXCITED DELIRIUM

Is Patient Combative? NO

YES Adult MedicalProtocol Section

NON Aggressive? Violent? R R R BEHAVIORAL R Agitation? BEHAVIORAL NO Threat to Self / others? Setting of Psychosis? Consider Other Causes: Excited Delirium Syndrome • Overdose / Toxic Ingestion Paranoia, disorientation, hyper – • Trauma aggression, hallucination, NO YES • Pain tachycardia, increased strength, Verbal • Hypoxia hyperthermia • Hypoglycemia De-escalation YES • Stroke YES Successful? EXIT to Appropriate Protocol Chemical Restraint NO P Ketamine P 2-4 mg / kg via IM Assess Need for Physical Restraint or Chemical Contact Medical Restraint Successful? P P Control Consider addition personnel NO Patient not combative and M for Additional M (BC, Fire, Police) condition improved? Ketamine order YES Physical Vascular Access Chemical Restraint Protocol; UP 3 R 2-Point Restraint R P Restraint P AND / OR Normal Saline 1 L Bolus 4-Point Restraint Then 150 – 200 mL / hr P May repeat 500 mL Bolus P NO as needed Successful? Max Dose 2 L External Cooling R R Measures YES Monitor and Reassess V / S q 5 minutes (Combative and / or Restrained) V / S q 15 minutes (If Verbal De-Escalation is Successful)

M Notify Destination or Contact Medical Control M

2020 Version 1 AM 5 Version 1 Adult Medical Protocol Section 2020 ChemicalRestraint: Restraints: Use model: SAFER General: safety:Scene Disposition: • • • Pearls • • • • • • • •

Extrapyramidal reactions:Extrapyramidal patientisIf DeliriumsuspectedofExcited suffers Syndrome consider cardiac a andbolus arrest, bicarbonate sodium fluid ea Delirium Excited Syndrome: positionanyis could patient Do suchrestrainedor thatcirculatorya respiratory transport impact not way the patients s or overlook Do domesticof not the possibility violence, associated child,or geriatric abuse. irritateDo theprolongedwith exam.not patient a Be tosureconsider medical/trauma all possible causes overdose,(hypoglycemia, behaviorfor headhypoxia,i abuse,substance upon arrival. their restraintpatients either Allchemical receive personnel be or physical ALSwho scene mustor bycontinuously observed on imm ambulance. Anywho Law handcuffed restrainedpatientmustbyaccompanied transportedlaw EMS byby is or Enforcement and enforcement be priority. mainsafetyCrew is responders / the Mental Exam:Recommended Lungs, Heart, Neuro Status, Skin, ------

restraint: This can cause life threatening condition. Contact Medical Control if necessary for Chemical restraint advice. Chemicalforrestraint if Control Contact necessary ThisMedical cause condition. restraint: canthreatening life Outline patient. communicate one provider with the patientshould (non front of Keepin hands body between yourselfexit. your an and patient rapport.) establishand Position so. law done even Searchhas toenforcement ensureno if patient weapons may to difficultdistinguish. very be cause. anypoint. isor if becomesscene staging Retreat from tosafe area weapon.reasonable weaponscene with of anysuspicion type armed or Transport:EMS Drug beablerescuerspatient. Drug withoutimparting toharm begivenmust or to MUSTPositionpatientnotairway of impede or breathing.be done This lateral should one supine above or arm with raised the control way patientbedone for Necessary required forcenot thea patient.uponand in must to inflict harm mustaandPatientposing beout control tothreat themselves of others. MUSTnotRestraintscirculation. impede must patient lateralPositionbedone airwaynot of This above or one impede breathing. should arm supine or the raised with necessary must toinflict control wayUseharm patientbedone minimum for required not force a thepatient.uponand in mustaandPatient posing beout control tothreat themselves of or others. R E F A S headPsychosistrauma,may hypoglycemia,include intoxication, acute CNS andsepsis,hypoxiaingestions. Psychosis insult, o Bevigilant ansureyour assessment in tomake medicalcondition is underlying not but medicalcondition isthe cause, assume beprecipitatedeven Behavioral conditionmedicalby underlyingwith psychiatric may disease.emergencies an known ispriorityFirstsafety on of Medical Control unsureMedical if contorted andtrunkwith neck difficult motor movements. When recognized give musclespasms Conditionmovements upper the face, causing typicallyneck of involuntary or May extremities. and present with - - - -

acilitate resources(Friends, family, chiefacilitate battalion chaplain); police, tabilize thetabilizesituation containingand lowering by unnecessary(remove thestimuli personnel, patient stress,reas remove from ncourage resourcesncourage availableandactions totakeuse patientinterest best theirin drugs suchdrugs as cocaine, crack cocaine, methamphetamine, oramphetamines similar agents. bizarretopain, violent insensitivity strength. and/ behavior,increased hyperthermia ecovery or in ecoveryPatientresponsible person, or or of referral: transport careprofessional to facility. medical Alcohol withdrawal or head trauma may also contribute to the condition. the to also contribute ortrauma headmay withdrawal Alcohol chronic particularly acute drug abuse, illness mentalor and/or serious history of male with a in subjects seen commonlyMost life Potentially disorientati disturbances, hallucinations, anxiety,speech agitation, delirium,psychomotor Combination of emergency: Medical ssess and acknowledge ssess and crisis - threatening and associated with with associatedand threatening - scene personnel. personnel. yourselfscene and othersProtect by approachenforcement.requestingDo law not if patient BLS: ALS: All other patients All other or patients All patients restrained receive who ALS care Behavioral

Do restrain position.Do prone innot patient use of physical control measures, including physical restraints and Tasers. and physical including restraints measures, of control use physical AM 5 ’ s choices and calmly set some boundaries of of somebehavior. boundaries s acceptable and calmly set choices

Do allowpatientcontinueDo not to struggle against Diphenhydramine 50IV/ Diphenhydramine Consult mg IM; IO / - threatening posture.) Only Only posture.) threatening tatus. rly njury, etc.)njury, r delirium delirium r ediately

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Adult Medical Protocol Section to to

injuries,

other Exit

Exit OR If If indicated Protocol(s) Protocol(s) Appropriate Cardiac Appropriate Cardiac Appropriate Trauma Appropriate Trauma AND NO AND personal dentist personal for complaints If during Ifhours business assist patient contacting patient contacting assist immediate appointmentimmediate YES YES Decay Infection Fracture Avulsion Abscess cellulitis Facial (wisdom) Impacted tooth TMJ syndrome infarction Myocardial R R R R R P P R

Differential • • • • • • • • • MMMM See belowSee NO NO AM 13 Cardiac Cardiac Monitor Pain Protocol; AM 6 AM 12 Lead ECG Procedure 12 Lead ECG teeth to exert pressure exert to teeth NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Monitor and Reassess 12 Lead ECG Interpretation12 Lead ECG ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Do not orrub scrub tooth Treat DentalAvulsion: Treat Place tooth in Milk / Normal May rinse gross contamination Saline / Commercial Preparation Small gauze rolled a intorolled gauze Small square and Control Bleeding with Direct PressureDirect with Bleeding Control Control Bleeding with Direct PressureDirect withBleeding Control placed into closingwithplaced socketinto patient MMMM Bleeding Pain Fever Swelling fractured Toothor missing P P R R R R R R

• • • • • Signs and Symptoms YES YES YES YES YES Dental Problems Dental NO NO NO NO NO Bleeding System Trauma System - Protocol; UP1Protocol; Significant or or Significant Significant Pain Significant Dental Avulsion Dental Universal Patient UniversalCare Dental or Jaw Pain Jaw or Dental Multi Suspicious for Cardiac for Suspicious Whole vs. partial Whole tooth vs. injury partial Medications pain / Onset injury of tooth out" withTrauma "knocked of toothLocation Age medicalhistoryPast

2020

Version 1 Version

• • • • • • • History Version 1 Adult Medical Protocol Section 2020 Disposition: • • • • • Pearls

sensitivity to to cold sensitivity tender (or touchto which teeth a is or tapping tooth with associatedshould with associated All be pain involvement cardiacanyandruleout early jaw. chestcan Consider to pain radiate the Occasionally cardiac for.cared tooth properly 4 is if the within hours tooth completeRe avulsions. minimizedinbe times should transport and Scene or a representcellulitis abscess. cavity oral can the or facetissue swelling to soft Significant Neuro Lungs, Chest, Mental Neck, Exam:Status, HEENT, Recommended EMS Transport: EMS or hot). or Dental Problems BLS: BLS: pain cardiac referred to related possibly pain atypical ALS: No Swelling, vitals within normal limits, afebrile afebrile limits, normal within vitals Swelling, No Significant soft tissue swelling with potential airway obstruction, obstruction, airway potential with swelling tissue soft Significant AM 6 - implantation possible implantation is Adult Medical Protocol Section

PPPP Stroke Stroke Stroke Seizure Seizure Seizure If If If indicated indicated If If If indicated indicated If If If indicated indicated If If indicated indicated BolusBolusBolusBolus Protocol; AM AM 33 Protocol; Protocol; Protocol; AM AM 14 14 Protocol; Protocol; Protocol; AM AM Protocol; Protocol; 16 16 AM AM Protocol; Protocol; 12 12 HypotensionHypotension ShockShock/ / Altered Altered Altered Mental Mental Status Status UPUP 33 500500500500 mLmLmLmL //// IV IV IV IV IOIOIOIO PPPP Vascular Access Protocol;Protocol;Access Access Vascular Vascular mg / dl / dl mg May neededneededneededneededrepeat repeat repeat repeat asasasasMay May May May NormalNormalNormalNormal SalineSalineSalineSaline Then infuse at 150 mLmLmLmL / / / / hr hr hr hr ThenThenThenThen at at at at 150 150 150 150 infuse infuse infuse infuse PPPP NO Blood Blood Sugar MMMM ≥ 250

Alcohol / Alcohol use drug Toxic ingestion injuryheadTrauma; Seizure CVA status mental Altered baseline PPPP YES

Differential • • • • • • B B YES 1mg1mg1mg1mg IM IM IM IM GlucagonGlucagonGlucagonGlucagon to to to

every 5 minutesminutesminutesminutes every every every every 5 5 5 5 mg / dl mg 2 FAILED attempts? Monitor and Reassess Reassess Reassess Reassess and and and and Monitor Monitor Monitor Monitor UPUP 11 Contact MedicalMedicalMedicalMedical Control Control Control Control ContactContactContactContact AM 7 AM NO NO EXITEXIT Notify Receiving Facility or Facility Facility Facility Facility Notify Notify Notify Notify or or or or Receiving Receiving Receiving Receiving 249

Protocol(s)Protocol(s) AppropriateAppropriate Repeat in ifififif 15 15 15 15 minutesminutesminutesminutesin in in in Repeat Repeat Repeat Repeat needed needed needed needed Normal? – Procedure Procedure Blood Blood Sugar Until Blood Glucose 60 mg / dl or greater greater greater greater or or or or dl dl dl dl //// mg mg mg mg 60 60 60 60 Glucose Glucose Glucose Glucose Blood Blood Blood Blood Until Until Until Until 61 if condition changes condition if PPPP MMMM Blood Glucose Analysis Blood Glucose Blood Glucose Analysis Diabetic Universal Patient Care Protocol; Patient Patient Protocol; Protocol; Care Care UniversalUniversal PPPP Another protocol appropriate? B NO B Altered mental statusAltered mental /Combative irritable Diaphoresis Seizures Abdominal pain vomiting Nausea / Weakness Dehydration / Deepbreathing rapid PPPP B R

• • • • • • • • • Signs and Symptoms YES

Oral AND to to to UPUP 33

mg / dl mg YES YES minutesminutesminutesminutes Consider EXITEXIT ≤ 60 Blood Blood Sugar Successful? Awake 1 Packet PO Oral Glucose Protocol(s)Protocol(s) Consider DextroseDextroseDextroseDextrose %%%% 10 10 10 10 AppropriateAppropriate Protecting airway? Vascular Access Vascular Protocol;Vascular Protocol;Access Access inininin 250250250250 mLmLmLmL overoveroverover bag bag bag bag 10 10 10 10 Solution (Juices / Food) PPPP B R Recent blood glucose Recentcheck blood mealLast Past medicalhistoryPast Medications

NO 2020 Version 1 Version

• • • • History Version 1

2020 Adult Medical Protocol Section The 250ml bag nowis mixed and nowis Add one (1) ampof Remove 50 ofml fluid from 250mla bag of To make If Congestive HeartFailure patientswho haveBlood Glucose> 250: Hypoglycemia with InsulinAgents: Hypoglycemia with Oral Agents: Patient • • • • • • Pearls Disposition: Dextrose D10

gestu or ideation suicidal about / witnesses / friends family ask patients/ and overdose, insulin intentional consider Always stores glycogen liver to poor due to Glucagon notrespond may disease liver advanced with patient and Alcoholics glucometers. for all recommendation manufacturers per maintained be should checks control Quality airway. their protect or to swallow able not are that to patients glucose oral administer not Do to glucagon. respond not my hypoglycemia prolonged with Patients Neuro. effort, and Respirations Skin, Status, Mental exam: Recommended ’ s refusing transport medicalto facility after treatmentof hypoglycemia: ------

Dextrose consumemeal. a even afternormal a blood glucoseis established. consumemeal. a after normal bloodglucose is established. facility. deficits. EMS Transport: EMS Limit fluidboluses unless they have signs of volume depletion, dehydration, poorperfusion, hypotension, Patient Notinsulin all have prolonged actionso Contact Medical Controlfor advice. Many forms insulinof now exist. Longer actinginsulin placesthe patient at ofrisk recurrent hypoglycemia Patient Notoral all agents have prolongedaction soContact Medical Controlfor advice. They are at risk recurrentof hypoglycemia that can delayedbe forhours andrequire close monitoring even Patient SeeUniversal Patient Care Protocol; UP1. Must demonstratecapacity to make informed health caredecisions. Patient returns to normal mental statusand normal has a neurological exam with nonew neurological Patient must have known historyof diabetes and not takingany oral diabetic agents. Blood sugarmust be and/or shock. res. is not available then ’ ’ ’ s s who meet criteriatorefuse care shouldbe instructed to contact theirphysician immediately and s who meet criteriatorefuse care shouldbe instructed to contact theirphysician immediately and s taking oraldiabetic medications shouldbe encouraged to allow transportation medical to a ** – Dextrose

Must meet allofthe above criteriato AMA; otherwise contact medical control** D10 from – ≥ 80,≥ Dextrose

D50 ALS:

patient has abilitytoeat and availability foodof with responders onscene. into the bag Normalof Saline Dextrose D50 Dextrose – All patients receiving ALS intervention or any medication any or intervention ALS receiving patients All

D50 Normal Saline Diabetic –

is usedto be and the concentration mixed as shown below. D10 AM 7 .

Adult Medical Protocol Section 11

- to

Exit as as indicated Appropriate Cardiac Appropriate Protocol(s); AC 1 1 AC Protocol(s); R AM 12 If If indicated P Hypotensive / Protocol; Shock P MMMM Congestive heart failure Pericarditis Diabetic emergency Sepsis Cardiac tamponade

P Differential • • • • • 1 gm IV / 1 gm IVIO 50 mEq IVIO /50 mEq Calcium Chloride Calcium Sodium BicarbonateSodium Diabetic Protocol; AM 7 Bolus

1 gm IV / 1 gm IVIO CHF / Pulmonary Edema Protocol; AC 3 Control Control Control Control P 50 mEq IVIO 50 /mEq Calcium Chloride Calcium 250 250 mL Nebulized Nebulized Albuterol Sodium BicarbonateSodium 5mg (may repeat once)(may 5mg as this will of causeshuntthe this as clotting will AM 8 AM Repeat as needed asRepeat Dressing must not compress fistula / must compress shunt Dressingfistula not (MAX Dose 1 1 Liter) (MAX Dose If lungs remain lungsclear Ifremain Normal Saline Normal Apply firm finger tip pressure to bleeding bleeding site firmpressure to tip finger Apply Apply dressing but avoid a compression dressing; dressinga avoid Applycompression dressing; but Notify Facility or Contact MedicalMedicalMedicalMedical Contact Contact Contact Contact Notify Notify Notify Notify or or or or Facility Facility Facility Facility YES P YES P R MMMM B Protocol; UPProtocol; 3 Vascular Access Vascular Access YES YES YES YES Hypotension Bleeding Fever imbalance Electrolyte or / and Nausea vomiting Mental Altered Status Seizure Arrhythmia

• • • • • • • • Signs and Symptoms Signs and sec NO NO NO NO NO NO ≥ 0.12 Arrest Cardiac Cardiac Dialysis / Renal / Dialysis Failure Renal Bleeding Pressure Pressure < 90 Systolic BloodSystolic Shunt /Shunt Fistula QRS QRS < 60 OR > 250? < > 60 OR Peaked T PeakedWave Pitting EdemaPitting Noted? Crackles noted in Lung fields?Lung noted Crackles in Blood Glucose Analysis ProcedureAnalysis GlucoseBlood Hypertensive? Hypertensive? Respiratory Distress? Universal Patient Care Protocol; UP 1 B

Catheter access noted Shunt access noted Hyperkalemia Peritoneal or Hemodialysis Anemia

2020

Version 1 Version

• • • • History • Version 1 Adult Medical Protocol Section 2020 Complicationsof DialysisTreatment: Peritoneal dialysis: Hemodialysis: Disposition: • • • • • • • Pearls

Renaldialysis patients have numerous medical problemstypically. Hypertension and cardiac diseaseare prevalent.medication. have one line you must runNormal saline wide open for1minute toflush line prior to administering second Sodium Bicarbonateand Calcium Chloride / Gluconate MUST notbe mixed. Ideally give separatein lines,but if only Always consider Hyperkalemia in all dialysisorrenal failure patients. uncontrolleddialysis fistulableeding is indicated. If hemorrhage cannotbe controlled withfirm, uninterrupteddirect pressure, application of tourniquet with Do takenot Blood Pressure startorIV in extremity whichhas a shunt fistula/ in place. Considertransport medicalto facility capableof providingDialysis treatment. Recommended exam: Mentalstatus. Neurological. Lungs. Heart. Fever: Equipmentmalfunction: Disequilibrium syndrome: Filtrationand decreased bloodlevels of some medications like someseizure medications Hypotension: from abdomen,the to hospital.the If patientcomplains of fever, abdominalpain, and/orback pain, bring PDthefluid bag, which hasdrained Somepatients doperform hemodialysisat home. Processwhich removes waste from bloodthe stream and occurs aboutthree timeseach week. EMS Transport: EMS Refer to Sepsis protocol; AM if15suspected Considersepsis in a dialysispatient withany catheter extendingoutside the body Electrolyte imbalance. Bleeding. Air embolism. andseizures. Shiftof metabolicwaste and electrolytes causing weakness, dizziness,nausea and/or vomiting or arrhythmia. Typicallyresponds tosmall fluid bolusof 250 mL Normal Saline.May resultin angina,AMS, seizure Dialysis / RenalFailureDialysis / ALS: All All patients AM 8 Adult Medical Protocol Section P P P P R R R R R MMMM Fever Hemorrhage medication or nutrient home from Reactions distress Respiratory Shock 4

–

Differential • • • • • NO As indicated As Clamp catheter Continue infusionContinue MedicalMedicalMedicalMedical ControlControlControlControl Monitor and Reassess Monitor and Stop infusion if Stop ongoing infusion if Stop ongoing infusion if ongoing Stop infusion if Do not exceed not 20 mL/kg Doexceed Airway Protocol(s); ARProtocol(s); Airway 1 Protocol(s) AM 9 AM NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Exit Appropriate to Apply directpressurearoundcatheter Apply aroundpressurecatheter directApply directpressurearoundApplycatheter Place on left side in head position onin down head sidePlaceleft MMMM R P P P P R R R R Complete catheter dislodgement catheter Complete catheter Damaged site catheter at Bleeding bleeding Internal clot Blood embolus Air about drainage or warmth Erythema, infection indicating site catheter External catheter dislodgement catheter External

• • • • • • • Signs and SignsSymptoms • YES YES YES YES YES YES Central Line Emergencies Line Central NO NO NO NO NO NO UP1

Chest Pain Chest catheter site catheter Hemorrhage at at Hemorrhage Ongoing infusion Ongoing Circulation Problem Circulation Damage to catheter to Damage Suspect Air Embolus Air Suspect Catheter completely completely Catheter or partially dislodged partially or Tachypnea, Dyspnea, Dyspnea, Tachypnea, PICC (peripherally inserted inserted (peripherally PICC catheter central catheter Implanted Hickman) / (Mediport Tunneled Catheter Tunneled Hickman) / (Broviac Universal Patient Care Patient Protocol Care Universal Occlusion of of line Occlusion dislodge partial or Complete disruption partial or Complete Central Venous Catheter Type Catheter Venous Central 2020 Version 1 Version

• • • • • • History Version 1 Adult Medical Protocol Section 2020 • • • • • • • • Pearls

Peripherally Inserted Central Catheter (PICC) Line (PICC) Catheter Central Inserted Peripherally care; etc. etc. care; critic an irritant; are Infusions access; peripheral of lack treatments; term long for placed be may Catheters Venous Central hypoglycemia. for monitor reason for any If stopped nutrition): (IV infusions Hyperalimentation guidance. further for direction medical on Get infusion. change or to stop it isappropriate if caregiver or family Ask to stop. detrimental be may infusions Some evident. occlusion if open catheter to force attempt not Do islocated. line PICC a where side same the on cuff BP or atourniquet place not Do centralline? their for kit an emergency given were they if patient Ask risk infection reduce to catheter indwelling an manipulating when technique clean strict Use skills. and knowledge have specific they as / caregivers family talk to Always oofo sc.r/dct on mskcc.org/educati hoto from P Central Central Line Emergencies Central lines can be for short term or long term treatments. treatments. term long or term short for be can lines Central CommonCentral Lines AM 9 From BC Campus BC From Percutaneous Central Venous Catheters Venous Central Percutaneous - line line al Adult Medical Protocol Section R MMMM R R R Trauma URI or(viralInfection Sinusitis) Allergic rhinitis Lesionsulcers) (polyps, Hypertension

YES Differential • • • • • NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Monitor and Reassess ContactContactContactContact MedialMedialMedialMedial ControlControlControlControl 1010

–– MMMM R YES YES Limits? to to to appropriateappropriate TraumaTrauma Direct Pressure

Head Tilt ForwardTiltHead Apply Nose ApplyClamp Position of Position Comfort Protocol(s);Protocol(s); 11 TB TB Suction Suction Active Bleeding Have Patient Blow Patient NoseBlow Have EXIT EXIT Vital Signs within normal VascularVascular AccessAccess Protocol;Protocol; UPUP 33 NO AM 10 AM R R R Bleeding from nasalpassage fromBleeding Pain Nausea Vomiting Epistaxis AM AM AM 12 12

• • • • Signs and Symptoms YES YES R Hypotension / Shock ProtocolProtocol ShockShockHypotensionHypotension / / - UPUP 11 NO NO Active Bleeding System Trauma Head Tilt Forward Position of Comfort Significant or Multi Universal PatientPatient UniversalUniversalCare Care Protocol; Protocol; Leave Gauze in place if present R Duration of bleeding Duration of of bleeding Quantity Medications (HTN, anticoagulants, aspirin, anticoagulants, Medications (HTN, NSAIDs) of epistaxis Previous episodes Trauma Age medicalhistoryPast

2020 Version 1 Version

• • • • • • • History Version 1 Adult Medical Protocol Section 2020 Disposition: • • • • • Pearls

contribute Anti (Pradaxa),rivaroxaban (Xarelto), and many over the counter headache powders.relief Anticoagulants includewarfarin (Coumadin), Apixaban(Eliquis), heparin, enoxaparin (Lovenox),dabigatran Bleeding mayalso be occurring posteriorly.Evaluate forposterior blood loss byexamining the posterior pharynx. It is very difficult to quantify the amount bloodof loss with epistaxis. Recommended Exam: Mental Status, HEENT, Heart, Lungs, Neuro EMS Transport: EMS - platelet agents like aspirin, clopidogrel (Plavix), aspirin/dipyridamole (Aggrenox), and ticlopidine (Ticlid) can to bleeding . BLS: ALS: continued bleeding and no orthostatic changes. orthostatic no and bleeding continued anti or anticoagulants taking Patient bleeding uncontrolled profuse any concerns, airway any or 110, > BP of diastolic elevated changes, orthostatic with patients All Epistaxis AM 10 - platelet medication. Any minor minor Any medication. platelet Adult Medical Protocol Section as MI, as

– and / or / and ints such ints as to to to to

s Response s ’ AM AM 3 Exit Exit Exit Exit consultation with consultation Protocol(s) Appropriate Protocol; AC 2 AC Protocol; Cushing Bradycardia and Hypertension Chest Pain / STEMIPainChest / Protocol(s); 1 Protocol(s); OB eclampsia / eclampsiaEclampsia - Obstetrical Emergency Obstetrical Stroke Protocol; AM16 Protocol;Stroke Hypertensive encephalopathy Hypertensive Injury Primary CNS Infarction Myocardial Aneurysm Dissection Aortic / Pre Altered Altered Mental Status Protocol;

Differential • • • • • R MM P YES YES YES YES ≥ 120 Diastolic BP Diastolic

BP in both arms

OR NO NO NO YES UP1 OR 20 / mg IV / IO 10 IV mg / / IM IO Consider Pregnancy Chest Pain CVA / AMS Dyspnea / CHF ≥ 220 manual given over 2 minutes NotifyNotify DestinationDestination oror AM 11 AM hospital setting in most cases. Aggressive hypertensionAggressive treatment can cases. of hospital in setting most ContactContact MedicalMedical ControlControl Labetalol - May Repeat x1 minutesq 10 Universal PatientUniversal Care Protocol; May Repeat x 1 q minutes 10 Pain and Anxiety Pain are and Anxiety addressed? Check Hydralazine Medical Medical Control. Systolic BP Systolic P MM BP taken on 2 occasions at least 5 minutes taken apart? least 2 5 BP occasions minutes on at Systolic BP greaterSystolic220 or BP Diastolicgreater 120 or R Headache PainChest Dyspnea Altered Mental Status Seizure

One oftheseOne • • atoftheseleastAND one • • • • • Signs and Symptoms Hypertension to

NO Exit Asymmetric? Appropriate Appropriate Protocol(s) YES Dissection? chest pain, pulmonary dyspnea, alteredor edema mental status should onbe treated andbased specific protocols Hypertension is not uncommon especially in an emergency setting. Hypertension is usually transient and in response to stressto in andresponse Hypertension usually antransient setting.is emergency is in uncommon especially Hypertension not result in harm. result even elevation in in significantMost patients,blood Specificonlywith pressure, need compla supportive care. Consider Aortic pain. Ais on hypertensive pressure emergencyalong based bloodsymptoms withsuggest an which organ suffering is damage such CVA or renal failure. This is very difficult to determine in the prethe very determine renal to is difficult in CVA or failure. This Pregnancy Failure; Cardiac Problems Cardiac Failure; Medications for Hypertension Hypertensive Compliance with Medications medicationsDysfunctionErectile Documented Documented Hypertension diseases: Related Diabetes; Renal CVA; 2020 Version 1

• • • • • • History Hypertension

Treatment of chronic hypertension is an extensive process requiring long term medical follow up. The purpose of this protocol is to treat only those patients who are experiencing signs and symptoms reflecting suspected end organ damage as evidenced by any one of the following in the presence of a hypertensive patient as outlined: Headache, Blurred Vision, Dizziness, Chest pain, shortness of breath, or Altered Mental Status.

Vital signs should be evaluated and documented ever 5 minutes to include Mean Arterial Pressure (MAP). The MAP is automatically calculated by the automated blood pressure machine / monitor. To calculate the MAP from a manual blood pressure utilize the formula:

(Systolic + (2 X Diastolic)) / 3 Example: BP of 120 / 80 = (120 + (2 X 80)) / 3 = (120 + 160) / 3 = 280 / 3 = 93 MAP = 93

The Treatment goal is a BP reduction of 20% in the MAP. If the MAP declines more than 20% immediately stop treatment of

Hypertensive Emergency. Continuously monitor the blood pressure as before. Adult Medical Protocol Section Protocol Medical Adult

Pearls • Recommended Exam: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back, Extremities, Neuro • Elevated blood pressure is based on two to three sets of vital signs. • Symptomatic hypertension is typically revealed through end organ dysfunction to the cardiac, CNS or renal systems. • All symptomatic patients with hypertension should be transported with their head elevated at 30 degrees. • Ensure appropriate size blood pressure cuff utilized for body habitus.

Disposition: EMS Transport: ALS: All patients

2020 Version 1 AM 11 Adult Medical Protocol Section P - YES if indicated if Successful / Obstructive Improvement? Needle Procedure Chest Decompression (PE, Tamponade, Tension pneumo) Tension Tamponade, (PE, P Ectopic pregnancy Dysrhythmias Pulmonary embolus Tension pneumothorax Medication effect / overdose Vasovagal Physiologic (pregnancy) Sepsis NO P

Differential • • • • • • • •

R PUMP PUMP P MMMM Distributive mmHg 100

– (Sepsis, Neurogenic, Anaphylaxis) Neurogenic, (Sepsis, AMAM 22 YES NO OR NO Rales If If If indicated indicated If If If indicated indicated If If If indicated indicated Protocol;Protocol; TBTB 88 AM 12 AM Auscultated? MAX L DoseMAX 2 Normal Saline Normal 10 mcg / min via IV / IO on IVminIO 10 on // mcg via - AllergicAllergic ReactionReaction / / mcg / kg kg IO /mcg //onvia min IV 1 ground emesis Trauma:Trauma: MultisystemMultisystem AnaphylaxisAnaphylaxis Protocol;Protocol; - SepsisSepsis Protocol;Protocol; AMAM 15 15 palpate a radial Pulse? radialpalpate a 20 Bolus 500 mL via IV / 500mLIVIO Bolus / via

NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Repeat to effect SBP> effectto90 Repeat – Maintain MAP > 65 mmHg MAP Maintain > 65 ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl maintain SBP 90 maintain 2 Restlessness, confusion Weakness, dizziness Weak, rapid pulse Pale, cool, clammy skin Delayed capillary refill Hypotension Coffee Tarry stools UniversalUniversal PatientPatient Care Care Protocol;Protocol; UP1 UP1 YES P History and Exam Suggestof Shock Type History Exam and Confirmed 100BPConfirmed systolic unable to OR < MMMM

• • • • • • • • Signs and Symptoms Hypovolemic R Norepinephrine Dopamine (Dehydration, Bleeding) (Dehydration, P Hypotension / / Hypotension Shock NO NO YES STEMI? (STEMI, CHF) (STEMI, Cardiogenic Cardiac Cardiac cause? Consider other Consider other YES vaginal or gastrointestinal

vomiting, diarrhea, fever -

to to to -

YES EXITEXIT

AppropriateAppropriate ACAC 22

STEMISTEMI History of poor oral intake Medications Allergic reaction Pregnancy Fluid loss Infection Cardiac ischemia (MI, CHF) Blood loss bleeding, AAA, ectopic CardiacCardiac / / Protocol,Protocol,

CardiacCardiac Protocol(s)Protocol(s)

ChestChest Pain:Pain: 2020

Version 1 Version

• • • • • • • • History Hypotension / Shock

Hypotension is defined as: Systolic BP < 90 OR MAP < 65

• Consider all possible causes of shock and treat per appropriate protocol: • Hypovolemic Shock: Hemorrhage, trauma, GI bleeding, ruptured aortic aneurysm or pregnancy-related bleeding. Consider TXA if patient hemorrhaging; administer 1 gram over 10 minutes via IV / IO • Cardiogenic Shock: Heart failure: MI, Cardiomyopathy, Myocardial contusion, Ruptured ventricle / septum / valve / toxins. • Distributive Shock: Sepsis Anaphylactic Neurogenic: Hallmark sign is warm, dry, pink skin with normal capillary refill time and typically alert. Toxins • Obstructive Shock: Pericardial tamponade: muffled heart sounds, hypotension, jugular vein distension (Beck’s Triad) Pulmonary embolus: consider embolus if 12 – Lead indicates S1 Q3 T3 sign S1 = S wave in lead I Q3 = Q wave in lead III T3 = T-wave in lead III Tension pneumothorax: hypotension, absent or decreased breath sounds on affected side

• Acute Adrenal Insufficiency: Sudden defective production of adrenal steroids (cortisol and aldosterone). Can occur in the presence of infection, dehydration, trauma, surgery, adrenal gland, or pituitary gland injury. Contact Medical Control if considering administration of steroids

Adult Medical Protocol Section Protocol Medical Adult

Pearls • Recommended Exam: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro • VITAL SIGNS SHALL BE MONITORED EVERY 5 MINUTES • Repeat Vital Signs AFTER each Bolus or Change in Pharmacologic Therapy (Change in dose or agent) • Hypotension can be defined as a systolic blood pressure of less than 90. This is not always reliable and should be interpreted in context and patients typical BP if known. • Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation. • For non-cardiac, non-trauma hypotension, consider Norepinephrine when hypotension unresponsive to fluid resuscitation. • Unknown or unidentifiable cause? Consider Acute Adrenal Insufficiency or Congenital Adrenal Hyperplasia as cause for symptoms

Disposition: EMS Transport: ALS: All patients

2020 Version 1 AM 12 Pain Control

History Signs and Symptoms Differential • Age OPQRST • Per the specific protocol • Location • Onset • Musculoskeletal • Duration • Provocation (made worse?) Relation to movement? • Visceral (abdominal) • Severity (1 - 10) Respiration? Increased with palpation of area? • Cardiac • Quality (sharp, dull, etc.) • Past medical history • Pleural / Respiratory • Radiation • Medications • Severity • Neurogenic • Drug allergies • Time • Renal (colic)

Enter from Protocol based on Specific Complaint

Universal Patient Care Protocol; UP1

Assess Pain Severity AND/OR clinical signs indicate need for pain

control medication present. Adult MedicalProtocol Section YES

R Pulse Oximetry /EtCO2 R

P Cardiac Monitor P

Vascular Access Protocol; UP 3

Consider Zofran 4 mg – 8 mg IV / IO / IM / ODT for P nausea / vomiting P MAX Dose 8 mg

Consider Ketorolac (Toradol) Patient over age 60 30 mg IV / IO All pain medication doses 60 mg IM reduced by half MAX Dose 60 mg If > 60 years old cut dose in half Contraindications for Non- Fentanyl 1 mcg / kg Steroidal Agents via IV / IO / IN / IM • Active Bleeding May repeat q 5 minutes • Possible Surgery MAX Single Dose 100 mcg MAX Total Dose 200mcg • Renal Disease P P OR Contraindications for IV Pain Control Morphine 0.1 mg / kg • Severe Head Injury May repeat x 1 q 5 minutes • End-Stage Lung Disease MAX Single Dose 10 mg IV / IO MAX Total Dose 20 mg IV • Untreated Hypotension Consider Ketamine for refractory pain 0.3 mg / kg via IV / IO

Monitor and Reassess R Every 5 minutes following Pain R medication

Notify Destination or M Contact Medical Control M

2020 Version 1 AM 13 Pain Control

Pearls • Recommended Exam: Mental Status, Area of Pain, Neuro • Pain severity (0-10) is a vital sign to be recorded before and after PO, IV, IO or IM medication delivery and at patient hand off. • Monitor BP closely as sedative and pain control agents may cause hypotension.

Adult Medical Protocol Section Protocol Medical Adult • Vital signs should be obtained before, 5 minutes after, and at patient hand off with all pain medications. • Ketorolac (Toradol) and Ibuprofen should not be used in patients with known renal disease or renal transplant, in patients who have known drug allergies to NSAID's (non-steroidal anti-inflammatory medications), with active bleeding, headaches, abdominal pain, stomach ulcers or in patients who may need surgical intervention such as open fractures or fracture deformities. • All patients who receive IM or IV medications must be observed 15 minutes for drug reaction • Burn patients may required higher than usual opioid doses to titrate adequate pain control. Consider Ketamine early. - For adult patients with significant burns involving > 15% BSA: - Maximum Total Dose of Fentanyl 200 mcg - Maximum Total Dose of Morphine 20 mg • Fentanyl may be administered Intranasally as to not delay pain management for vascular access • Allergies must be recorded prior to medication administration • Women of childbearing age with abdominal pain should be treated as an ectopic pregnancy until proven otherwise • In patients over the age of 50 with abdominal pain should consider diagnosis of an abdominal aneurysm dissection until proven otherwise. • Reference Medication formulary for further guidance or additional information for medication administration.

Disposition: EMS Transport: ALS: All patients with abnormal vital signs, pain > 6 out of 10, received ALS treatment / intervention BLS: Vitals within normal limits, no pain medication has been administered, pain rated < 6 out of 10

2020 Version 1 AM 13 Adult Medical Protocol Section P P MMMM Drip UP 22 UP UP If If If indicated indicated Magnesium 10 IM mg / IN

PUMP NO IV PUSH IV NO Still Seizing? Sulfate CervicalCervical Protocol;Protocol; Spine Spine Versed Consider additional ordersordersordersorders additionaladditionaladditionaladditional Saline over minutes 15 via 2 grams in 100 mL Normal P compliance - Contact MedicalMedicalMedicalMedical ContactContactContactContact Control Control Control Control for for for for P CNS (Head) CNStrauma Tumor failure Renal or Metabolic, Hepatic, Hypoxia (Na, Ca, abnormality Mg) Electrolyte Drugs, Medications, Non /Infection Fever withdrawal Alcohol Eclampsia Stroke Hyperthermia Hypoglycemia Epilepsy NO YES YES R YES

MMMM MMMM Differential • • • • • • • • • • • • • B - OR NO NO NO NO or > or250 epilepsy Protocol? Procedure Still Seizing? < 60 Blood GlucoseBlood Seizure recurs?Seizure Spine cleared perSpine cleared AM 14 AM MedicalMedicalMedicalMedical ControlControlControlControl - C > 20 wks Pregnant? > 20 wks Monitor and Reassess Monitor and partum] w/ no Hx no of Hx partum] w/ Active Seizure Activity Active Seizure Blood Glucose Analysis Blood Glucose [Eclampsia or post recent[Eclampsia or VascularVascular AccessAccess Protocol;Protocol; UPUP 33 NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Seizure B MMMM R NO Decreased Decreased mental status Sleepiness Incontinence Observed activity seizure of Evidencetrauma Unconscious YES YES

• • • • • • Signs and Symptoms 4 4

–– UPUP 11 AMAM 77 If If If indicated indicated DiabeticDiabetic Protocol;Protocol; Protect patientProtect AirwayAirway Protocol(s);Protocol(s); ARAR 11 Universal Patient Care Protocol; Patient Patient Protocol; Protocol; Care Care UniversalUniversal Loosen any constrictive clothing Loosen any constrictive Alcohol use, abuse or abrupt cessation use, Alcohol abuse abrupt or Fever History of pregnancy pregnancy History of onset Time of seizure of Document seizures number Medical alert tag informationtag Medical alert medications Seizure trauma History of diabetes History of Reported / witnessed seizure /activity Reported seizure witnessed history Previous seizure

2020 Version 1 Version

• • • • • • • • • • • History Seizure

Pearls

• Recommended Exam: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro Adult Medical Protocol Section Protocol Medical Adult • Adult: Midazolam 5 – 10 mg IM / IN is effective in termination of seizures. • Midazolam is well absorbed when administered IM. • Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport. • Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma. • Focal seizures affect only a part of the body and are not usually associated with a loss of consciousness, but can propagate to generalized seizures with loss of consciousness. • Be prepared for airway problems and continued seizures. • Assess possibility of occult trauma and substance abuse. • Be prepared to assist ventilations especially when Midazolam is used. • For any seizure in a pregnant patient, follow the OB Emergencies Protocol.

Disposition: EMS Transport ALS: All patients not cleared by medical control and not meeting criteria below BLS: Single seizure with return to baseline mental status with normal vital signs, and no ALS treatment performed

2020 Version 1 AM 14 Sepsis

History Signs and Symptoms/ Significant Findings Differential • Age > 18 years old • Hyperthermia (>100.4O F / 38O C) • Infections: UTI, Pneumonia, Skin / • Duration of fever • Hypothermia (< 96.8O F / 36O C) wound • Severity of Fever • Tachypnea • Cancer / Tumors / Lymphomas • Altered Mental Status • Tachycardia • Medication or drug reaction • Past Medical History • Acute mental status change • Connective tissue disease: Arthritis, • Medications • Suspected meningitis, endocarditis, or vasculitis • Immunocompromise osteomyelitis • Hyperthyroidism o Transplant • Warm / flushed / diaphoretic • Heat Stroke o HIV • Meningitis o Diabetes • Endocarditis o Cancer • Osteomyelitis • Environmental Exposure • Last Acetaminophen / Ibuprofen • Recent Antibiotic use • Indwelling device • High risk (elderly / very young) Universal Patient Care Protocol; UP 1 Is the patient’s presentation suggestive Airway Protocol(s); AR 1 – 4 of any of the following infections? Vascular Access Protocol; UP 3

• Pneumonia (cough/thick sputum) Adult MedicalProtocol Section B Place patient on ETCO2 B • Urinary tract infection • Acute AMS / change in mental status B 12 / 15-lead procedure B • Blood stream / catheter related • Abdominal pain and/or diarrhea P 12 / 15-lead Interpretation P • Wound infection • Skin / Soft tissue infection

Obvious or Suspected Infection PLUS Any TWO (2) of the following symptoms present AND new to the patient • Hyperthermia (>100.4O F / 38O C) OR

Hypothermia (< 95O F / 35O C) • Heart rate > 90 beats per minute • Respiratory rate > 20 breaths per minute OR YES SEPSIS ALERT Mechanical Ventilation • Signs of poor perfusion P Establish Second IV/IO P • ETCO2 of < 25mmHg • New onset Altered Mental Status • SBP < 90 mmHg Administer Normal Saline P 30 mL / kg via IV/IO P Unless concern for fluid overload

NO Persistent Hypotension after Fluid Bolus SBP < 90 mmHg

YES Altered Mental Status Protocol; AM 3 Norepinephrine 1 – 10 mcg / min OR If needed NO P Dopamine 5 – 20 mcg / kg / min P EXIT to appropriate Protocol via IV / IO on PUMP YES

R Monitor and Reassess R

Notify Destination or M M Contact Medical Control

2020 Version 1 AM 15 Sepsis

Morbidity and Mortality of septic patients is significantly high (>40%) requiring aggressive and timely treatment.

IV access of 2 large IV’s or insertion of Intraosseous device(s) are required to properly manage a patient in sepsis or septic shock.

Patients in SEPTIC SHOCK (Sepsis with hypotension) may present in a hyperdynamic state as evidenced by hyperthermia, tachycardia, tachypnea, and/or increased glucose utilization. Such patients are prone to third spacing and must have aggressive fluid replacement.

EtCO2 monitoring should be performed on patients with suspected sepsis/septic shock. An EtCO2 measurement of < 25 mmHg is strongly correlated with lactate levels > 4 mm/L and increased mortality.

Evaluation for Sepsis Are any (2) two of the following symptoms present AND new to the patient? • Hyperthermia (>100.4O F / 38O C) OR Hypothermia (< 95O F / 35O C) • Heart rate > 90 beats per minute • Respiratory rate > 20 breaths per minute OR Mechanical Ventilation • Signs of poor perfusion (SBP < 90 mmHg or MAP < 65mmHg)

Is the patient’s presentation suggestive of any of the following infections? • Pneumonia (cough/thick sputum) • Urinary tract infection • Acute AMS / change in mental status • Blood stream / catheter related • Abdominal pain and/or diarrhea • Wound infection • Skin / Soft tissue infection

If positive for sepsis call a SEPSIS ALERT and initiate rapid transport.

Pearls • Septic Shock: o Hypotension (SBP <90 mmHg OR MAP <65mmHg) refractory to fluid bolus. o Consider Pressor Agent.

• Bolus Fluids up to 30 mL / kg, MUST REASSESS auscultate lung sounds every 500 cc of fluid administration Adult Medical Protocol Section Protocol Medical Adult • Early recognition of Sepsis allows for attentive care and early administration of antibiotics • Aggressive IV fluid therapy is the most important prehospital treatment for sepsis. Suspected sepsis patients should receive repeated fluid boluses (max of 2 liters) while being checked frequently for signs of pulmonary edema, especially patients with known history of CHF or ESRD on dialysis. STOP fluid infusion in the setting of pulmonary edema • Septic patients are especially susceptible to traumatic lung injury and ARDS. If artificial ventilation is necessary, avoid ventilating with excessive tidal valumes. If CPAP is utilized, airway pressure should be limited to 5 cmH20 • Attempt to identify source of infection if possible and relay previous treatments and related history to ED physician or nurs ing staff. • Elevated serum lactate levels are a useful marker of hypoperfusion in sepsis and often become elevated prior to the onset of hypotension. End Tidal CO2 levels are correlated with lactate levels, trend and monitor EtCO2 • Disseminated Intravascular Coagulation (DIC) is an ominous, late stage manifestation of sepsis characterized by frank, extens ive bruising, bleeding from multiple sites and finally tissue death. • If possible meningitis, utilize precautions and notify receiving ED facility of possible meningitis. • During fluid resuscitation, lung sounds should be auscultated and blood pressure obtained after each 500 cc fluid bolus

Disposition EMS Transport: ALS: All Patients

2020 Version 1 AM 15 Stroke

History Signs and Symptoms Differential • Prior Stroke / TIA • Altered mental status • Altered Mental Status • Previous cardiac / vascular surgery • Weakness / Paralysis • TIA (Transient ischemic attack) • Associated diseases: diabetes, • Blindness or other sensory loss • Seizure hypertension, CAD • Aphasia / Dysarthria • Hypoglycemia • Atrial fibrillation • Syncope • Tumor • Medications (blood thinners) • Vertigo / Dizziness • Trauma • History of trauma • Vomiting • Headache • Seizures • Respiratory pattern change • Hypertension / hypotension Universal Patient Care Protocol; UP 1 Blood Glucose MUST be assessed and documented on ALL Diabetic Protocol; AM 7 Stroke patients.

Prehospital Stroke Screen Adult MedicalProtocol Section R Perform / Document Cinncinnati Stroke R Scale

Transport to STROKE SCREEN POSITIVE NO R R appropriate hospital YES Determine and Document Consider Appropriate Protocol P Time Last Known Well (LKW) P

LKW = >3 and <6 LKW = <3 hours LKW = >6 hours hours

Transport to Transport to Transport to Level 1 or 2 Stroke Level 1 or 2 Stroke Level 1 Stroke Center Center *** Center ***

R 12-Lead Procedure R EXIT to Appropriate Cardiac Protocol; AC 1 - 11 P 12-Lead Interpretation P If needed Consider: Level 1 Stroke Center: Hypertension Protocol; AM 11 • University of Missouri Medical Hypotension / Shock Protocol; AM 12 Center Seizure Protocol; AM 14 • Boone Hospital

Vascular Access Protocol; UP 3 Level 2 Stroke Centers: • Capital Region Medical Center Notify Destination or M Contact Medical Control M

2020 Version 1 AM 16 Stroke

- Clearly determine time of onset of symptoms or the last time seen well - If the patient wakes from sleep or is found with symptoms of stroke, the time of onset of first symptoms is defined as the last time the patient was observed to be normal.

***Consider the time for transport, the patient’s condition, air/ground/hospital options for timely and medically

appropriate care and the treatment windows. Adult Medical Protocol Section Protocol Medical Adult

Pearls • Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Scene times should be limited to 10 minutes, early destination notification/activation should be provided and transport times should be minimized. • Elevated blood pressure is commonly present with stroke. Consider treatment per Hypertensive Clinical Guideline. • Be alert for airway problems (swallowing difficulty, vomiting/aspiration). • Hypoglycemia can present as a localized neurologic deficit.

2020 Version 1 AM 16 Adult Medical Protocol Section R P B B MMMM P Vasovagal Orthostatic hypotension Cardiac syncope / syncope Defecation Micturition Psychiatric Stroke Hypoglycemia Seizure Shock(see ShockProtocol) (Alcohol) Toxicological (hypertension)effectMedication PE AAA

Differential • • • • • • • • • • • • • mmHg ≥ 90 Lead Lead ECG Lead ECG

NO NO NO YES NO – – shock Procedure Maximum 2 L Maximum 2 Repeat as neededasRepeat potential cause? Monitor and Reassess 12 / 15 15 12 / 12 / 15 Procedure Abnormal? Procedure Titrate SPB SPB Titrate Blood Glucose Analysis GlucoseBlood NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Serious SignsSymptoms Serious/ Interpretation abnormal ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Normal Saline 500 mL Bolus Saline Normal mL 500 Hypotension, poor perfusion, Hypotension, poor Primary Assessment reveal VascularVascular AccessAccess Protocol;Protocol; UPUP 33 P UniversalUniversal PatientPatient Care Care Protocol;Protocol; UP UP 11 MMMM R B P B AM 17 AM YES YES YES YES SYNCOPE Loss of consciousness with recovery Lightheadedness, dizziness Palpitations, slow or rapid pulse Pulse irregularity Decreased blood pressure

• • • • • Signs and Symptoms Signs and 44

–– 1111

–– AMAM 33 AMAM 1212 If If If indicated indicated If If If indicated indicated If If If indicated indicated If If If indicated indicated If If If indicated indicated ACAC 11 DiabeticDiabetic Protocol;Protocol; AMAM 77 AirwayAirway Protocol(s);Protocol(s); ARAR 11 HypotensionHypotension / Shock/ Shock Protocol;Protocol; AlteredAltered MentalMental StatusStatus Protocol;Protocol; AppropriateAppropriate CardiacCardiac Protocol(s);Protocol(s); Trauma:Trauma: MultisystemMultisystem Protocol;Protocol; TBTB 88 Past medical history Medications Females: LMP, vaginal bleeding Fluid loss: nausea, vomiting, diarrhea Cardiac history, stroke, seizure Occult blood loss (GI, ectopic)

• • • • History • • 2020 Version 1 Version SYNCOPE

• Differential should remain wide and include: - Cardiac arrhythmia - Neurological problem - Choking - Pulmonary embolism - Hypo or Hyperglycemia - Hemorrhage - Stroke - Respiratory - GI Hemorrhage - Seizure - Sepsis

• High-risk patients: - Age ≥ 60 - Syncope with exertion - History of CHF - Syncope with chest pain - Abnormal ECG - Syncope with dyspnea

Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro • Syncope is both loss of consciousness and loss of postural tone. Symptoms preceding the event are important in determining etiology.

• Syncope often is due to a benign process but can be an indication of serious underlying disease in both the adult and Adult Medical Protocol Section Protocol Medical Adult pediatric patient. • Often patients with syncope are found normal on EMS evaluation. In general patients experiencing syncope require cardiac monitoring and emergency department evaluation. • Abdominal / back pain in women of childbearing age should be treated as pregnancy related until proven otherwise. • The diagnosis of abdominal aneurysm should be considered with abdominal pain, with or without back and/or lower extremity pain or diminished pulses, especially in patients over 50 and/or patients with shock/ poor perfusion. Notify receiving facility early with suspected abdominal aneurysm. • Consider cardiac etiology in patients > 50, diabetics and/or women especially with upper abdominal complaints. • Heart Rate: One of the first clinical signs of dehydration, almost always increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal. • Syncope with no preceding symptoms or event may be associated with arrhythmia. • Assess for signs and symptoms of trauma if associated or questionable fall with syncope. • Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope. • These patients should be transported. Patients who experience syncope associated with headache, neck pain, chest pain, abdominal pain, back pain, dyspnea, or dyspnea on exertion need prompt medical evaluation. • More than 25% of geriatric syncope is cardiac dysrhythmia based. Disposition: EMS Transport: ALS: All patients

2020 Version 1 AM 17 Trauma and Burn Protocol Section t ’ blistering

painful (Don

- painless/charred orpainless/charred

red red

Protocol;Protocol; TBTB 33 Explosions Protocol;Protocol; TBTB 88 hemorrhage Protocol;Protocol; TBTB 1010 (See Pearls) Degree):

RadiationRadiation IncidentIncident nd BurnsBurns Protocol;Protocol; 2 2 TB TB Trauma:Trauma: MultisystemMultisystem Degree):

rd Trauma:Trauma: CrushCrush SyndromeSyndrome prevent life threateningprevent life aggressively managed toaggressively Accidental / Intentional Bleeding control should controlBleeding be Degree):

st Electrical Electrical injury

– P R Superficial (1 Superficial in TBSA)include Thickness (2 Partial (3 Full Thickness skin leathery injuryThermal Chemical injury Radiation injuryBlast YES YES MMMM

Differential • • • • • • • YES Trauma.

TB 1 TB NO NO NO NO NO YES if indicated if indicated indicated if if Burn Injury? Cardiac Cardiac Monitor Airway patent? MedicalMedicalMedicalMedical ControlControlControlControl and ventilation? Traumatic Injury? Blast Lung Injury? Radiation Exposure? Adequate oxygenation PainPain ControlControl Protocol;Protocol; AMAM 1313 Multiple Patients? MCI? / VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Spinal Motion Restriction; 2 UP DecontaminationDecontamination ProcedureProcedure NotifyNotifyNotifyNotify destinationdestinationdestinationdestination orororor ContactContactContactContact UniversalUniversal PatientPatient Protocol;Protocol; Care Care 1 1 UP UP Burns, Burns, pain, swelling Dizziness of consciousnessLoss Hypotension/shock be compromise/distress could Airway hoarseness/wheezing /indicated by Hypotension and Go with Assessment / Treatment Enroute / Treatmentwith and Assessment Go

• • • • • Signs and Symptoms Scene Scene Safety / andQuantify Patients Triage / Load YES MMMM NO YES P R Blast Injury / Incident / Injury Blast 4 4

Open /Open Closed. ––

Intervening protective barrier. Other barrier.hazards, Intervening environmental protective

Incendiary / Explosive Incendiary /

ARAR 11 Agent / Amount. Industrial Explosion. Terrorist Incident. Improvised Explosive Device. Explosive Incident.Terrorist Improvised Industrial Explosion. Amount. Agent /

See PEARLS on back Blunt Trauma / Crush Injury / Compartment Syndrome / Traumatic Brain Injury / Concussion / Tympanic Membrane Rupture / Tympanic RuptureMembrane / Concussion / Injury SyndromeCrush/ Brain Compartment Traumatic Blunt / Injury / Trauma

AirwayAirway Protocol(s);Protocol(s); TriageTriage Protocol;Protocol; 2222UP UP Loss of Consciousness Loss status Tetanus/Immunization Inhalation injury Inhalation Time of Injury medicalhistory Past/Medications trauma Other Type of exposure (heat, of gas, exposure Type(heat, chemical)

2020 Version 1 Version

• • • • • • • History Evaluate Evaluate for: Injury Lung Penetratingand Evisceration, Abdominal Blast or hemorrhage Nature of Environment:ofNature Distance Device: from Nature of Device:ofNature Method of Delivery: Blast Injury / Incident

Types of Blast Injury: - Primary Blast Injury: From pressure wave. - Secondary Blast Injury: Impaled objects. Debris which becomes missiles / shrapnel. - Tertiary Blast Injury: Patient falling or being thrown / pinned by debris. - Most Common Cause of Death: Secondary Blast Injuries.

Triage of Blast Injury patients: - Blast Injury Patients with Burn Injuries Must be Triaged using the Thermal / Chemical / Electrical Burn Destination Guideline s for Critical / Serious / Minor Trauma and Burns - Patients may be hard of hearing due to tympanic membrane rupture.

Blast Lung Injury: - Blast Lung Injury is characterized by respiratory difficulty and hypoxia. Can occur (rarely) in patients without external thoracic trauma. More likely in enclosed space or in close proximity to explosion. - Symptoms: Dyspnea, hemoptysis, cough, chest pain, wheezing and hemodynamic instability. - Signs: Apnea, tachypnea, hypopnea, hypoxia, cyanosis and diminished breath sounds. - Air embolism should be considered and patient transported prone and in slight left-lateral decubitus position. - Blast Lung Injury patients may require early intubation but positive pressure ventilation may exacerbate the injury, avoid hyperventilation. - Air transport may worsen lung injury as well and close observation is mandated. Tension pneumothorax may occur requiring chest decompression. Be judicious with fluids as volume overload may worsen lung injury.

Care of Blast Injury Patients: - Patients may suffer multi-system injuries including blunt and penetrating trauma, shrapnel, barotrauma, burns, and toxic chemical exposure. - Consider airway burns which should prompt early and aggressive airway management. - Cover open chest wounds with semi-occlusive dressing. - Use Lactated Ringers (if available) for all Critical or Serious Burns. - Minimize IV fluids resuscitation in patients with no sign of shock or poor perfusion.

Trauma and Burn Protocol Section Protocol Burn and Trauma Pearls • Accidental Explosions or Intentional Explosions: - All explosions or blasts should be considered intentional until determined otherwise. - Attempt to determine source of the blast to include any potential threat for aerosolization of hazardous materials. Evaluate scene safety to include the source of the blast that may continue to spill explosive liquids or gases. - Consider structural collapse / Environmental hazards / Fire. - Conditions that led to the initial explosion may be returning and lead to a second explosion. - Greatest concern is potential threat for a secondary device. - Patients who can, typically will attempt to move as far away from the explosive source as they safely can. - Evaluate surroundings for suspicious items; unattended back packs or packages, or unattended vehicles. - If patient is unconscious or there is(are) fatality(fatalities) and you are evaluating patient(s) for signs of life - Before moving note if there are wires coming from the patient(s), or it appears the patient(s) is(are) lying on a package/pack, or bulky item, do not move the patient(s), quickly back away and immediately notify a law enforcement officer. - If there are no indications the patient is connected to a triggering mechanism for a secondary device, expeditiously remove the patient(s) from the scene and begin transport to the hospital. - Protect the airway and cervical spine, however, beyond the primary survey, care and a more detailed assessment should be deferred until the patient is in the ambulance. - If there are signs the patient was carrying the source of the blast, notify law enforcement immediately and most likely, a law enforcement officer will accompany your patient to the hospital.

Disposition: EMS Transport: ALS: All patients

2020 Version 1 TB 1 BURNS

History Signs and Symptoms Differential • Type of exposure (heat, gas, chemical) • Burns, pain, swelling • Superficial (1st Degree): red - painful (Don’t • Inhalation injury • Dizziness include in TBSA) • Time of Injury • Loss of consciousness • Partial Thickness (2nd Degree): blistering • Past medical history /Medications • Hypotension/shock • Full Thickness (3rd Degree): painless/charred • Other trauma • Airway compromise/distress could be or leathery skin • Loss of Consciousness indicated by hoarseness/wheezing / • Thermal injury • Tetanus/Immunization status Hypotension • Chemical – Electrical injury • Radiation injury • Blast injury

Scene Safety Universal Patient Care Protocol; UP 1 Quantify and Triage Patients Load and Go with Assessment / Treatment Enroute Assess Burn Type Associated Injury Severity (See Back)

Initial Actions AFTER THERMAL BURN CHEMICAL BURN ELECTRICAL BURN RADIATION BURN

determining SCENE Traumaand Burn ProtocolSection SAFE is to STOP THE YES BURN ! YES Brush off any DRY Chemical Radiation Incident (if indicated) Protocol; TB 10 YES R Irrigate area copiously with R YES Normal Saline for AT LEAST 15 minutes

Decontamination Procedure (If indicated) Assure Chemical Source is Consider NOT Hazardous to Spinal Motion Restriction Protocol; UP 2 Responders. NO Assure power source is Cardiac Arrest Protocol; AC 4 YES Pulseless? secured and turned OFF. NO Assure Electrical Source is Airway, Respirations, or NO longer in contact with Airway Protocol(s); AR 1 – 4 YES Ventilations INADEQUATE? patient before touching patient. NO Carbon Monoxide / YES Carbon Monoxide / Cyanide Poisoning? Cyanide Protocol; TE 2 When Trauma coexists in NO the Burn Patient – initial transport to a verified R Cover burns with Dry Sterile Dressings R Trauma Center is warranted Vascular Access Protocol; UP 3

THERMAL BURN OR CHEMICAL BURN? ELECTRICAL BURN?

YES YES

Lactated Ringer initiated at Lactated Ringer initiated at P 0.125 mL x kg x % TBSA per hour P P 0.25 mL x kg x % TBSA per hour P (for first 8 hours) via PUMP infusion (for first 8 hours) via PUMP infusion

Consider Trauma: Multisystem Protocol; TB 8 Consider Pain Control; AM 13 M Notify Destination or Contact Medical Control M

2020 Version 1 TB 2 BURNS

• Lactated Ringers is first choice for fluid resuscitation over Normal Saline, if it is available. • CHEMICAL / THERMAL BURNS: fluid resuscitation 2 mL x kg x % TBSA = TOTAL FLUID, give half in first 8 hours; then, second half over next 16 hours • ELECTRICAL BURNS: Fluid resuscitation 4 mL x kg x % TBSA = TOTAL FLUID, give half in first 8 hours; then, second half over next 16 hours Critical or Serious Burns • > 5-15% total body surface area (TBSA); 2nd or 3rd degree burns, or • 3rd degree burns > 5% TBSA for any age group, or • circumferential burns of extremities, or • electrical or lightning injuries, or • suspicion of abuse or neglect, or • inhalation injury, or • chemical burns, or • burns of face, hands, perineum, or feet, or • any burn requiring hospitalization. (These burns will require direct transport to a burn center, or transfer once seen at a local facility where the patient can be stabilized with interventions such as airway management or pain relief if this is not available in the field or the distance to a Burn Center is significant.)

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

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

Pearls • For isolated burns meeting the criteria for burn center treatment, consider air medical transport to a Burn Center. If ANY trauma is present, transport to a Trauma Center first. • Green, Yellow and Red In burn severity do not apply to Triage systems. • Refer to Rule of Nines: Remember the extent of the obvious external burn from an electrical source does not always reflect more extensive internal damage not seen. • Burn Patients are trauma patients, evaluate for multisystem trauma • Burns patients are prone to HYPOthermia – never apply ice or cool the burn, must maintain normal body temperature • Never administer IM pain injections to a burn patient Trauma and Burn Protocol Section Protocol Burn and Trauma • CONSIDER Water Jel application to minor burned areas. Water jels are contraindicated for full-thickness burns and/or partial-thickness burns • Estimate spotty areas of burn by using the size of the patient’s palm as 1 % • Chemical Burns: - Refer to Decontamination Procedure. - Normal Saline or Sterile Water is preferred, however if not available, do not delay irrigation and use tap water. Other water sources may be used based on availability. - Flush the area as soon as possible with the cleanest readily available water or saline solution using copious amounts of fluids. • Thermal Burns: - Evaluate the possibility of geriatric abuse with burn injuries in elderly patients • Electrical Burns: - DO NOT contact patient until you are certain the source of the electrical shock is disconnected. - Attempt to locate contact points (generally there will be two or more.) A point where the patient contacted the source and a point(s) where the patient is grounded. - Sites will generally be full thickness. - Do not refer to as entry and exit sites or wounds. - Cardiac Monitor: Anticipate ventricular or atrial irregularity including VT, VF, atrial fibrillation and / or heart blocks. - Attempt to identify the nature of the electrical source (AC / DC), the amount of voltage and the amperage the patient may have been exposed to during the electrical shock.

Disposition: EMS Transport: ALS: All patients TB 2 BURNS

Cole County EMS Closest Appropriate Designated BURN Centers:

Mercy St. Louis Hospital – 615 S. New Ballas Road, St. Louis, MO 63141 Barnes -Jewish Hospital – 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110

Cole County EMS Closest Appropriate PEDIATRIC Designated BURN Centers:

St. Louis Children’s Hospital, One Children’s Place, St. Louis, MO 63110 Mercy St. Louis Hospital – 615 S. New Ballas Road, St. Louis, MO 63141

IF there is any trauma involved in the mechanism of injury the patient should be transported to the closest appropriate designated Trauma Center.

If both trauma and burns involved, the MOST appropriate protocol based on airway, breathing, and circulation Traumaand Burn ProtocolSection compromise should be exhausted first followed by the other protocol. CONSIDER Burns Protocol; TB 2 and Trauma protocols; TB 3 - 9 Reference the Transport: Trauma Criteria Protocol; UP 19 for closest appropriate trauma center taking into account your current location.

County Locations with transport times > 30 minutes via ground; consider air transport if time permits. At no time should a crew wait on scene for air transport when ground transport can be initiated and transport time < 30 minutes to designated trauma center.

If scene location South of the intersection of highway 54 and Route D, closest appropriate trauma center is Lake Regional Hospital regardless of trauma classification level.

2020 Version 1 TB 2 This Page Intentionally Left Blank

2020 Version Trauma and Burn Protocol Section 7

– to to

Exit if indicated if application of of application AC 11 10 AC /

Appropriate Appropriate Cardiac Cardiac Arrest – Protocol; AC 4 AC Protocol; Arrhythmia Protocol(s); Arrhythmia considered administer Lactated Lactated administer

to release of the to release to an to /extremityan compression should be shouldcompression Ringers to patients that that to Ringers patients MMMM a proximal tourniquet priortourniquet a proximal extremities have suffered a Crush have a injurysuffered P If the Crush injury is isolated is injury If the Crush DO NOT Entrapment without crush syndrome crushwithout Entrapment deficit perfusion injuryVascular with syndrome Compartment status mental Altered P

Differential • • • • 1 IV g / IO

mg 5

3 minutes – - Infusion Consider 2.5 50 mEq IV / IO May repeat 3 x MedicalMedicalMedicalMedical ControlControlControlControl Over 2 Albuterol Nebulizer Sodium Bicarbonate Hyperthermia Protocol; TE 4 TE Hyperthermia Protocol; TB 3 TB Calcium Chloride NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Hypotension / HypotensionProtocol;12Shock / AM 1 Liter per IVhour / IO Normal Saline Hypothermia / HypothermiaFrostbite 5 / TEProtocol; P MMMM 1 L / hr of / Saline1 Normal L hr unable to obtain IV access, access, to obtain unableIV once extrication complete. once extrication If prolonged extrication and and extrication If prolonged get IV access access get and IVadminister P Hypotension Hypothermia findings Abnormal ECG Pain Anxiety NO

P • • • • • Signs and Symptoms Signs and P 4 4

––

seconds seconds OR OR NO IV / IO

≥ 0.12≥ ≥ 0.46 Loss of P waveLoss Abnormal ECG Abnormal Peaked T Waves Peaked QT YES QRS QRS YES Normal Saline If If If indicated indicated

Trauma: Crush Crush Trauma: Syndrome Asystole VT PEA VF // / Protocol; 88 Protocol; TBProtocol; TB Hemodynamically Unstable Hemodynamically Infusion Trauma: MultisystemMultisystemTrauma:Trauma: Cardiac Monitor BurnsBurns Protocol;Protocol; 22 TB TB Entrapped 2 > hours Stage until Scene Safe 500 mL per hour AirwayAirway Protocol(s);Protocol(s); ARAR 11 Decrease PainPain ControlControl Protocol;Protocol; AMAM 1313 VascularVascular AccessAccess Protocol;Protocol; UPUP 33 P UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP P Call for assistance and additional resources

Extremity / body crushedbody Extremity / trench collapse,collapse,Building pinned under heavy industrial accident, equipment Entrapped and crushed under under heavy Entrapped crushedand minutes load > 30

2020

Version 1 Version

• • History • Trauma: Crush Syndrome

Cole County EMS Closest Appropriate Designated Trauma Centers:

LEVEL 1 University of Missouri Healthcare, One Hospital Drive Columbia, MO 65212; ER Number: 573-882-8091

LEVEL 3 Lake Regional Health System, 54 Health Drive, Osage Beach, MO 65065 SSM Health St. Joseph Hospital-Lake St. Louis, 100 Medical Plaza, Lake St. Louis, MO 63367

**Reference Transfer: Trauma Criteria Protocol; UP 19 for further guidance.** Trauma and Burn Protocol Section Protocol Burn and Trauma Pearls • Recommended exam: Mental Status, Musculoskeletal, Neuro • Scene safety is of paramount importance as typical scenes pose hazards to rescuers. Call for appropriate resources. • Crush syndrome typically manifests after 2 – 4 hours of crush injury, but may present in < 1 hour. • Fluid resuscitation: If access to patient and initiation of IV fluids occurs after 2 hours, give 2 liters of IV fluids in adults and then begin > 2 hour dosing regimen. • Shock may be present with a normal blood pressure initially. • Shock often is present with normal vital signs and may develop insidiously. Tachycardia may be the only manifestation. • Consider all possible causes of shock and treat per appropriate protocol. • Patients may become hypothermic even in warm environments. • Hyperkalemia from crush syndrome can produce ECG changes described in protocol, but may also be a bizarre, wide complex rhythm. Wide complex rhythms should also be treated using the VF/Pulseless VT Protocol.

Disposition: EMS Transport: ALS: All patients

2020 Version 1 TB 3 Trauma and Burn Protocol Section R R 4 4

–– Abrasion Contusion Laceration Sprain Dislocation Fracture Amputation

Tourniquet ProcedureTourniquet Differential • • • • • • •

if indicated if - AirwayAirway Protocol(s);Protocol(s); ARAR 11 and place in air tight container. Wound Care Place CONTAINER on ice if available Clean amputated part, Wrap part in sterile dressing soaked in normal saline R R YES NO YES YES R R TB 4 TB NO P MMMM Deformity function motor / sensation Altered refill capillary / pulse Diminished temperature extremity Decreased Pain, swelling Pain,

• • • • Signs and SignsSymptoms • TBTB 33 NO NO NO NO YES YES Tourniquet ProcedureTourniquet Splinting Splinting

Consider if available if if indicated if - Wound care Adequate? Open Fracture? Airway Patent? MedicalMedicalMedicalMedical ControlControlControlControl bleeding noted? Trauma: Extremity Trauma: PainPain Protocol;Protocol; AMAM 1313 Any major external Amputation and / or Bleeding Controlled? Bleeding Controlled? Monitor and Reassess Respiration Ventilation / VascularVascular AccessAccess Protocol;Protocol; UPUP 33 NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Trauma:Trauma: CrushCrush SyndromeSyndrome Protocol;Protocol; Trauma:Trauma: MultisystemMultisystem Protocol;Protocol; TBTB 88 Wound Care Topical HemostaticTopical / DressingAgent HypotensionHypotension / Shock/ Shock Protocol;Protocol; AMAM 1212 UniversalUniversal PatientPatient Protocol;Protocol;Care Care UP UP 11 Control Hemorrhage with Pressure Hemorrhage Control Direct P MMMM R R Open vs. closed wound / fracture / wound closed vs. Open contamination Wound history Medical Medications Type of of injury Type /amputation penetrating / crush Mechanism: injury of Time 2020 Version 1 Version

• • • • • • • History Version 1

2020 Trauma and Burn Protocol Section Disposition: • • • • • • • • • Pearls

Reference Procedure ## for tourniquet application if if needed ## application tourniquet for Reference Procedure of pressure. direct instead first may Procedureconsidered Tourniquet be casualty incident: Multiple injury. of time the hours within6 from repair for mustevaluated be Lacerations injuries. with extremity orconcealedbenot apparent lossmay Blood ifapplicable. transport early air andconsiderlocation compromise; with vascular transport any injury Urgently ePCRin findings frequentlydocument and sensation compromise; assess circulation, vascular of havea incidence high / dislocations fracture kneeand elbow and Hip dislocations control. notifymedical andtrauma facility Transportappropriate to is timecritical. amputations, In isstatusimportant neurovascular Peripheral Extremity,NeuroStatus, Exam:Mental Recommended EMS Transport: EMS BLS: ALS: Trauma: Trauma: Extremity Patients with minimal controlled bleeding, normal vitals signs, and no anticoagulant use. use. anticoagulant no and signs, vitals normal bleeding, controlled minimal with Patients amputation. and/or bleeding, uncontrolled signs, vital abnormal tourniquets, with patients All TB 4

pulse, and pulse, Trauma: Eye

History Signs and Symptoms Differential • SAMPLE • Shooting or streaking lights • Globe Rupture • OPQRST • Halos • Acute Closed Angle Glaucoma • Time of Injury • “Lowering Shade” in vision • Stroke • Previous Visual Impairment • Acute vision loss • Retinal Artery Occlusion • Contacts / glasses • Bleeding • Thermal / Chemical Burn • Retinal Venous Thrombosis • Detached Retina • Impalement

Universal Patient Care Protocol; UP 1

Nature of

Complaint? Traumaand Burn ProtocolSection

Non – Traumatic Injury Traumatic EXIT to Injury isolated to Trauma: Pain / Vision Loss NO eye(s) Multisystem; TB 8 Visual Assessment / Pupil Assessment NO YES Normal?

NO Blunt Injury? Impalement? EXIT to Neurological exam Stroke YES abnormal with focal Protocol deficit? Stabilize object AM 16 Globe Rupture? YES R in place. R NO DO NOT REMOVE

YES Chemical Burn? NO

Visual Irrigate with 2 L NO R Assessment R R Normal Saline or R Sterile Water

R Shield and Protect R Both eyes

Vascular Access Protocol; UP 3

P Ondansetron 4 mg P IV / IO / ODT

Pain Protocol; AM 13

R Monitor and Reassess R Notify Destination or M Contact Medical Control M

2020 Version 1 TB 5 Trauma: Eye

Globe Rupture: teardrop shaped pupil; concern for open globe rupture. DO NOT apply pressure to injured eye to prevent increase in intraocular pressure.

Chemical Burns to the eye: irrigate chemical burns to the eyes with copious amounts of normal saline or sterile water. - Alkali substances lead to very rapid and deep eye injury, irreversible damage to the eye can occur within a few minutes of alkali exposure. -Acid burns tend to be less severe, but still can result in significant eye damage, especially if the chemical is not rapidly removed.

Closed Angle Glaucoma: occurs when fluid cannot drain from the eye, increasing intraocular pressure. s/s would include blurry vision, headache, severe eye pain, halos, n/v.

Hyphema: a pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris) caused by injury to the eye. Compared to a subconjunctival hemorrhage a Hyphema is usually painful.

All severe eye injuries should be transported to the closest appropriate facility; consult medical control as needed. Trauma and Burn Protocol Section Protocol Burn and Trauma

Pearls • Required exam: VS, GCS, Visual Assessment, Neurological exam, Pupils • Stabilize any penetrating objects. DO NOT remove any embedded / impaled objects • Transport with head of stretch elevated to 60 degrees to help reduce intraocular pressure • Remove contact lenses when possible • Always cover both eyes to prevent further injury • Orbital fractures increase concern for glove or optic nerve injury; continually assess for visual changes • Normal visual acuity can be present, even in severe injury • Detached retina; clinical sign is visual loss; may describe “Lowering shade” over eye.

Disposition: EMS Transport: ALS: All patients BLS: Patient with non-critical burns, SPO2 > 94% on room air and vital signs within normal limits

2020 Version 1 TB 5 Trauma and Burn Protocol Section mmHg 35

– 4 4

–– See Pearls Evidence of Brain Herniation: HYPERVENTILATE of Pupils / Posturing DO NOT ROUTINELY EtCO2 30 Hyperventilate to maintain Unilateral or Bilateral Dilation Skull fractureSkull Contusion,injury Brain (Concussion, Laceration)orHemorrhage Epidural hematoma hematomaSubdural Subarachnoid hemorrhage injurySpinal Abuse

Differential • • • • • • • AirwayAirway Protocol(s);Protocol(s); ARAR 11 DiabeticDiabetic Protocol;Protocol; AMAM 77 TB 6 TB NO B P R P P YES MMMM Pain, swelling, bleeding Pain, swelling, statusAltered mental Unconscious failure /distress Respiratory Vomiting mechanism of injury traumaticMajor Seizure

Trauma: Head Trauma: • • • • • • • Signs and Symptoms Signs and ≥ 94% mmHg YES If indicatedindicated IfIf NO NO 45 > 250 mg /dl?

If If If indicated indicated If If indicated indicated

– adequate? OR 35

Maintain EtCO2 Airway Patent? Cardiac Monitor Maintain SpO2 Maintain SpO2 SeizureSeizure Protocol;Protocol; AMAM 1414 Obtain and Record Obtain GCS and < 60 Monitor and Reassess trauma NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination andandandand - ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl PainPain ControlControl Protocol;Protocol; AMAM 1313 Ventilations / Respirations VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Universal Patient Care Protocol; UPUPPatient Patient Protocol; Protocol; Care Care UniversalUniversal11 Blood Glucose Analysis ProcedureAnalysis GlucoseBlood Supplemental oxygen as oxygen neededSupplemental as to Spinal Motion Restriction Protocol; UPUP Protocol;Protocol;22 Motion Motion Restriction Restriction Spinal Spinal Trauma:Trauma: MultisystemMultisystem Protocol;Protocol; TBTB 88 HypotensionHypotension / / ShockShock Protocol;Protocol; AMAM 1212 AlteredAltered MentalMental StatusStatus Protocol;Protocol; AMAM 22 Prevent Oxygen desaturation events < 90% Prevent desaturation events Oxygen MMMM B P R P P Evidence formultiEvidence Loss of consciousnessLoss Bleeding historymedicalPast Medications Time Time of injury vs.(bluntpenetrating)Mechanism

2020 Version 1 Version

• • • • • • History • Trauma: Head

Glascow Coma Score

Pearls • Recommended Exam: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro • A single episode of hypoxia and/or hypotension can significantly increase morbidity and mortality with head injury. • Hyperventilation in head injury: - Hyperventilation lowers CO2 and causes vasoconstriction leading to increased intracranial pressure (ICP) and should not be done routinely. - Use in patient with evidence of herniation (blown pupil, decorticate / decerebrate posturing, bradycardia, decreasing GCS). - If hyperventilation is needed, ventilate at 14 – 18 / minute to maintain EtCO2 between 30 - 35 mmHg. Short term option only used for severe head injury typically GCS ≤ 8 or unresponsive. • Do not place in Trendelenburg position as this may increase ICP and worsen blood pressure. • Poorly fitted cervical collars may also increase ICP when applied too tightly. • In areas with short transport times, Medication Facilitated Intubation is not recommended for patients who are spontaneously breathing and who have oxygen saturations of ≥ 90% with supplemental oxygen including BIAD / BVM. • Hypotension: - Limit IV fluids unless patient is hypotensive. - Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushing's Response). Trauma and Burn Protocol Section Protocol Burn and Trauma - Usually indicates injury or shock unrelated to the head injury and should be aggressively treated. - Patients ages 15 – 49 and > 70 years old: Goal is to maintain systolic BP greater than 110 mmHg - Patients ages 50 – 69 years old: Goal is to maintain systolic BP greater than 100 mmHg • An important item to monitor and document is a change in the level of consciousness by serial examination. • Consider Restraints if necessary for patient’s and/or personnel’s protection per Behavioral Protocol; AM 5 • Concussions: - Traumatic brain injuries involving any of a number of symptoms including confusion, LOC, vomiting, or headache. - Any prolonged confusion or mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated by a physician ASAP. - EMS Providers should not make return-to-play decisions when evaluating an athlete with suspected concussion. This is outside the scope of practice.

Disposition: EMS Transport: ALS: Patient with abnormal neurologic exam, loss of consciousness, respiratory distress, significant mechanism of injury, or persistent vomiting BLS: Patients with normal neurological exam and physical findings suggestive of a head injury

2020 Version 1 TB 6 Trauma and Burns Protocol Section 11

– 6

7 –

– Thermal InjuryThermal Electrical Injury Injury Blast Infarction Acute Myocardial Altered Mental Status

Differential • • • • • Cardiac Arrest Protocol; AM 3 to to appropriate Cardiac Protocol; AC 4

Protocol(s); AR 1 Airway / Respiratory Altered Mental Status Diabetic Protocol; AM 7 Seizure Protocol; AM 14 EXIT M Arrhythmia Protocol; AC 1 TB 7 TB Stage and call for NO YES additional resources YES YES YES YES Medical Control Notify Destination or Contact or Notify Contact Destination Wounds to hands, feet, or areas feet, of hands,toareas contact or Wounds /Vomiting /Nausea Diarrhea Peripheral / Central pulses Amnesia Altered Mental Status deficitsNeuro

• • • • • • Signs and Symptoms Signs and NO M P B B NO Lead Lead

– NO NO NO NO NO YES YES YES Trauma: Lightning Strike Lightning Trauma: Lead Procedure

Seizure? – CONSIDER adequate? 12 / 15 15 12 / < 60 OR > 250?< 60 > OR Scene Safety Scene Cardiac Arrest? 12 / 15 15 12 / Blood Glucose Procedure Blood Glucose Interpretation abnormal? Interpretation abnormal? Vascular Access Protocol; UP 3 Altered Level of Consciousness? Universal Patient Protocol;Care UP 1 P B B Spinal Motion Restriction Protocol; 2 UP Airway Patent, Oxygenation and ventilation

Duration of Unresponsiveness Duration of Time of strike Number of patients Type of Strike (Direct, Splash, orSplash, of Contact) Strike Type(Direct, Unresponsiveness

2020

Version 1 Version

• • • • History • Version Trauma and Burns Protocol Section 2020 Disposition • • • • • • • • Pearls

Outdoor injury is most common, but contact with plumbing, phone lines, etc. struck by lightning can cause injury to people to people injury in cause can lightning by struck etc. lines, phone plumbing, with contact but common, most is injury Outdoor first breathing not are who those to provided be should Resuscitation un apply not circumstances. do these protocols triage typical survive; arrest or respiratory cardiac suffer not do who strike lightning of Victims include: strike a lightning from damage myocardial to direct due changes ECG Potential Medical from Co consultation with made be should resuscitation of termination however, guidelines, ACLS per is arrest Cardiac are injuries spinal c as consciousness of level altered an with patients all in performed be should Restriction Motion Spinal for safe t place a to patient the remove providers, EMS to risk continued is if there a myth; is twice hea striking not thunder or Lightning seen is lightning last the after minutes 30 for continues risk that state guidelines safety lightning National Neuro Back, Extremity, Abdomen, Lungs, Heart, HEENT, Status, Mental Exam: reatment. ommon from the concussive force of the strike and/or involuntary muscle spasms muscle involuntary and/or strike of the force concussive the from ommon doors. ntrol. ntrol. Transport T Elevation, Segment ST Trauma: Trauma: Lightning Strike ALS:

All patients All –

Wave Inversion, and prolongation of the QT interval. QT the of prolongation and Inversion, Wave TB 7 der der rd Trauma and Burn Protocol Section P AMAM 1212 If If If indicated indicated if indicated if Abnormal Tension pneumothorax Tension Flail chest Flail tamponade Pericardial wound chest Open Hemothorax

abdominal abdominal bleeding ------Monitor and Reassess Monitor and 1 gm over 10 minutes IV / IO 10minutes/ 1 gm over IV

Chest: Intra fracture PelvisFemur / / SpineCord injury fracture injuryHead Trauma) (see Head Extremity Dislocation fracture / obstruction)HEENT (Airway Hypothermia M HypotensionHypotension / / ShockShock Protocol;Protocol; TXA

Differential (Life threatening) Differential (Life • • • • • • • • R R P P R P 4 4

–– If indicatedindicated IfIf If If If indicated indicated If If If indicated indicated If If If indicated indicated If If indicated indicated Notify Destination oror Notify Notify Destination Destination TB 8 TB Contact MedicalMedical ContactContactControl Control Protocol; UPUP Protocol; Protocol; 22 If If indicated Cardiac Cardiac Monitor Consider tourniquet Consider tourniquet Spinal Motion Restriction MotionMotion Spinal Spinal Restriction Restriction

VS / Perfusion / GCS Obtain and Record GCS Splint SuspectedFractures Splint AirwayAirway Protocol(s);Protocol(s); ARAR 11 AlteredAltered MentalMental Status;Status; AMAM 33 Trauma:Trauma: HeadHead Protocol;Protocol; TBTB 66 MM PainPain ControlControl Protocol;Protocol; AMAM 1313 Control External Hemorrhage External Hemorrhage Control VascularVascular AccessAccess Protocol;Protocol; UPUP 33

Needle DecompressionNeedle Procedure R Pain, swelling Deformity, lesions, bleeding Altered mental status or unconscious Hypotension or shock Arrest UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP

R R P P R • • • • • Signs and Symptoms Trauma: Multisystem Normal Monitor and Reassess Repeat Assessment Procedure RepeatAdult to < 10minutes to < Limit scene time Limit scene R Restraints / protective equipment Past medical history Medications Location in structure or vehicle Others injured or dead Speed and details of MVC Time and mechanism of injury Damage structure to vehicle or

• • • • • • History • • 2020 Version 1 Version Trauma: Multisystem

Cole County EMS Closest Appropriate Designated Trauma Centers:

LEVEL 1 University of Missouri Healthcare, One Hospital Drive Columbia, MO 65212; ER Number: 573-882-8091

LEVEL 3 Lake Regional Health System, 54 Health Drive, Osage Beach, MO 65065 SSM Health St. Joseph Hospital-Lake St. Louis, 100 Medical Plaza, Lake St. Louis, MO 63367

**Reference Transport: Trauma Criteria; UP 19 for further guidance.**

Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lung, Abdomen, Extremities, Back, Neuro • Transport to Level 1 Trauma Center, Notify prior to arrival “TRAUMA ALERT” • Scene times should not be delayed for procedures. These should be performed en route when possible. Rapid transport of the unstable trauma patient to the appropriate facility is the goal. • Control external hemorrhage and prevent hypothermia by keeping patient warm. • Consider Chest Needle-Decompression with signs of shock and injury to torso and evidence of tension pneumothorax. • Trauma Triad of Death: Metabolic acidosis / Coagulopathy / Hypothermia Appropriate resuscitation measures and keeping patient warm regardless of ambient temperature helps to mitigate metabolic acidosis, coagulopathy, and hypothermia. • Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained ≥ 90% • Tranexamic Acid (TXA):

Trauma and Burn Protocol Section Protocol Burn and Trauma - Should be administered in the presence of extensive bleeding in a patient who is hemodynamically unstable (hypotensive and tachycardic) and within the first hour from onset of incident • Trauma in Pregnancy: - Providing optimal care for the mother = optimal care for the fetus. After 20 weeks gestation (fundus at or above umbilicus) transport patient on left side with 10 – 20° of elevation. Reference Obstetrical Emergencies Protocol; OB 5 for further guidance • Geriatric Trauma: - Evaluate with a high index of suspicion. - Often occult injuries are more difficult to recognize and patients can decompensate unexpectedly with little warning. - Risk of death with trauma increases after age 55. - SBP < 110 may represent shock / poor perfusion in patients over age 65. - Low impact mechanisms, such as ground level falls might result in severe injury especially in age over 65. • Severe bleeding from an extremity not rapidly controlled with direct pressure may necessitate tourniquet application. • Maintain high-index of suspicion for domestic violence or geriatric abuse. Disposition: EMS Transport: ALS: Abnormal exam Abnormal vital signs Loss of consciousness Respiratory distress Significant mechanism of injury BLS: All other patients

2020 Version 1 TB 8 Trauma and Burns Protocol Section M P NO Examiner Contact Law Enforcement Resuscitation and / Medical or YES Do Do Not Attempt Procedure Decompression Medical Control Consider Needle Consider Needle YES weeks Notify Destination or Contact or Notify Contact Destination P Pregnant > 22 M P NO YES 4

– Resuscitation Protocol; 4UP Criteria for Death / Withholding 10

– TB 9 TB YES NO YES YES Pulse? Return of Asystole OR PEA < bpm 40 Protocol; AC 4 500 mL IVvia / IO YES to appropriateto Trauma Normal Saline Bolus Protocol; 1 Protocol; TB

Airway Protocol(s); ARProtocol(s); Airway 1 EXIT Vascular Access UP Protocol;3 Access Vascular YES P Start Resuscitation per Cardiac Arrest P Rapid Transport Level to 1 Trauma Center NO NO YES NO Monitor Trauma: Traumatic Arrest Traumatic Trauma: Blunt Trauma Continuous CardiacContinuous Decomposition of body tissue Injuries incompatible with life? (Incineration, Decapitation, etc. P Rigor Mortis, Dependent Lividity, Universal Patient Protocol; Care 1 UP 2020 Version 1 Version

Trauma: Traumatic Arrest Trauma and Burns Protocol Section Protocol Burns and Trauma

Pearls • Required Exam Palpation of pulses, heart and lung auscultation, pupillary light reflex • Injuries incompatible with life include: decapitation, incineration, massive deformity to head or chest, dependent lividity, rigor mortis • As with all trauma patients, Limit scene time to less than 10 minutes, and transport to Level 1 Trauma Center per Transport: Trauma Criteria Protocol; UP 19 • Consider using medical cardiac arrest protocol if uncertainty exist regarding etiology of arrest • Be aware of crime scene potential; do your best to avoid disturbing forensic evidence • If provider safety concern, transport of deceased patients to hospital is acceptable • In pregnant patients palpating the gravid uterus above the umbilicus is generally a pregnancy > 22 weeks.

2020 Version 1 TB 9 Radiation Incident

History Signs and Symptoms Differential • Type of exposure (heat, gas, • Burns, pain, swelling • Superficial (1st Degree): red – painful chemical) • Dizziness o Don’t include in TBSA • Inhalation injury • Loss of consciousness • Partial Thickness (2nd Degree): blistering • Time of Injury • Hypotension/shock • Full Thickness (3rd Degree): painless/ • Past medical history /Medications • Airway compromise/distress could be charred or leathery skin • Other trauma indicated by hoarseness/wheezing / • Thermal injury • Loss of Consciousness Hypotension • Chemical – Electrical injury • Tetanus/Immunization status • Radiation injury • Blast injury

Initiate HAZMAT notification Scene Safety early Quantify and Triage Patients Load and Go with Assessment Treatment Enroute Collateral Injury: Most all injuries immediately seen will be a result of collateral injury, such as heat from the blast, trauma from concussion, Universal Patient Care Protocol; UP 1 treat collateral injury based on typical care for the type of injury displayed. Traumaand Burns Protocol Section

Radiation Burn or Exposure? Qualify: Determine exposure type; external irradiation, external contamination with radioactive material, internal contamination with radioactive material. Assess Burn and Associated Injury Severity

Quantify: Determine exposure (generally measured in Grays/Gy). Information may be available from those on site who have monitoring Decontaminate patient equipment, do not delay transport R AT THE SCENE R to acquire this information.

Burns Protocol; TB 2

Appropriate Cardiac Protocol(s)

Must provide early notification to receiving facility in order to facilitate proper decontamination procedures

Notify Destination or M M Contact Medical Control

2020 Version 1 TB 10 2012 Radiation Incident

Pearls • Dealing with a patient with a radiation exposure can be a frightening experience. Do not ignore the ABC’s, a dead but decontaminated patient is not a good outcome. Refer to the Decontamination Procedure for more information. • Normal Saline or Sterile Water is preferred, however if not available, do not delay irrigation using tap water. Other water sources may be used based on availability. Flush the area as soon as possible with the cleanest readily available water or sal ine solution using copious amounts of fluids. • Three methods of exposure: o External irradiation o External contamination o Internal contamination • Two classes of radiation: o Ionizing radiation (greater energy) is the most dangerous and is generally in one of three states: Alpha Particles, Beta Particles and Gamma Rays. o Non-ionizing (lower energy) examples include microwaves, radios, lasers and visible light. • Radiation burns with early presentation are unlikely, it is more likely this is a combination event with either thermal or chemical burn being presented as well as a radiation exposure. Where the burn is from a radiation source, it indicates the patient has been exposed to a significant source, (> 250 rem). • Patients experiencing radiation poisoning are not contagious. Cross contamination is only a threat with external and internal

Trauma and Burn Protocol Section Protocol Burn and Trauma contamination. • Typical ionizing radiation sources in the civilian setting include soil density probes used with roadway builders and medical uses such as x-ray sources as well as radiation therapy. Sources used in the production of nuclear energy and spent fuel are rarely exposure threats as is military sources used in weaponry. Nevertheless, these sources are generally highly radioactive and in the unlikely event they are the source, consequences could be significant and the patient’s outcome could be grave. • The three primary methods of protection from radiation sources: o Limiting time of exposure o Distance from o Shielding from the source • Dirty bombs ingredients generally include previously used radioactive material and combined with a conventional explosive device to spread and distribute the contaminated material. • Refer to Decontamination procedure for dirty contamination events. • If there is a time lag between the time of exposure and the encounter with EMS, key clinical symptom evaluation includes: Nausea/ Vomiting, hypothermia/hyperthermia, diarrhea, neurological/cognitive deficits, headache and hypotension. • This event may require an activation of the National Radiation Injury Treatment Network.

Disposition: EMS Transport: ALS: All patients BLS: Patient with non-critical burns, SPO2 > 94% on room air and vital signs within normal limits

2020 Version 1 TB 10 2012 Toxin-Environmental Protocol Section NO contact Document with Animal Contact and 1222 - Control Officer 222 - As needed As 800 - Poison Control 1 YES Transport Mammal Bite Animal Animal bite bite Human (poisonous) Snake bite Spider bite (poisonous) tick) bite (bee, ant, / wasp, Insect sting risk Infection Rabies risk Tetanus risk

Differential • • • • • • • • R R R MMMM R R R R R if ableif TE 1 TE If If If indicated indicated If If If indicated indicated If If If indicated indicated If If indicated indicated If If indicated indicated jewelry clothing / bands clothing / Snake Bite ProtocolProtocol AMAM 22 Redness Redness andTime DO NOT apply ICE Immobilize Injury NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Monitor and Reassess Remove any Remove constricting any Keep bite at level bite of atKeep heart Mark Margin of Swelling / Margin of / MarkSwelling ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Identification of Animal PainPain ControlControl Protocol;Protocol; AMAM 1313 AppropriateAppropriate TraumaTrauma ProtocolProtocol R R R R VascularVascular AccessAccess Protocol;Protocol; UPUP 33 R AllergicAllergic ReactionReaction / Anaphylaxis/ Anaphylaxis General Wound GeneralProcedure Care ExtremityExtremity TraumaTrauma Protocol;Protocol; TBTB 44 UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP MMMM Rash, skin break, wound Pain, tissue soft swelling, redness Blood oozing from the bite wound Evidence of infection Shortness of breath, wheezing Allergic reaction, hives, itching Hypotension or shock Remove any constricting clothing / / bands Remove constricting clothing any

R R R R R • • • • • • • Signs and Symptoms Signs and Bites Envenomationsand if ableif Apply IcePacksApply becomes to to appropriate resources Keep bite at level bite of atKeep heart

hemodynamically Spider Bite / Bee Wasp or Sting protocol if patient unstable airway or EXIT compromise notedis Stage until scene safe

Call help for / additional

R R 2020

Tetanus and Rabies risk Immunocompromised patient Time, location, size of bite / sting Previous reaction to bite / sting Domestic vs. Wild Type of bite / sting Description / photo identification for Version 1 Version

• • • • • • History • Toxin-Environmental Protocol Section • • • • • • • • • • Pearls

Disposition: Version 1 2020 Do NOT apply a Tourniquet for envenomation for Tourniquet a apply NOT Do bites: Spider bites: Snake bites: Carnivore / Cat / Dog bites: Human to wound. proximal streaks red fever, drainage, redness, swelling, infection: of Evidence infection for increased risk at an are etc. patients, transplant chemotherapy, undergoing patients diabetics, such as patients Immunocompromised purposes. identification for or insect animal an capture to attempting in danger put responders not Do (1 guidance for Center Control Poison the contacting Consider Back, an Abdomen, Heart, Lung, Neck, complete a and injury), of (Location Extremities Skin, Status, Mental Exam: Recommended EMS Transport:EMS d Neuro exam if systemic effects are noted are effects systemic if exam Neuro d - - are bites snake of 25 % About isunlikely. envenomation swelling, or pain Ifno spring. in early and snakes larger with worse generally is variable, envenomation of Amount yellow on "Red toxic. very but pain Very little rare: are bites snake Coral copperhead. and rattlesnake family: pit viper the of generally are area this in snakes Poisonous multicoda). (Pasteurella bacteria to a specific due rapidly infection to progress may bites Cat exposure. Rabies of risk all and have infected to become likely more much are bites Carnivore bacteria. mouth normal due to bites animal than rates infection higher have bites Human

the site of the bite develops over the next few days (brown spider with fiddle shape on back). on shape fiddle with spider (brown days few next the over develops bite the of site the belly). on hourglass red with isblack (spider develop may Brown Recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at at necrosis tissue but initially isnoted reaction Little painless. to painful minimally are bites spider Recluse Brown pain abdominal severe and pain muscular hours, a few over but painful, be minimally to tend bites spider Widow Black Bites andBites Envenomation BLS ALS: : All other patients All :other Significant Significant swelling snakebite Poisonous distressRespiratory Anaphylaxis TE 1 Uncontrolled bleedingUncontrolled swallowing speakingDifficulty / Rapid progression symptoms of - 800 - 222 - 1222). -

kill a fellow, red on black black on red fellow, a kill “ dry ” bites. Epinephrine usedEpinephrine Chestpain Hypotension -

venom lack." lack." venom

Toxin-Environmental Protocol Section

OR 44

–– If If If indicated indicated If If indicated indicated If If indicated indicated ARAR 1 1 As indicated indicated As As DiabeticDiabetic Protocol;Protocol; AMAM 77 CO reading SAFEof Trauma:Trauma: HeadHead Protocol;Protocol; TBTB 66 AppropriateAppropriate AirwayAirway Protocol(s);Protocol(s); ingestant exposures or - AlteredAltered MentalMental StatusStatus Protocol;Protocol; AMAM 33 Diabetic related Infection MI Anaphylaxis Renal failure / dialysis problem Head injury / trauma Co Do not enter building with multiple

unconscious patients without SCBA Differential • • • • • • • YES NO NO R R P TE 2 TE R R MMMM AMS like illness Malaise, flu weakness, Dyspnea Symptoms; cramping GIN/V; Dizziness Seizures Syncope skin Reddened painChest

YES NO AMAM 1212 YES • • • • • • • • • Signs and Symptoms If If If indicated indicated If If indicated indicated Trauma:Trauma: MultisystemMultisystem

Protocol;Protocol; TBTB 88 of Cyanide Scene Scene Safe? Continue Care Continue High Suspicion Airway Patent? Patient Alert and High Oxygen Flow Monitor and Reassesand Monitor Breathing Adequate? NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor Oriented x 4? GCS 15? ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl Continue High Flow Continue Oxygen HypotensionHypotension / / ShockShock Protocol;Protocol; VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Cardiac Cardiac Monitor COMonitor / ConsiderConsider UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP Immediately Remove from Exposure R R MMMM CarbonMonoxide Cyanide / R P R Past Medical PastHistory Duration of Time /exposure Eating large quantity of fruit pits quantity large Eating of Industrial exposure Trauma accidental Suicide,Reason: criminal, Smoke inhalation cyanide Ingestion of

2020 Version 1 Version

• • • • • • • • History Carbon Monoxide / Cyanide

Environmental Protocol Section Protocol Environmental

- Toxin

Pearls • Recommended exam: Neuro, Skin, Heart, Lungs, Abdomen, Extremities • Scene safety is priority. • Consider CO and Cyanide with any product of combustion • Normal environmental CO level does not exclude CO poisoning. • Symptoms present with lower CO levels in pregnancy, children and the elderly. • Continue high flow oxygen regardless of pulse ox readings.

Location of Hyperbaric Chamber and treatment of CO poisoning: University of Missouri Hospital, 1 Hospital Dr., Columbia, MO

Disposition EMS Transport: ALS: All Patients

2020 Version 1 TE 2 Toxic-Environmental Protocol Section R 9

– 11 11

to to ––

Protocol NO YES Pulse? EXIT as indicated as as tolerated as Cardiac Cardiac Arrest Unresponsive Consider Hypothermia 5 Breaths via BVM via5 Breaths BVM Protocol(s); AC Protocol(s); 4 AC to appropriate appropriate to to

R EXITEXIT immersion immersion syndrome Hypoglycemia Cardiac Dysrhythmia Barotrauma sickness Decompression - existing existing medical problem - Cardiac Protocol; AC 1 1 AC AC Cardiac Cardiac Protocol; Protocol; YES Trauma Pre (SCUBA diving) injury Pressure Post R

Differential • • • • R R P B P MMMM YES 66

–– NO YES YES TE 3 TE If If If indicated indicated Lead Lead Procedure As indicated indicated As As As indicated indicated As As

– Lead Lead Interpretation as tolerated as as tolerated as Abnormal?

– Cardiac Cardiac Monitor 5 5 Breaths via BVM Dry / Warm Dry Patient / Remove clothing wet Supplemental Oxygen Supplemental Airway Protocol(s); ARARProtocol(s);Protocol(s); 1 1 AirwayAirway Awake but with AMS NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor 12 / 15 15 12 / ContactContactContactContact MedicalMedicalMedicalMedical ControlControlControlControl 12 / 15 15 12 / VascularVascular AccessAccess Protocol;Protocol; UPUP 33 AlteredAltered MentalMental Status Status Protocol; Protocol; AM AM 33 Drowning UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP P MMMM SpinalSpinal MotionMotion RestrictionRestriction Protocol;Protocol; 22 UP UP Unresponsive changes Mental status signs absent vitalorDecreased Vomiting Foaming / Rales, Wheezing,Rhonchi, Coughing, Stridor Apnea P B R R

• • • • • • Signs and Symptoms R R R R NO YES symptoms evaluation even if evaluation even if Awake and Alert Dry / Warm Patient Dry / Remove wet clothing Remove wet Monitor and Monitor Reassess and Encourageand transport symptoms within 6 hours within symptoms6 hours call 911 if any they911 if call develop (refusing betransport) should asymptomatic or minimalwith asymptomatic or instructed to seek seek tomedical care/ instructed Asymptomatic Asymptomatic drowningpatients Possible history Possibleof trauma submersion/ Duration of immersion of possibilityTemperature of or water hypothermia Submersion in water regardless of waterSubmersion regardless in of depth

2020 R R R Version 1 Version

• • • • History Version 1 Toxic-Environmental Protocol Section 2020 Disposition: • • • • • • • • • • • • • • Pearls

EMS Transport:EMS Spinal motion restriction is usually unnecessary. When indicated it should not interrupt ventilation, oxygenation and/or CPR. and/or oxygenation ventilation, interrupt not should it indicated When unnecessary. isusually restriction motion Spinal hypoxia. has <1 typically patient Drowning conditions. ambient warm with even injuries submersion and drowning with associated often is Hypothermia tra death, obvious Unless status. mental with correlate not does and is difficult setting prehospital in prognosis Predicting worsen to potential due hypoxia) sounds, lung abnormal dyspnea, foam, (cough, patients symptomatic of all transport Encourage high to important equally are ventilation and airway hypoxia, by caused is in drowning arrest Cardiac foa through BVM with Ventilate suction. to attempting time waste NOT DO copious, may be and in airway present is usually Foam temperature water of Regardless temperature water of Regardless danger. of areas from patients remove should rescuers certified and trained appropriately only feasible, When would among death of cause leading isa Drowning safety. scene Ensure oxygen. supplemental of mode appropriate apply then tolerate not does patient if ventilations, BVM with Begin liq a in / immersion submersion from symptom) respiratory (any impairment respiratory experiencing of process is the Drowning Neuro Skin, Survey, Trauma status, Mental Respiratory, Exam: Recommended uid. nsport. ing over the next 6 hours. 6 the next over ing m (suction water and vomit only when present.) present.) when only vomit and water (suction m ALS: Allpatients – – –

resuscitate all patients with known submersion time of of time submersion known with patients all resuscitate If submersion time time Ifsubmersion 3 mL/kg of water in lungs (does not require suction) Primary treatment is reversal of of isreversal treatment Primary suction) require not (does lungs in water of mL/kg Drowning TE 3 ≥ 1 ≥ hour consider moving to recovery phase instead of rescue. of instead phase recovery to moving consider hour - be rescuers. be ≤ 25 ≤ minutes. minutes. - quality CPR. quality

Toxic-Environmental Protocol Section P R R MMMM Procedure Hot, dry skin Hot, dry of hyperthermiaof HEAT STROKE HEAT 4 4

–– Hypotension, AMS / Coma / Hypotension, AMS Temperature Measurement Temperature Measurement should NOT delay treatment Fever, usually > 104°F (40°C) Fever, usually Fever (Infection) Dehydration Medications (Thyroid Storm)Hyperthyroidism tremens (DT's) Delirium exhaustion,Heat cramps, stroke lesionsCNS tumors or

Differential • • • • • • • AMAM 33 AMAM 1212 As indicated indicated As As indicated indicated As As As indicated indicated As As R MAX Dose L 2 500 mL / IV IO MedicalMedicalMedicalMedical ControlControlControlControl Monitor and Reassess Monitor and Normal Saline Bolus Active Active cooling measures AirwayAirway Protocol(s);Protocol(s); ARAR 11 Repeat to effect SBP 90 > Target Temp < 102.5° F 102.5° Temp (39°C) Target < HypotensionHypotension / / ShockShock Protocol;Protocol; VascularVascular AccessAccess Protocol;Protocol; UPUP 33 AlteredAltered MentalMental StatusStatus Protocol;Protocol; NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact MMMM P R R TE 4 TE As indicated indicated As As environment Cool, skin moist Cooling measuresCooling HEAT EXHAUSTION HEAT Remove clothingtight DiabeticDiabetic Protocol;Protocol; AMAM 77 Assess Symptom AssessSeverity Elevated body temperature Elevated body Blood Glucose AnalysisProcedure Blood Glucose Weakness, Anxious, Tachypnea Anxious, Weakness, Remove heat to from coolsource Altered coma mental status / sweatyHot,or dry skin Hypotension shock or Seizures Nausea

R • • • • • Signs and Symptoms Hyperthermia R HEAT CRAMPSHEAT Protocol;Protocol; UPUP 11 Warm, moist skinWarm, moist PO Fluids as tolerated as PO Fluids Monitor and Reassess Monitor and UniversalUniversal PatientPatient Care Care Weakness, Muscle Muscle crampingWeakness, Normal to elevated temperature to body Normal Fatigue and / or muscle cramping muscleor Fatigue / and or humidity or medicalhistoryMedications Past/ exposure Time duration and of exertion Poor PO extreme intake, Age, very very young Age,old and temperatures /and Exposure increased to

2020 R Version 1 Version

• • • • • • History Hyperthermia

Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Neuro • Extremes of age are more prone to heat emergencies (i.e. young and old). Obtain and document patient temperature if able. • Predisposed by use of: tricyclic antidepressants, phenothiazines, anticholinergic medications, and alcohol. • Cocaine, Amphetamines, and Salicylates may elevate body temperatures. • Intense shivering may occur as patient is cooled. • Heat Cramps: Consists of benign muscle cramping secondary to dehydration and is not associated with an elevated temperature. • Heat Exhaustion: Consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea and vomiting. Vital signs usually consist of tachycardia, hypotension, and an elevated temperature. • Heat Stroke: Consists of dehydration, tachycardia, hypotension, temperature ≥ 104°F (40°C), and an altered mental status. Sweating generally disappears as body temperature rises above 104°F (40°C). The young and elderly are more prone to be dry with no sweating. Exertional Heat Stroke: In exertional heat stroke (athletes, hard labor), the patient may have sweated profusely and be wet on exam.

Rapid cooling takes precedence over transport as early cooling decreases morbidity and mortality. Environmental Protocol Section Protocol Environmental

- Monitor temperature and remove patient when temperature reaches 102.5°F (39°C). Your goal is to decrease temperature below 104°F (40°C) with target of 102.5°F (39°C) within 30 minutes. Other methods include cold wet towels below and above the body or spraying cold water over body continuously.

Toxic • Neuroleptic Malignant Syndrome (NMS): Neuroleptic Malignant Syndrome is a hyperthermic emergency which is not related to heat exposure. It occurs after taking neuroleptic antipsychotic medications. This is a rare but often lethal syndrome characterized by muscular rigidity, AMS, tachycardia and hyperthermia. Drugs Associated with Neuroleptic Malignant Syndrome: Prochlorperazine (Compazine), promethazine (Phenergan), clozapine (Clozaril), and risperidone (Risperdal) metoclopramide (Reglan), amoxapine (Ascendin), and lithium. Management of NMS: Supportive care with attention to hypotension and volume depletion. Use benzodiazepines midazolam for seizures; if muscular rigidity is a concern, consult medical control for additional order.

Disposition: EMS Transport: ALS: Mental Status Changes Hypotension Seizures Temperature >101° F Orthostatic Changes Significant Dehydration Nausea and Vomiting Dehydration Severe Cramping BLS: Patient without above conditions

2020 Version 1 TE 4 Toxic-Environmental Protocol Section to to

NO Pulse Exit See Pearls See Protocol(s) Unresponsive Procedure hypothermia Appropriate Cardiac Appropriate Cardiac Temperature Temperature Measurement Temperature Measurement should NOT delay treatment of NOT delay treatment should Stroke injuryHead cord Spinal injury YES Sepsis exposureEnvironmental Hypothyroidism Hypoglycemia dysfunction CNS

Differential • • • • • R R B P P P MMMM R Systemic Systemic Hypothermia 44

–– TE 5 TE AMAM 33 As indicated indicated As As AMAM 1212 As indicated indicated As As As indicated indicated As As As indicated indicated As As indicated indicated As As Dry / Warm Dry Patient / MAX Dose 2 L DoseMAX 2 500 mL IV / IO 500 mL / IV Cardiac Monitor Cardiac Remove wet Removeclothing wet DiabeticDiabetic Protocol;Protocol; AMAM 77 MedicalMedicalMedicalMedical ControlControlControlControl Hypothermia / Frost Hypothermia / Bite Normal Saline Normal Bolus Passive warming measures Passive Monitor Monitor and Reassess Active warming measures warmingActive Vascular Access UPUP Protocol;Protocol;33 Access Access Vascular Vascular AirwayAirway Protocol(s);Protocol(s); ARAR 11 Awake with / without AMS Awake / without with Blood Glucose Analysis ProcedureAnalysis Blood Glucose HypotensionHypotension / / ShockShock Protocol;Protocol; MultipleMultiple TraumaTrauma Protocol;Protocol; 88 TB TB AlteredAltered MentalMental StatusStatus Protocol;Protocol; Altered coma mental status / clammy Cold, Shivering Extremity abnormality pain sensory or Bradycardia Hypotension shock or NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact Repeat to titrate SBP > 90mmHgtitrateto RepeatSBP >

B R R • • • • • • Signs and Symptoms P P P R Hypothermia / Frostbite Hypothermia MMMM R R R Hypothermia Frostbite Hypothermia / Skin warm to Protocol;Protocol; UPUP 11 DO NOT Massage NOTDO General Wound Wound Care General Localized ColdInjuryLocalized UniversalUniversal PatientPatient Care Care DO allow DO NOTrefreezing DO NOT Rub Rub Skin NOTDO warm to R R R Length of exposure / Wetness / / Wind of Length chill / Wetness exposure may occur occur in normal maytemperatures medicalhistoryMedications Past/ use: barbituates DrugAlcohol, Sepsis Infections / Age, very very young Age,old and butExposure decreased temperatures to

2020 Version 1 Version

• • • • • • History Hypothermia / Frostbite

Pearls • Recommended Exam: Mental Status, Heart, Lungs, Abdomen, Extremities, Neuro • NO PATIENT IS DEAD UNTIL WARM AND DEAD (Body temperature ≥ 93.2° F, 32° C.) • Many thermometers do not register temperature below 93.2° F. • Hypothermia categories: - Mild 90 – 95° F ( 32 – 35° C) - Moderate 82 – 90° F ( 28 – 32° C) - Severe < 82° F ( < 28° C) • Mechanisms of hypothermia: - Radiation: Heat loss to surrounding objects via infrared energy ( 60% of most heat loss.) - Convection: Direct transfer of heat to the surrounding air. - Conduction: Direct transfer of heat to direct contact with cooler objects (important in submersion.) - Evaporation: Vaporization of water from sweat or other body water losses. • Contributing factors of hypothermia: Extremes of age, malnutrition, alcohol or other drug use.

Environmental Protocol Section Protocol Environmental • If the temperature is unable to be measured, treat the patient based on the suspected temperature. - • CPR: - Severe hypothermia may cause cardiac instability and rough handling of the patient theoretically can cause ventricular fibrillation. - This has not been demonstrated or confirmed by current evidence. Intubation and CPR techniques should not be with-held due to

Toxic this concern. - Intubation can cause ventricular fibrillation so it should be done gently by most experienced person. - Below 86°F (30° C) antiarrhythmics may not work and if given should be given at increased intervals. Contact medical control for direction. Epinephrine can be administered. Below 86° F (30°C) pacing should not utilized. - Consider withholding CPR if patient has organized rhythm or has other signs of life. Contact Medical Control. - If the patient is below 86° F (30° C) then defibrillate 1 time if defibrillation is required. Deferring further attempts until more warming occurs is controversial. Contact medical control for direction. - Hypothermia may produce severe bradycardia so take at least 60 seconds to palpate a pulse. • Active Warming: - Remove from cold environment and to warm environment protected from wind and wet conditions. - Remove wet clothing and provide warm blankets / warming blankets. - Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly against the patient's skin.

Disposition: EMS Transport: ALS: Temperature <95° F (35° C) Mental status change Bradycardia Hypotension Hypoglycemia BLS: All other patient

2020 Version 1 TE 5 Toxin-Environmental Protocol Section - P P P 1222 - 222

- (Coreg) 800 - Poison Control: 1 YES over 5 minutes over 5 1 g IVIO 1 Bolusg / Atropine Calcium Calcium Chloride 1 mEq / kg IVIO/ 1 / mEq kg procedure Protocol;Protocol; UPUP 33 Common Beta Blockers: Sodium Bicarbonate Sodium May repeat x 2 x repeat May VascularVascular AccessAccess 0.5 mg IV / 0.5 mg IVIO XL), Atenolol, (Tenormin), symptomatic? for for severe cases LA, InnoPran XL), Carvedilol Labetalol, Propanolol (Inderal Metoprolol, (Lopressor, Toprol Consider external pacing Consider pacing external Suspected Suspected Hyperkalemia? Status Status Epilepticus Anticholinergic Syndrome Tetanus Meningitis, Hyperventilation HypomagnesemiaHypocalcemia, Oropharyngeal infections SyndromeSerotonin Sepsis P P Bradycardia, Dysrhythmia, and/or Bradycardia, Dysrhythmia, P

Differential • • • • • • • • P MMMM R 4 4

YES –– ≥ 0.12 AR 1 1 1 AR AR YES YES Protocol;Protocol; AMAM 12 12 as needed as HypotensionHypotension / Shock/ Shock Airway Protocol(s); Protocol(s); Protocol(s); Airway Airway over 5 minutes minutes 5 over TE 6 TE bronchospasm, 1 mEq / kg IV / IO IO IV / kg / mEq 1 Propranolol?

Monitor Monitor and Reassess Hypoglycemia, MedicalMedicalMedicalMedical Control Control Control Control

- Sodium Bicarbonate Bicarbonate Sodium - hypotension,

QRS widening? Stupor -

- Notify Destination or Contact orororor Notify Notify Notify Notify Contact Contact Contact Contact DestinationDestinationDestinationDestination R P M Cardiac bradycardia, AV Block Pulmonary wheezing Metabolic Hyperkalemia Neuro YES YES Identified? Beta Blocker Blocker Beta

P B P • • • • Signs and Symptoms and Signs B NO 2 minutes 2 - YES YES Sotalol? NO NO Overdose: BetaOverdose:Blocker Magnesium Sulfate Sulfate Magnesium lead Procedure Abnormal? - lead Interpretation lead - Monitor Monitor for Prolonged 2g IV / IO over 1 over / IO IV 2g Hypotension? QT / Torsades dePointes TorsadesQT / Scene Scene Safety Blood Glucose Procedure Blood Glucose Blood Glucose < 60 12/15 12/15 Poor perfusion, Shock, P Inadequate Respirations / Oxygenation / Ventilation? UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP YES B P B AMAM 77 DiabeticDiabetic Protocol;Protocol;

Available medications in home Past medical history, medications Substance ingested, route, quantity Time of ingestion Reason (suicidal, accidental, criminal) Ingestion or suspected ingestion of a potentially toxic substance

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Version 1 Version

• • • • • • History

OverdoseOverdose: / Toxic Beta IngestionBlocker Environmental Protocol Section Protocol Environmental

- Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Bring bottles, contents, emesis to ED.

Toxin • Time of Ingestion: 1. Most important aspect is the TIME OF INGESTION PLUS the substance, amount ingested, and any co-ingestant. 2. Every effort should be made to elicit this information before leaving the scene. • Many beta blocker ingestions do not cause symptoms; exceptions are the elderly poor cardiac / respiratory reserve, and co- ingestions with other cardiac medications • Contact Poison Control 1-800-222-1222 • Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. • Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. • Patients will present with bradycardia, hypotension, and decreased cardiac output – ultimately leading to poor organ perfusion. • Overdose can also cause conduction disturbances such as first degree heart block and delayed intraventricular conduction/ widened QRS. • Cardiogenic pulmonary edema is possible. Administer Normal Saline for blood pressure support with caution • Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. Disposition: EMS Transport: ALS: All patients

2020 Version 1 TE 6 Toxin-Environmental Protocol Section 4 4 4

–– 1222 - 222 AR 1 1 1 AR AR - 800 - Poison Control: 1 Airway Protocol(s); Protocol(s); Protocol(s); Airway Airway Status Epilepticus Anticholinergic Syndrome Meningitis, Tetanus Hyperventilation Hypocalcemia, Hypomagnesemia Oropharyngeal infections Serotonin Syndrome Sepsis

Differential • • • • • • • • YES B P B M R P P 3 - minutes NO NO NO NO NO for for severe cases lead Procedure Calcium Chloride Calcium pacing procedure pacing procedure Consider external TE 7 TE - 1 g IV / IO over 2 IVIO 1 over g / Protocol;Protocol; UPUP 11 lead Interpretation Bradycardia? Monitor and Reassess Monitor and - Hypotension? MedicalMedicalMedicalMedical Control Control Control Control Dysrhythmias? pulmonary edema, rales, Scene Safety Scene

Hyperglycemia (can be

- - Blood Glucose < 60 UniversalUniversal PatientPatient Care Care hypotension, bradycardia, 12/15 Poor perfusion, Shock, Blood Glucose Procedure Blood Glucose

Seizures, dizziness, syncope, -

12/15 Inadequate Respirations / Notify Destination ororororNotifyNotifyNotifyNotify DestinationDestinationDestinationDestinationContact Contact Contact Contact - VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Oxygenation / Ventilation? P P R Overdose: Overdose: Nausea, vomiting

- MMMM Cardiac shock Pulmonary crackles Metabolic marker of severity) Neuro GI P B B YES

• • • • • Signs and Symptoms and Signs YES YES Calcium Channel Blocker Channel Calcium AMAM 1212 AMAM 77 Protocol(s)Protocol(s) AppropriateAppropriate CardiacCardiac DiabeticDiabetic Protocol;Protocol; HypotensionHypotension / / ShockShock Protocol;Protocol; (Cardizem, Tiazac), Nicardipine, Amlodipine (Norvasc), Diltiazem Nifedipine (Procardia), Verapamil

Common Calcium Channel Blockers:

2020

Version 1 Version

• • • • • • History Overdose:

OverdoseCalcium Channel/ Toxic BlockerIngestion

Environmental Protocol Section Protocol Environmental

- Toxin

Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Bring bottles, contents, emesis to ED. • Time of Ingestion: 1. Most important aspect is the TIME OF INGESTION and the substance and amount ingested and any co-ingestants. 2. Every effort should be made to elicit this information before leaving the scene. • Sustained release preparations may have delayed onset of toxic symptoms (up to 12 hours) • Overdoses with Calcium Channel Blockers have a high mortality!! Electrical conduction abnormalities, vasodilation, myocardial depression are severe. • Contact Poison Control 1-800-222-1222 • Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. • Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. Disposition: EMS Transport: All patients ALS

2020 Version 1 TE 7 Toxin-Environmental Protocol Section 44

–– 1222 - 222 - AR 1 1 AR AR P 800 Protocol;Protocol; AMAM 12 12 - Poison Control: 1 HypotensionHypotension / / ShockShock Airway Protocol(s); Protocol(s); Protocol(s); Airway Airway MMMM R Notify Hazmat Team Major Symptoms Head injury Hazmat Exposure Electrolyte Imbalance Diabetes Myelitis CVA Seizure Sepsis Respiratory Distress / Failure / Distress Respiratory

Altered Mental Status, Seizure, Seizure, Status, Mental Altered

Differential • • • • • • • YES YES YES UP 3 UP 2 mg IV / IO / IM IO / / IV mg 2 resolve

Consider P B B Monitor Monitor and Reassess MedicalMedicalMedicalMedical ControlControlControlControl Atropine Vascular Access Protocol; NotifyNotifyNotifyNotify ororororDestinationDestinationDestinationDestination Contact Contact Contact Contact Repeat q 3 to 5 minutes until symptoms symptoms until minutes 5 to 3q Repeat R MMMM P Minor Symptoms NO NO NO NO TE 8 TE NO Respiratory Distress + SLUDGEM Distress Respiratory lead Procedure abnormal - Toxidrome Protocol;Protocol; UPUP 11 lead Interpretation - Hypotension? Scene Safety Scene Symptom Severity UniversalUniversal PatientPatient Care Care Evidence of Exposure Evidence/ 12/15 Blood Glucose Procedure Poor perfusion, Shock, Overdose: Overdose: 12/15 Inadequate Respirations / Oxygenation / Ventilation? SLUDGEM DUMBELLS Seizures Mental Status Change Vomiting Dysrhythmias

• • • • • • Signs and Symptoms and Signs P B B YES YES YES Asymptomatic Cholinergic / Organophosphate Cholinergic If If If indicated indicated Management: Protocol(s)Protocol(s) AppropriateAppropriate CardiacCardiac Consider provider safety, Consider numbersafety, provider andearly of notification patients facility of receiving occurcrewthe to Toxicity may topical inhalation orfrom agentexposure the to offending DiabeticDiabetic Protocol;Protocol; AMAM 77 Organophosphates / Pesticide Organophosphates / Exposure / CholinergicExposurePatient / Crisis

• •

2020

Version 1 Version

• • • • • • History Overdose:

CholinergicOverdose // OrganophosphateToxic Ingestion

Environmental Protocol Section Protocol Environmental

- Toxin

Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Bring bottles, contents, emesis to ED. • Time of Ingestion: 1. Most important aspect is the TIME OF INGESTION and the substance and amount ingested and any co-ingestants. 2. Every effort should be made to elicit this information before leaving the scene. • Contact Poison Control 1-800-222-1222 • Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. • Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure. • S.L.U.D.G.E: Salivation, Lacrimation, Urination, Defecation, GI Distress, Emesis • D.U.M.B.B.E.L.S: Diarrhea, Urination, Miosis, Bradycardia, Bronchorrhea, Emesis, Lacrimation, Salivation.

Disposition: EMS Transport: ALS: All Patients

2020 Version 1 TE 8 Toxin-Environmental Protocol Section P P P 4 4 11

–– – 1222 -

AR 1 1 AR AR 222 - YES STEMI? YES 800 - Arrhythmia? Airway Protocol(s); Protocol(s); Airway Airway 1 Consider 4 mg / kg 4 IM mg / Ketamine

Ketamine to to Appropriate Cardiac - Midazolam

Protocol; AC 1 2 mg / / kg 2 IVmg / IO Still agitated? 2 - Contact Poison Control: YES 1 EXIT 5 mg IV / 5 / x1 mg IV IN IO IM / Behavioral Protocol; BehavioralAM 5 Status Status Epilepticus Anticholinergic Syndrome Meningitis, Tetanus Hyperventilation Hypocalcemia, Hypomagnesemia Oropharyngeal infections SyndromeSerotonin Sepsis Subarachnoid Hemorrhage Pheochromocytoma

Differential • • • • • • • • • • YES P P P P P B B R YES NO MMMM NO NO NO TE 9 TE Abnormal? lead interpretation lead procedure - - Agitation? Protocol;Protocol; UPUP 11 SpO2 <94% Normal Saline Scene Safety Scene UniversalUniversal PatientPatient Care Care Blood Glucose < 60 Bolus 250 mL IV / IO 12/15 12/15 Blood Glucose Procedure Inadequate Respirations / Overdose: Overdose: Oxygenation / Ventilation? VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Administer Supplemental if O2 Hypertension Tachycardia Agitation Seizure Dilated Pupils Increased Temperature P P B NO NO R

B • • • • • • Signs and Symptoms and Signs Seizure? YES MedicalMedicalMedicalMedical ControlControlControlControl NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination orororor ContactContactContactContact YES MMMM Cocaine and Sympathomimetic Cocaine Pseudoephedrine, Ephedrine, Phenylephrine, AM AM 14 Common Sympathomimetics: Methamphetamine, Terbutaline DiabeticDiabetic Protocol;Protocol; AMAM 77 Seizure Protocol;Seizure

2020

Version 1 Version

• • • • • • History Overdose:

CocaineOverdose and / SympathomimeticToxic Ingestion

Environmental Protocol Section Protocol Environmental -

Toxin Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Bring bottles, contents, emesis to ED. • Time of Ingestion: 1. Most important aspect is the TIME OF INGESTION and the substance and amount ingested and any co-ingestants. 2. Every effort should be made to elicit this information before leaving the scene. • Sympathomimetics: Drugs that mimic the effects of the sympathetic nervous system • Patients on MAOIs for depression may have symptoms of a Sympathomimetic Overdose after eating certain foods such as aged cheese, beer, or mushrooms • Patient with Cocaine or Sympathomimetic overdose are at high risk of arrhythmias, Myocardial Infarction, and Stroke • Contact Poison Control 1-800-222-1222 • Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. • Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure.

Disposition: EMS Transport: ALS: All Patients

2020 Version 1 TE 9 Toxin-Environmental Protocol Section 77

-- 4 4

–– AR 1 1 AR AR to to to AppropriateAppropriate

if indicate indicate if if

CardiacCardiac ArrestArrest CardiacCardiac Protocol(s)Protocol(s) EXITEXIT Protocol(s);Protocol(s); ACAC 4 4 Protocol;Protocol; AMAM 12 12 Airway Protocol(s); Protocol(s); Airway Airway HypotensionHypotension / / ShockShock ictal After Seizure - Post Hypothyroidism ETOH / Benzodiazepine Overdose Intracranial Hemorrhage Hypoglycemia YES YES P

P B Differential • • • • • R B NO P Awake,

– OR 0.4mg 2 mg IM /IM IN 2 mg

YES NO NO YES NO YES AND Pulse? lead Procedure lead Interpretation to 250 mLto - - SpO2 <94%; SpO2 <94%; TE 10 TE Dextrose 10% Dextrose 10% Naloxone Scene Scene Safety respirations respirations return RESPIRATIONS? Maintain 35 EtCO2 Blood Glucose < 60 12/15 12/15 Blood Glucose Procedure Blood Glucose MAX Dose MAX Arrhythmia / STEMI? Rapid Infusion to effectto Infusion Rapidup Alert, and Oriented 4? x Administer Supplemental O2ifSupplementalAdminister VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Patient APNEIC or AGONAL Suspected Opioid Overdose Repeat q 1 1 q minute until Repeatadequate P UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP B Adequate Respirations? Hypotension / Hypertension Tachycardia, dysrhythmias Decreased Respiratory Rate Seizure Pinpoint Pupils Mental Status Changes R P B P

• • • • • • Signs and Symptoms and Signs YES Overdose: Opioid Overdose: M NO R ” 1222 - Refer to Policy:

222 - MedicalMedicalMedicalMedical ControlControlControlControl Program Completed 800 - Naloxone Leave Behind Monitor and Reassess Monitor and Poison Control: 1 **REMINDER** Common Opioids: Notify Destination or Contact orororor Notify Notify Notify Notify Contact Contact Contact Contact DestinationDestinationDestinationDestination 09 “ Hydrocodone (Vicodin) -

Oxycodone (OxyContin), leave behind Narcan Kit After Transport OR AMA

Morphine, Fentanyl, Heroin, R

Crew Must Complete Agency Available medications in home Past medical history, medications Substance ingested, route, quantity Time of ingestion Reason (suicidal, accidental, criminal) Ingestion or suspected ingestion of a potentially toxic substance

2020

M Reporting Form

For Directions / disbursement of 5001 Version 1 Version

• • • • • • History OverdoseOverdose: / Toxic Opioid Ingestion

Naloxone is administered to restore adequate ventilation and oxygenation; NOT to restore consciousness. Patients that received Naloxone should be highly encouraged to allow transport to hospital. Narcotic-dependent patient may experience violent withdrawal symptoms. Before administering Naloxone to a suspected opioid overdose, consider if supportive care alone may be adequate.

When appropriate contact Poison Control Center for guidance. DO NOT delay intervention for life threatening event to contact Poison Control.

Naloxone leave behind Kit should be left with person residing with overdose patient, if no one available, leave kit with patient either at hospital or at residence. Must educate either person or patient on how to use the kit and resources available. Reference policy # 5001-09 “Naloxone Leave Behind Program” for clarification of process

AMA Criteria when Naloxone Administered: 1. Patient must be awake, alert, and oriented x4 to person, place, time, and event; GCS 15 2. Leave behind Narcan Kit must be given to patient, teaching must occur, and patient must be able to teach back how to admin ister Naloxone as needed 3. Normal AMA signatures and assessment documentation must be met

4. Narcan Kit Training and Kit distribution documented in ePCR

Environmental Protocol Section Protocol Environmental - Pearls • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro Toxin • Bring bottles, contents, emesis to ED. • Time of Ingestion: 1. Most important aspect is the TIME OF INGESTION and the substance and amount ingested and any co-ingestants. 2. Every effort should be made to elicit this information before leaving the scene. • All opiates have effects that last longer than Naloxone. Extended Release and Long-Acting formulations will likely need repeat Naloxone Dosing in overdose • While there is no maximum for Naloxone, if the patient does not respond after 2 doses emphasis should be on airway and ventilation support while assessing for other causes of altered mental status. • Intranasal Naloxone should be distributed between both nares to optimize absorption (MAX 1 ml per nare) • Contact Poison Control 1-800-222-1222 • Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. • Consider restraints if necessary for patient's and/or personnel's protection per the Behavioral Protocol; AM 5 and Restraint Procedure

Disposition: EMS Transport: ALS: All Patients

2020 Version 1 TE 10 Toxin-Environmental Protocol Section P P Bolus

– 4 4

–– UP 33 UP UP YES NO AR 1 1 AR AR order Improved? Midazolam Poor Perfusion Protocol; AM 3 Protocol; Normal Saline 250 mL / IV IO Protocol AM 12 Airway Protocol(s); Protocol(s); Protocol(s); Airway Airway to to Appropriate Cardiac to Altered to Mental Status

Protocol; AC 1

Shock / Hypotension Hypotension / Shock VascularVascular AccessAccess Protocol;Protocol; 5 mg IV / IO / IM / IN x1 //IN 5 mg IV/ IM IO EXIT EXIT If still still seizing Iffor call additional P Acetaminophen (Tylenol) Acetaminophen Depressants Stimulants Anticholinergic medications Cardiac agents Solvents, Alcohols, Cleaning (organophosphates) Insecticides Head Injury Electrolyte imbalance Sepsis P

Differential • • • • • • • • • • NO YES YES P YES P B B YES sec QRS Narrowing? ≥ 0.12

TE 11 TE NO YES NO YES NO NO lead interpretation lead procedure AND - Seizure? - Arrhythmia? Sodium Bicarbonate 12/15 12/15 Overdose: Overdose: Wide QRS? Alerted Mental Status? Blood Glucose Procedure (repeat in 10 minutes as needed) as minutes 10 in (repeat Inadequate Respirations / VascularVascular AccessAccess Protocol;Protocol; UPUP 33 Oxygenation / Ventilation? Mental status changes status Mental hypertension / Hypotension rate respiratory Decreased dysrhythmias Tachycardia, Seizures Vomiting S.L.U.D.G.E. D.U.M.B.B.E.L.S 50 mEq IV / IO over 5 minutes UniversalUniversal PatientPatient Protocol,Protocol, Care Care UPUP 11

BP improved • • • • • • • • Signs and Symptoms and Signs P B B P YES P R MMMM Tricyclic Antidepressant YES NO 1222 - NO If If indicated 35 35 mmHg - 222 - Improved? 30 Diabetic Protocol; AM 7 Sodium Bicarbonate Sodium 800 Notify Destination orororor Notify Notify Notify Notify Destination Destination Destination Destination Assisting Ventilations? Ventilations? Assisting - Contact MedicalMedicalMedicalMedical ContactContactContactContactControl Control Control Control 1

Hyperventilate to goal EtCO2 goalto Hyperventilate 100 mEq in in 1 L 100 mEqSaline Normal 200 mL / hr via IVPUMPIO / on/200 mL via hr

Contact Control:PoisonContact Available medications in home Past medical history, medications Substance ingested, route, quantity Time of ingestion Reason (suicidal, accidental, criminal) Ingestion or suspected ingestion of a potentially toxic substance M

2020

Version 1 Version

Common Tricyclic Antidepressants:

P R

Amitriptyline, Clomipramine, Doxepin, • • • • • • History Imipramine, Nortriptyline, Protriptyline Overdose:

OverdoseTricyclic Antidepressant/ Toxic Ingestion

Environmental Protocol Section Protocol Environmental -

Pearls

Toxin • Recommended Exam: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro • Bring bottles, contents, emesis to ED. • Time of Ingestion: 1. Most important aspect is the TIME OF INGESTION and the substance and amount ingested and any co-ingestants. 2. Every effort should be made to elicit this information before leaving the scene. • Tricyclic: 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert mental status to death. • If arrhythmias occur in TCA overdose, first step is to give more Sodium Bicarbonate. Then move on to appropriate arrhythmia Protocol • Avoid BETA-BLOCKERS and AMIODARONE as they may worsen hypotension and conduction abnormalities • Contact Poison Control 1-800-222-1222 • Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or has any weapons. • Consider restraints if necessary for patient's and/or personnel's protection per the Restraint Procedure.

Disposition: EMS Transport: ALS: All Patients

2020 Version 1 TE 11 Obstetrical Protocol Section R s hipss ’ APGAR Appearance Pulse Reflex Grimace / Activity Respirations EXIT OB 4 OB YES

Breech? Protocol; 5 OBProtocol; • • • • • Abnormal Delay Delivery: Delay Delivery: Obstetrical Emergency Obstetrical Prolapsed Cord?Prolapsed Shoulder dystocia?Shoulder Limb Limb Presentation? Keep babycord Keep off notEncourage push to motherElevate for transport Prepare R

to High Risk Child Birth / Birth Labor ChildHigh to Risk / Buttock Foot Hand • • • • R Abnormal Abnormal presentation cordProlapsed Placenta previa Abruptio placenta YES YES

Differential • • • • R MMMM minute minute

Presentation – – APGAR to Bornto Newly

5 1 Physical exam Protocol; 2 OBProtocol; R EXIT Baby Assessment R NO YES Deliver: R Normal OB 1 OB Procedure Is Birth Imminent?Is Birth Contact MedicalMedicalMedicalMedicalContactContactContactContact Control Control Control Control Prepare for for Childbirth Prepare Hypertension /Hypertension Hypotension Abnormal Vaginal Bleeding/ Abnormal Vaginal Presentation (Inspect (no Perineum Presentation digital exam) vaginal pushtoUrge Short Duration between contractions Head needed cordCheck if for nuchal & fix needed) /mouthSuction (if nose Shoulders vagina levelbaby Keep until of at pulsing cord stops cordClampcut / / Stimulatedry Bundle Swaddle / Spasmodic painSpasmodic discharge bleeding or Vaginal urgepushtoorCrowning Meconium Vascular Access UP Protocol;3 Access Vascular Universal Patient Care Protocol; UP Patient 1 Protocol; Care Universal Immediately Notify DestinationDestinationDestinationDestination OROROROR Immediately Immediately Immediately Immediately Notify Notify Notify Notify

• • •

R • • • • Signs and Symptoms Childbirth Childbirth • • • • • • • • MMMM Delivery Care Delivery Care R - Primary Assessment Post

Protocol; Protocol; 3 OB

- EXIT P B High Flow Oxygen to Mother to High Flow Oxygen Monitor and Reassess Vital Signs Reassess Monitor and Vital Mother NO R strength Expedite TransportExpedite Priority Priority Symptoms: of contractions ALS Monitoring ALS during transport during Left lateral position lateralLeft Monitor and Reassess Monitor and Confirm no Crowning Time contractions and noteand Time contractions Prepare for possible delivery for possible Preparedelivery Severe vaginal bleeding vaginal Severe gestation Multiple Crowning gestation weeks <36 presentation Abnormal Vascular Access Protocol; UP Protocol;3 Access Vascular Medications Status Para / Gravida complications Predicted pregnancy, Risk High Time / amount of any vaginal bleeding vaginal any of amount / Time checkup baby last activity, fetal of Sensation last Care, Prenatal history, delivery medical, Past period menstrual Expected Due date Due Expected often how / started contractions Time membranes of Rupture 2020 P B

Version 1 Version • • • • •

• • • • • • • • • History Childbirth

Preparing for Delivery: • Rule of thumb: Typically 24 weeks is the earliest a fetus can be viable. • If time allows, establish IV access in the mother and initiate oxygen therapy and ALS monitoring • Prepare a sterile field and the delivery equipment • Position mother in semi-fowler’s with knees bent and open. Coach breathing. • Inspect perineum for crowning; do not perform a digital vaginal exam • Control the delivery of the head gently and support it as it emerges. Protect the perineum with gentle pressure and puncture the amniotic membrane if still intact. • Check if nuchal cord is present and remove; clamp and cut cord if it is unable to be removed; if time contact Medical Control for guidance. • Suction the mouth then the nose using a bulb syringe as needed • As the shoulders emerge, guide head and neck downward to deliver anterior shoulder; support and lift • Keep the newborn level with the vagina until cord ceases pulsating. Clamp 4 inches and 6 inches from baby. • Cut between the umbilical clamps • Dry the newborn and wrap in a warm blanket, place infant on the mother’s chest to maintain warmth.

Pearls • Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro • Record APGAR at 1 minute and 5 minutes after birth. • Duration between contractions measured from beginning of one contraction to the beginning of another • Consider second ambulance if the pregnancy or delivery are high risk • After delivery, if significant bleeding noted, massage the fundus (firm ball at the level of the umbilicus) will promote uterine contraction and help to control post-partum bleeding. • Document all times (delivery, contraction frequency, and length). • Transport or Delivery? - Decision to transport versus remain and deliver is multifactorial and difficult. Generally it is preferable to transport. - Factors that will impact decision include: number of previous deliveries; length of previous labors; frequency of

Obstetrical Protocol Section Protocol Obstetrical contractions; urge to push; and presence of crowning. • Maternal positioning for labor: - Supine with head flat or elevated per mother’s choice. Maintain flexion of both knees and hips. Elevated buttocks slightly with towel. - If delivery not imminent, place mother in the left, lateral recumbent position with right side up about 10 – 20°. • Umbilical cord clamping and cutting: - Cutting the cord is not an urgent consideration - Once assessment is complete and cord stops pulsing. Place first clamp about 4 inches from infant’s abdomen and second clamp about 2 inches away from first clamp. • Multiple Births: - Twins occur about 1/90 births. Typically manage the same as single gestation. If imminent delivery call for additional resources, if needed. Most twins deliver at about 34 weeks so lower birth weight and hypothermia are common. - Twins may share a placenta so clamp and cut umbilical cord after first delivery. Notify receiving facility immediately. • Watch for signs of pulmonary embolism (cough, rapid heart rate, chest pain, dyspnea) • Watch for signs of uterine rupture (rigid abdomen, tearing pain) • If maternal seizures occur, refer to the Obstetrical Emergencies Protocol. • Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.

Disposition: EMS Transport: ALS: Patient with priority symptoms, imminent delivery, or pregnancy risk factors

2020 Version 1 OB 1 Obstetrical Protocol Section R R 65% 85%

– – – 160 160 bpm - YES YES possible Respirations temperature per minute? Maintain normal Crying / AdequateCrying Heart Rate > 100 Infant with ifmother Infant with Normal Vital Normal Signs Resp /40 Resp min: R Monitor and Monitor Reassess and P Clear airway if necessaryif Clear airway Clear airway if necessary if Clear airway Warm, Warm, Dry Stimulate and SpO2 at 1 min: 60 1 SpO2min: at 80 5 SpO2min: at Heart 120 Rate:Heart R R Secretions Respiratory drive Bolus NO

Airway failureAirway Infection effect Maternal medication Hypothermia Hypovolemia, Hypoglycemia, heart Congenital disease 1:10,000

Differential • • • • • CPR needed May repeat x 1 x repeat May If no improvement If no 10 mL / kg IVIO / 10 /mL kg 0.01 mg/kg IVIO / mg/kg 0.01 CPR at 120/ CPR atminute (Reference Handtevy) (Reference Normal Saline Normal Epinephrine Epinephrine Every 3 to 5tominutes Every as 3 MMMM Ventilate at 3 : 1 Ratio : 1 withRatio atVentilate 3 Pediatric Airway Pediatric Protocol(s) Airway Vascular Access Protocol; UP Protocol;3 Access Vascular P R NO YES OB 2 OB Universal Patient Protocol; Care 1 UP R R Less than 60 seconds seconds 60 than Less R R R

MedicalMedicalMedicalMedical ControlControlControlControl Neonatal Assessment Triangle Neonatal Assessment – Newly Born Respiratory Respiratory distress (normal) mottling cyanosis Peripheral or cyanosis Central (abnormal) of responsiveness level Altered Bradycardia Heart Heart Rate < 60 NotifyNotifyNotifyNotify DestinationDestinationDestinationDestination ContactContactContactContact OR OR OR OR

Lead

• • • • • Signs and Symptoms – a minute a MMMM 60 Dry / Warm Newborn (use towel and stimulate back for 30 seconds) 30 for back stimulate and towel (use Newborn Warm / Dry as needed airway clear to syringe bulb Use position. sniffing in newborn Place nose) then (Mouth, patient the Assess

– YES YES

• • • Respirations R Check chest movement chest Check position airway Change Technique BVM Change Clamp / Cut Cord CutClamp / Gasping / ApneicGasping / CPR at 120/ CPR atminute Supplemental Oxygen Supplemental Monitor Monitor and Reassess

a • • • Heart Rate < 100 bpm? a rate of a40 Cardiac Monitor / 3 Cardiac Monitor / (Suction nose) Mouth then 100

– Reassess Breathing / Heartrate Reassess /Breathing 60 Ventilate at 3 : 1 Ratio :with1 Ratio atCPR Ventilate 3

– BVM Ventilations over 30 seconds over at30 seconds Ventilations BVM Position and Position clear necessaryif airway R R R YES bpm? R R minute APGAR rate of 40rate of BVM VentilationsBVM Heart Rate 60 Rate Heart over 30 seconds a over at 30 Grimace / / ReflexGrimace Activity Respirations Appearance Pulse

substance abuse, smoking, lack substance of abuse, smoking, prenatal care Meconium / Delivery difficulties /Meconium Delivery disease Congenital (maternal) Medications as such Maternal risk factors Due date and date gestational and age Due (twins Multiple gestation etc.) R

2020 • • • • • Version 1 Version

• • • • • • History Version 1 Obstetrical Protocol Section 2020 Disposition: • • • • • • • • • • • • • Pearls

Maternal sedation or narcotics will sedate infant (Naloxone NO LONGER recommended LONGER NO (Naloxone infant will sedate narcotics or sedation Maternal compressions. chest of interruptions Limit recommended. is back the supporting 2 ratio. ventilation to compression a 3:1 with compressions/minute 120 is infants in CPR palm. or wrist, arm, upper right the to applied be should oximetry Pulse 3 by assessed best is lifeand of moments few first the during critical is rate Heart birth: following immediately readings Oximetry Pulse Expected staining: Meconium heat. radiant mattress, thermal wrap, cap,plastic delivery; following infant of warmth Maintain rate. heart and effort respiratory / respirations are born newly the in signs vital important Most recommended. longer is no suctioning Routine resuscitation. no need will generally tone goodmuscle with and breathing / cry strong gestation, Term not If respondi infant epinephrine. and/or compressions, BVM, / to ventilations respond resuscitation requiring newborns Most PCR in Apgars minute 5 1 and Document Neuro Extremities, Abdomen, Heart, Chest, Neck, HEENT, Skin, Status, Mental Exam: Recommended EMS Transport: EMS minutes 10 minutes 5 minutes 4 minutes 3 minutes 2 minute 1 recommended. longer no is suctioning endotracheal direct recommended, is ventilation pressure Positive vigorous: is not who staining meconium through born Infant ng consider hypovolemia, pneumothorax, and/or hypoglycemia (< 40 mg/dL). 40 (< hypoglycemia and/or pneumothorax, hypovolemia, ngconsider BLS: ALS: 85 80 75 70 65 60 – – – – – –

65% 95% 85% 80% 75% 70% Normal delivery with 5 with delivery Normal below. than other patients All Newly Born Newly APGAR Score Chart Score APGAR OB 2 - minute APGAR 9 or 10. or 9 APGAR minute - lead ECG. lead - supportive care only). care supportive - thumbs encircling chest and and chest encircling thumbs Obstetric Protocol Section R placenta R MMMM Await Delivery of DO NOT PULL ON UMBILICAL CORD eclampsia / eclampsiaEclampsia - R Pre Placenta previa Placenta abruptio Spontaneous abortion

Differential • • • • NO NotifyNotifyNotifyNotify OROROROR DestinationDestinationDestinationDestination Monitor and Reassess R Contact MedicalMedicalMedicalMedical ContactContactContactContactControl Control Control Control NO R MMMM NO YES Massage NO OB 3 OB Perform Fundal > 500 mL? delivered? Placenta been Postpartum bleeding Delivery Care R R P - R UniversalUniversal PatientPatient Protocol;Protocol; Care Care 11 UP UP YES Vaginal bleeding Vaginal Abdominal pain Seizures Hypertension Severe headache Visual changes of faceand Edema hands Bolus

• • • • • • • Signs and Symptoms Signs and 1 Liter YES Post Fundal Massage Postpartum Hemorrhage Have mom try Normal Saline fundal massage? breastfeeding, if able to Bleeding continued after VascularVascular AccessAccess Protocol;Protocol; UPUP 33 P R R

Prenatal Prenatal care births pregnancies /Prior /Gravida Para Past medical historymedicalPast meds Hypertension

2020

Version 1 Version

• • • • History •

Post-Delivery Care Obstetric Protocol Section Protocol Obstetric

Pearls • Recommended Exam: Mental Status, Abdomen, Heart, Lungs, Neuro • Monitor for abnormal amounts of bleeding

Disposition: EMS Transport: ALS: Any patient other than listed below BLS: First trimester bleeding without either hypotension or bleeding > 3 pads per hour

2020 Version 1 OB 3 Obstetrical Protocol Section R YES Breech Birth T PULL Buttock Foot Hand ’ Determine Determine presenting part refrainto motherEncourage from pushing Support presenting parts DON 2nose fingers along Placeside tissue face pushand from away imminent, Unless delivery in kneeTransport chest to Left OR Position lateral position Abnormal Abnormal presentation cordProlapsed Frank Delivery dystocia Shoulder Placenta previa placenta Abruptio

• • • • • • Differential • • • • • • R MMMM R R R P R s ’ YES YES OB 4 OB (see back) (see Dystocia Shoulder Maneuver delivery occurs MedicalMedicalMedicalMedical Control Control Control Control Perform Perform McRobert Emergent Transport Emergent Childbirth Childbirth Procedure Monitor and Reassess Monitor and Prepare for for aPrepare potential Delivery in processandDelivery in shoulders become become stuck shoulders Notify destination early Notify destination Childbirth Protocol; OB 1 OB Childbirth Protocol; Spasmodic painSpasmodic discharge bleeding or Vaginal urgepushtoorCrowning Meconium Hypertension / HypertensionHypotension Abnormal Vaginal Bleeding /Bleeding VaginalAbnormal High Flow Oxygen to Mother to High Flow Oxygen Consider additional Considerresources Vascular Access Protocol; UP Protocol;3 Access Vascular Notify Destination OROROROR NotifyNotifyNotifyNotify Contact Contact Contact Contact DestinationDestinationDestinationDestination resuscitationthenewborn ofif

• • • • Signs and Symptoms Universal Patient Care Protocol; UP Patient 1 Protocol; Care Universal P R R Notify Receiving Notify Facility Receiving Immediately R R MMMM R YES transport Over cordOver Hips Hips Elevated Knees to Chest to Knees Saline Dressing Prolapsed Cord Position patient in Position to relieve pressure on relieve to on pressure High Risk Childbirth Labor Risk High / Childbirth cord and/or create air cord create and/or air Trendelenberg positionTrendelenberg Insert fingers into vaginaInsert fingers into passage; maintain during passage; maintain during R as indicated as Protocol; 5 OBProtocol; Obstetrical Emergency Obstetrical Medications Status Para / Gravida complications Predicted pregnancy, Risk High Time / amount of any vaginal bleeding vaginal any of amount / Time checkup baby last activity, fetal of Sensation last Care, Prenatal history, delivery medical, Past period menstrual Expected Due date Due Expected often how / started contractions Time membranes of Rupture 2020 Version 1 Version

• • • • • • • • • History High Risk Childbirth / Labor

McRobert’s Maneuver: 1. Dedicate one provider to delivery of the baby. This provider will need to enter the vagina to create an air passage for the newborn 2. Hyperflex the legs of the mother 3. Push downward on the abdomen superior to the symphysis pubis NEVER PULL ON ANY PRESENTING PARTS OF THE NEWBORN

Pearls • Recommended Exam (of Mother): Mental Status, Heart, Lungs, Abdomen, Neuro • Record APGAR at 1 minute and 5 minutes after birth. • After delivery, if significant bleeding noted, massage the fundus (firm ball at the level of the umbilicus) will promote uterine contraction and help to control post-partum bleeding. • Document all times (delivery, contraction frequency, and length). • Transport or Delivery? - Decision to transport versus remain and deliver is multifactorial and difficult. Generally it is preferable to transport. - Factors that will impact decision include: number of previous deliveries; length of previous labors; frequency of contractions; urge to push; and presence of crowning. • Maternal positioning for labor:

Adult Obstetrical Protocol Section Protocol Obstetrical Adult - Supine with head flat or elevated per mother’s choice. Maintain flexion of both knees and hips. Elevated buttocks slightly with towel. - If delivery not imminent, place mother in the left, lateral recumbent position with right side up about 10 – 20°. • Umbilical cord clamping and cutting: - Place first clamp about 4 inches from infant’s abdomen and second clamp about 6 inches away from infant. Cut between clamps. • Multiple Births: - Twins occur about 1/90 births. Typically manage the same as single gestation. If imminent delivery call for additional resources, if needed. Most twins deliver at about 34 weeks so lower birth weight and hypothermia are common. - Twins may share a placenta so clamp and cut umbilical cord after first delivery. Notify receiving facility immediately. • If maternal seizures occur, refer to the Obstetrical Emergencies Protocol; OB 5 • Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.

NOTE: Viable pregnancy confirmed by Last Menstrual Period or Ultrasound is 22 weeks or greater. Questions, contact medical control Disposition: EMS Transport: ALS: Patient with priority symptoms, imminent delivery, or pregnancy risk factors

2020 Version 1 OB 4 Obstetrical Emergencies

History Signs and Symptoms Differential • Past medical history (Gestational Diabetes, • Vaginal bleeding / cramping • Pre-eclampsia / Eclampsia Pre-eclampsia, Seizure hx, PIH) • Abdominal pain / tenderness / nausea / • Placenta previa • Hypertension meds vomiting • Abruptio Placenta • Prenatal care • Seizures • spontaneous abortion • Prior pregnancies / births • Hypertension / hypotension • Ectopic Pregnancy • Gravida / Para • Severe headache • Uterine Rupture • Estimated Due Date • Visual changes • Vaginal Bleeding • Edema of hands and face

Universal Patient Care Protocol; UP 1

R Left lateral recumbant position R Diabetic Protocol; AM 7 Blood Glucose If indicated B Analysis Procedure B

Vascular Access Protocol; UP 3

P Cardiac Monitor P Obstetric Protocol Section

Known or Abdominal Pain Vomiting and Suspected Pregnancy? NO Diarrhea Protocol; AM 1 Missed Period? If indicated Vaginal Bleeding?

YES

Abruptio Uterine Ectopic Spontaneous Placenta Previa Seizure Placenta Rupture Pregnancy Abortion YES

Magnesium Sulfate • Bleeding Control 4 g IV / IO • Estimate Blood Loss Over 2 – 3 minutes R • Oxygen to maintain SpO2 > 94% R May repeat x 1 • Emotional Support P If continued seizure P CONSIDER Hypotension / Shock Protocol; AM 12 Midazolam 5 mg IM If indicated Midazolam 2 mg IN Pain Control; AM 13 (MAX Dose 10 mg) If indicated

Childbirth / Labor Protocol; OB 1 If indicated

R Monitor and Reassess R

Notify Destination OR M M Contact Medical Control

2020 Version 1 OB 5 Obstetrical Emergencies

Abruptio Placenta: • Third Trimester • Dark-colored vaginal blood • Abdominal and/or back pain • Uterine Tenderness • Signs of labor • Hypotension

Placenta Previa: • Second or Third Trimester • Bright red vaginal blood • No Pain • Fetal movement • Hypotension

Uterine Rupture: • Can be trauma related • Loss of fetal contour • Sharp / tearing abdominal pain • Weakness / dizziness • Hypotension

Ectopic pregnancy: First Trimester; Implantation of fertilized egg outside the uterus, commonly in or on the fallopian tube. As fetus grows, rupture may occur. Vaginal bleeding may or may not be present. Many women with ectopic pregnancy do not know they are pregnant. Usually occurs within 5 to 10 weeks of implantation. Maintain high index of suspicion with women of childbearing age experiencing abdominal pain.

Eclampsia: Seizures occurring in the context of preeclampsia. Remember, women may not have been diagnosed with preeclampsia.

Preeclampsia: Occurs in about 6% of pregnancies. Defined by hypertension and protein in the urine. RUQ pain, epigastric pain, N/V, visual disturbances, headache, and hyperreflexia are common symptoms. In the setting of pregnancy, hypertension is defined as a BP greater than 140 systolic or greater than 90 diastolic, or a relative increase of 30 systolic and 20 diastolic from the patient's normal (pre-pregnancy) blood pressure. Risk factors: < 20 years of age, first pregnancy, multi-gestational pregnancy, gestational diabetes, obesity, personal or family history of gestational hypertension.

Spontaneous Abortion:

First Trimester, Cramping, Abdominal pain, bleeding, and possible expulsion of fetal tissue and / or blood clots Obstetric Protocol Section Protocol Obstetric

Pearls • Recommended Exam: Mental Status, Abdomen, Heart, Lungs, Neuro • Magnesium Sulfate should be administered as quickly as possible. May cause hypotension and decreased respiratory drive, but typically in doses higher than 6 g. • Magnesium Sulfate is first line treatment for Eclamptic seizures, if still seizing consider versed. • Consider HELLP Syndrome with Pre-eclampsia • Midazolam 5 – 10 mg IM / IN is effective in termination of seizures. • Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation. Greater than 20 weeks generally require 4 to 6 hours of fetal monitoring. DO NOT suggest the patient needs an ultrasound. • Signs of Magnesium overdose: Reduced muscle tone, reduced reflexes, and hypotension • Maintain patient in a left lateral position, right side up 10 - 20° to minimize risk of supine hypotensive syndrome. • Ask patient to quantify bleeding - number of pads used per hour. Disposition: EMS Transport: ALS: Any patient other than listed below BLS: First trimester bleeding without either hypotension or bleeding > 3 pads per hour

2020 Version 1 OB 5 General Infectious Diseases

History Signs and Symptoms Differential • Recent travel to known high risk area • Acute Fever • Influenza • Anthrax • Close contact with potential exposed • Cough • Coronavirus • C-Diff person(s) • Difficulty breathing • Meningitis • MRSA • Close contact with laboratory confirmed case • Ebola • Tuberculosis

GOALS: To identify and prevent responding personnel from accidental exposures and ensure that appropriate precautions are correctly in place.

Refer to CCEMS Primer on Infectious Diseases and EMS Infectious Disease Playbook for further guidance.

**Notify Destination early if there is a potential exposure to allow hospital adequate time to establish proper isolation

precautions or decontamination SpecialCircumstances Protocol Section

Scene Safety

Universal Patient Care Protocol; UP 1

Consider Biohazard exposure if: Notify HAZMAT • Unknown substance? And reference YES • Multiple patients? CCEMS Policy • Unknown etiology of sickness?

Consider: • Recent Travel? STANDARD PRECAUTIONS • Signs of respiratory infection? CONSIDER: • Multiple patients? NO Nitrile gloves, gown, Eye • Caution issued by Dispatch, Police, Protection / face shield Fire? EXPOSURE RISK POTENTIAL?

YES EXIT to Infectious Diseases Matrix Protocol; SC 2 Consider Infectious Disease exposure if: If unsure of infectious disease. • Recent Travel to known “hot” area • Fever? YES OR • Cough/ Difficulty Breathing • Recent antibiotic use & diarrhea IF, obvious infectious disease • Night Sweats identified, EXIT to appropriate protocol NO

Consider alternate more appropriate protocol if indicated

Notify Destination or M Contact Medical Control M

2020 Version 1 SC 1 General Infectious Diseases

Universal Precautions: Minimum PPE for all patient care is long nitrile gloves.

Contact Precautions: Patient- Cover open wound or infection site Provider- MINIMUM = gloves and gown

Droplet Precautions: Patient- Place surgical mask on Patient Provider- MINIMUM = N95 Mask and eye protection

Airborne Precautions: Patient- Surgical mask, will need negative pressure room Provider – MINIMUM= N95 Mask and eye protection

Special Respiratory Precautions: n95 mask, eye protection, face shield, gown or tyvek suits, shoe covers, and gloves

Donning / Doffing Sequence: Donning Sequence 1. Remove personal items (jewelry, watches, belts, etc) and tie back long hair 2. Get appropriate sizes and inspect PPE prior to donning 3. Hand Hygiene (allow to dry) 4. Put on boot covers first then put on coverall or gown 5. Put on gloves (long nitrile gloves should be over gown or coverall wrist area) 6. Mask / Respirator 7. Eye protection / face shield 8. Perform safety check with Donning buddy Doffing Sequence 1. Insect PPE for visible contaminates, cuts, tears, etc. 2. Disinfect gloves and remove gloves discarding into red biohazard waste bag 3. Don new pair of clean gloves and perform hand hygiene 4. Remove gown or coverall and boot shoe covers (if needed) and discard 5. Disinfect gloves 6. Remove goggles/ face shield 7. Disinfect gloves 8. Remove Mask / Respirator 9. Remove gloves 10. Perform hand hygiene

To dispose of contaminated items, place in large RED Biohazard bag. Dispose of biohazard bag either at hospital destination or Special Circumstances Protocol Section Protocol Circumstances Special bring back to STATION 1 for proper disposal. ***DO NOT TAKE TO OUTLYING STATION***

Documentation: Avoid documentation during transport, should ONLY be completed after the following are complete: 1. Patient transferred 2. PPE properly disposed 3. Hand hygiene has been performed

Documentation will include ALL personnel involved in the incident AND level of patient contact. Pearls • REFERENCE CCEMS EMS PRIMER ON INFECTIOUS DISEASES • PPE should be donned prior to patient contact, if possible • When dealing with a potential Coronavirus or Ebola patient bring in minimum necessary personnel and equipment utilized • If come in contact with suspected Coronavirus or Ebola patient without prior notification, immediately NOTIFY dispatch to prevent unnecessary personnel from being exposed.

2020 Version 1 SC 1 Infectious Diseases Matrix

History Signs and Symptoms Differential • Recent travel to known “hot” area • Acute Fever • Influenza • Close contact with potential exposed • Cough • Coronavirus person(s) • Difficulty breathing • Meningitis • Close contact with laboratory • Bleeding • Ebola confirmed case • Sore throat • Tuberculosis • Headache • Anthrax • Myalgia • C-Diff • MRSA

*** Notify Destination Notified by EMS DISPATCH? Scene Safety Positive screening based on Emerging Infectious EARLY Disease Surveillance Tool to allow time for proper Universal Patient Care 1. “P36 [ Insert Chief Complaint ], Check CAD for preparation Protocol; UP 1 guidance” OR Close contact with 2. “P36 [ Insert Chief Complaint ], staging required” lab positive diagnosed person? If YES exit to appropriate Infectious Disease

Protocol SpecialCircumstances Section YES

Recent Travel YES to known high NO risk area? Other Travel considerations NO Travel to High to needed? risk area? AFRICA? YES YES YES

Cough/ Difficulty Fever? Fatigue? Fever? Breathing? Generalized Body aches? Antibiotic use? Hemoptysis? Neck Stiffness? Fever? weakness? Exposed to Diarrhea? Night Sweats? Altered Mental Sore Throat? Unexplained bleeding confirmed Status? Open Wounds? Weight loss? Loss of taste / smell? or bruising? influenza person?

YES YES YES YES YES YES

EXIT to EXIT to EXIT to EXIT to EXIT to EXIT to EXIT to Bacterial / Viral Tuberculosis; Coronavirus; SC 4 Ebola; SC 5 Influenza; SC 6 C-diff; SC 3 MRSA; SC 3 Meningitis; SC 7 EMS Playbook EMS Playbook SC 8 EMS Playbook EMS Playbook EMS Playbook 5- EMS Playbook 6-33 – 6-41 EMS Playbook 7-42 – 7-64 3-15 – 3-20 3-15 – 3-20 4-21 – 4-26 4-21 – 4-26 27 – 5-32 Primer pg. 46 Primer pg. 75 (Primer pending) (Primer pending) Primer pg. 20 Primer pg. 16 / 26 Primer pg. 24

None of the above protocols applicable? REASSESS and MONITOR patient

STANDARD PRECAUTIONS

Notify Destination or M M Contact Medical Control

2020 Version 2 SC 2 Infectious Diseases Matrix

Refer to CCEMS Infectious Disease Primer for further guidance Universal Precautions: Minimum PPE for all patient care is long nitrile gloves. 1. Contact Precautions: Patient- Cover open wound or infection site Provider- MINIMUM = gloves and gown 2. Droplet Precautions: Patient- Place surgical mask on Patient Provider- MINIMUM = surgical mask 3. Airborne Precautions: Patient- Surgical mask, will need negative pressure room Provider – MINIMUM= N95 Mask, Eye Protection, face shield 4. Special Respiratory Precautions: Patient- Surgical mask, if possible maintain at least 6ft distance. Provider – N95 Mask or higher, Goggles/ Full Face Shield, Fluid Resistant Gown/suit, Disposable boot/shoe covers, extended Cuff Nitrile Gloves w/ double-gloving

Donning / Doffing Sequence: Donning Sequence 1. Remove personal items (jewelry, watches, belts, etc) and tie back long hair 2. Get appropriate sizes and inspect PPE prior to donning 3. Hand Hygiene (allow to dry) 4. Put on coverall or gown then boot covers 5. Put on gloves (long nitrile gloves should be over gown or coverall wrist area) 6. Mask / Respirator 7. Eye protection / face shield 8. Perform safety check with Donning buddy Doffing Sequence 1. Insect PPE for visible contaminates, cuts, tears, etc. 2. Disinfect gloves and remove gloves discarding into red biohazard waste bag 3. Don new pair of clean gloves and perform hand hygiene 4. Remove gown or coverall and boot shoe covers (if needed) and discard 5. Disinfect gloves 6. Remove goggles/ face shield 7. Disinfect gloves 8. Remove Mask / Respirator 9. Remove gloves

10. Perform hand hygiene Special Circumstances Section Circumstances Special Disposal: To dispose of contaminated items, place in large RED Biohazard bag. Dispose of biohazard bag either at hospital destination or bring back to STATION 1 for proper disposal. ***DO NOT TAKE BACK TO OUTLYING STATION***

Pearls • Reference CCEMS Primer on Infectious Diseases March 2020 and EMS Infectious Disease Playbook for further guidance. • Reference Policy Number: 3003-04 “Infectious Disease Response Plan” • N95 mask and eye protection on prior to patient contact • When dealing with a potential Coronavirus or Ebola patient bring in minimum necessary personnel and equipment to provide appropriate care and necessary care • If come in contact with suspected Coronavirus or Ebola patient without prior notification, immediately NOTIFY dispatch to prevent unnecessary personnel from being exposed and distance self from patient at least 6 feet; give patient surgical mask, iftolerable for patient.

2020 Version 1 SC 2 C-Diff / MRSA

History Signs and Symptoms Differential • Close contact with potential exposed • Infection source • Influenza • Anthrax person(s) • Large open / draining wounds • Coronavirus • C-Diff • Close contact with a lab positive person • Recent / current antibiotic use • Meningitis • MRSA • Recent hospital / long term care facility • Ebola • Seizures stays • Tuberculosis • Altered Mental Status GOALS: • Prevention of Emergency personnel exposure. • Safe transport and supportive care provided for patient

IF high risk incident identified by notification or by detection during patient contact FOLLOW Policy 3003-04 “Infectious Disease Response Plan”

Universal Patient Care

Protocol; UP 1 SpecialCircumstances Protocol Section

Pre-screened Complete Current Door Jamb Survey, NO YES by EMD Are symptom based questions Positive? YES

YES NO

NOTIFIED by Dispatch: MUST don CONTACT “P36 [ Chief Complaint ]” R R Precautions check CAD for guidance

Cover any open or R draining wounds R

EXIT to appropriate YES R Life Threat? R protocol NO EXIT to Sepsis YES Patient appears Septic? Protocol; AM 15 / PM 13 P P

YES Patient Hypotensive NO

Vascular Access Protocol; UP 3

Normal Saline bolus P 500mL via IV / IO P

Notify Destination or M M Contact Medical Control

2020 Version 1 SC 3 C-Diff / MRSA

Refer to Policy 3003-04 for Positive Screened patient’s via EID Surveillance Tool

Don appropriate PPE: Contact Precautions

Transport/ Decontamination: 1. All First responders will doff PPE outside of ambulance and place in Red Biohazard bag, if patient condition allows for time to do so. 2. Cab of ambulance will be closed off from patient care compartment. 3. Doff contact isolation protection (Gown or Tyvek suit and gloves). Then driver will don a new gown and nitrile gloves prior to entering cab. 4. Exhaust fan will remain ON during transport. 5. Once at destination, doors to ambulance remain open with exhaust fan running. 6. Crew notifies CCEMS communications, out of service for “DECON”

Disposal: To dispose of contaminated items, place in large RED Biohazard bag. Dispose of biohazard bag either at hospital destination or bring back to STATION 1 for proper disposal.

***DO NOT TAKE TO OUTLYING STATION*** Special Circumstances Protocol Section Protocol Circumstances Special

Pearls • Reference Policy Number: 3003-04 “Infectious Disease Response Plan • Reference EMS Infectious Disease Playbook, 3-15 – 3-20 • If during door jam survey risk is identified, identify dispatch, and IMMEDIATELY back out to don appropriate PPE • Contact precautions should remain for the duration of patient contact • Consider signs of Sepsis early and treat per Sepsis Protocol • Keep any opened and/or draining wounds covered • If patient receiving 500 cc fluid bolus, continue until SBP > 90 and lung sounds remain clear. • Lung Sounds must be reassessed after each fluid bolus.

2020 Version 1 SC 3 COVID – 19 Coronavirus

History Signs and Symptoms Differential • Recent travel to known “hot” area • Acute Fever • Influenza • Anthrax • Close contact with potential exposed • Cough • Coronavirus • C-Diff person(s) • Difficulty breathing • Meningitis • MRSA • Close contact with laboratory confirmed case • Ebola • Tuberculosis GOALS: • Prevention of Emergency personnel exposure. • Safe transport and supportive care provided for patient **Notifications to be made** 1. Family to stay home due to potential contact and exposure risk 2. Destination early if there is a potential exposure to allow hospital adequate time to establish proper isolation precautions and identify patient unloading location 3. Battalion Chief, Chief of EMS, Deputy Chief of EMS

IF high risk incident identified by notification or by detection during patient contact

FOLLOW Policy 3003-04 “Infectious Disease Response Plan” SpecialCircumstances Protocol Section

Pre-screened Complete Current Door Jamb Survey, NO YES by EMD Are symptom based questions Positive? NO

YES YES

NOTIFIED by Dispatch: MUST don CONTACT, DOPLET, & YES R “P36 [ Chief Complaint ]” R AIRBORNE PPE check CAD for guidance

Place surgical mask on patient R (if tolerated by patient) R

EXIT to appropriate Life Threat? YES R R protocol

Airway Protocol; Respiratory Distress? YES AR 1 – 4 P SOB? P Respiratory Distress Protocol; AR 6 / PA 4 NO

1. Instruct patient to Don surgical mask; if tolerable. YES B Patient able to assist in care? B

Assist patient as needed and Transport to appropriate facility with B Patient ambulatory? B NO P available Negative pressure room P NO ROUTINE and appropriate isolation aerosolizing capabilities YES procedures

Instruct patient to stay inside Notify Destination or residence until directed to walk to M M Contact Medical Control ambulance by EMS providers

2020 Version 1 SC 4 COVID – 19 Coronavirus

Refer to Policy 3003-04 for Positive Screened patient’s via EID Surveillance Tool Refer to CCEMS Primer on Infectious Diseases, March 2020; page 46 and don appropriate PPE: 1. N95 2. Eye protection / Face Shields 3. Long Cuff Nitrile Gloves 4. Tyvek Suit with hood 5. Tyvek boot covers (if not with Tyvek suit)

Donning / Doffing Sequence: Donning Sequence 1. Remove personal items (jewelry, watches, belts, etc) and tie back long hair 2. Get appropriate sizes and inspect PPE prior to donning 3. Hand Hygiene (allow to dry) 4. Put on coverall or gown and then boot covers (if available) 5. Put on gloves (long nitrile gloves should be over gown or coverall wrist area) 6. Mask / Respirator 7. Eye protection / face shield 8. Perform safety check with Donning buddy Doffing Sequence 1. Insect PPE for visible contaminates, cuts, tears, etc. 2. Disinfect gloves and remove gloves discarding into red biohazard waste bag 3. Don new pair of clean gloves and perform hand hygiene 4. Remove gown or coverall and boot shoe covers (if needed) and discard 5. Disinfect gloves 6. Remove goggles/ face shield 7. Disinfect gloves 8. Remove Mask / Respirator 9. Remove gloves 10. Perform hand hygiene

Transport/ Decontamination: 1. All First responders will doff PPE outside of ambulance and place in Red Biohazard bag, if patient condition allows for ti me to do so. 2. Cab of ambulance will be closed off from patient care compartment. 3. Driver of ambulance will maintain appropriate respiratory protection precautions in place and doff contact isolation protection (Tyvek suit and gloves). Then driver will don a new pair of nitrile gloves prior to entering cab.

Special Circumstances Protocol Section Protocol Circumstances Special 4. Exhaust fan will remain ON during transport. 5. Once at destination, doors to ambulance remain open with exhaust fan running. 6. Crew notifies CCEMS communications, out of service for “DECON”

Disposal: To dispose of contaminated items, place in large RED Biohazard bag. Dispose of biohazard bag either at hospital destination or bring back to STATION 1 for proper disposal. ***DO NOT TAKE TO OUTLYING STATION*** Pearls • Reference Policy Number: 3003-04 “Infectious Disease Response Plan • Reference EMS Infectious Disease Primer; Pg. 46 and EMS Infectious Disease Playbook; 6-33 – 6-41 for further guidance • If during door jam survey risk is identified, identify dispatch, and IMMEDIATELY back out to don appropriate PPE • N95 mask and eye protection on prior to patient contact • When dealing with a potential Coronavirus patient bring in minimum necessary personnel and equipment utilized • If come in contact with suspected Coronavirus or Ebola patient without prior notification, immediately NOTIFY dispatch to prevent unnecessary personnel from being exposed and create at least 6 feet of space between you and the patient.

2020 Version 1 SC 4 Suspected Viral Hemorrhagic Fever Ebola

EMS Dispatch Center Evolving Protocol: Protocol subject to change at 1. Use Emerging Infectious Disease (EID) Surveillance Tool with the following chief complaints: any time dependent on Typical Flu-Like Symptoms changing outbreak locations. and/or Unexpected Bleeding Monitor for protocol updates. (not trauma or isolated nose bleed related) Viral Hemorrhagic Fevers: 2. Use EID Card (or equivalent) with the following protocols (or equivalent) Ebola is one of many. EMD 6 Breathing Problem EMD 10 Chest Pain EMD 18 Headache EMD 21 Hemorrhage (medical) DO NOT DISPATCH FIRST EMD 26 Sick Person RESPONDERS

3. Ask the following: Dispatch EMS Unit only YES In the past 21 days have you been to Africa or been exposed to someone who has? Discretely notify EMS

If YES: Supervisor or command SpecialCircumstances Protocol Section Do you have a fever? staff Notify Hazmat Team NO

EMS Do not rely solely on EMD personnel to identify a potential viral hemorrhagic fever patient – constrained by time and caller information

Obtain a travel history / exposure history and assess for clinical signs and symptoms Exit to Appropriate NO B EMS Immediate Concern B Protocol(s) 1. Traveler from area with known VHR (Ebola) outbreak with or without symptoms 2. Traveler from Sierra Leone, Guinea, or Liberia within past 21 days (Africa) AND Fever, Headache Joint and Muscle aches Weakness, Fatigue Vomiting and/or Diarrhea Abdominal Pain Anorexia Bleeding

YES See Back EMS Place surgical mask on patient Personal Protective Equipment Use Non-rebreather mask if Oxygen Needed Donning and Doffing Guidelines

Avoid aerosol generating procedures unless NO Routine medically necessary Aerosol Generating Procedures NIPPV / Nebulizer therapy / Intubation / BIAD / Suctioning

Avoid routine IV or IO access unless medically No Routine necessary IV or IO Lines If IV / IO necessary: Stop vehicle to lessen exposure risk

EMS Personnel / Equipment / Transport Unit Requires Refer to Decontamination Process Decontamination NO

Notify Destination as soon and as discretely as possible DO NOT M ENTER facility with patient until instructed Follow entry directions M from hospital staff

2020 Version 1 SC 5 Suspected Viral Hemorrhagic Fever Ebola PARTICULAR ATTENTION MUST BE PAID TO PROTECTING MUCOUS MEMBRANES OF THE EYES, NOSE, and MOUTH FROM SPLASHES OF INFECTIOUS MATERIAL OR SELF INOCULATION FROM SOILED PPE / GLOVES. THERE SHOULD BE NO EXPOSED SKIN

DONNING PPE: BEFORE you enter the patient area. Recommended PPE PAPR: A PAPR with a full face shield, helmet, or headpiece. Any reusable helmet or headpiece must be covered with a single-use (disposable) hood that extends to the shoulders and fully covers the neck and is compatible with the selected PAPR.

N95 Respirator: Single-use (disposable) N95 respirator in combination with single-use (disposable) surgical hood extending to shoulders and single-use (disposable) full face shield. If N95 respirators are used instead of PAPRs, careful observation is required to ensure healthcare workers are not inadvertently touching their faces under the face shield during patient care.

Single-use (disposable) fluid-resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood. Coveralls with or without integrated socks are acceptable.

Single-use (disposable) nitrile examination gloves with extended cuffs. Two pairs of gloves should be worn. At a minimum, outer gloves should have extended cuffs.

Single-use (disposable), fluid-resistant or impermeable boot covers that extend to at least mid-calf or single-use (disposable) shoe covers. Boot and shoe covers should allow for ease of movement and not present a slip hazard to the worker.

Single-use (disposable) fluid-resistant or impermeable shoe covers are acceptable only if they will be used in combination with a coverall with integrated socks.

Single-use (disposable), fluid-resistant or impermeable apron that covers the torso to the level of the mid-calf should be used if Ebola patients have vomiting or diarrhea. An apron provides additional protection against exposure of the front of the body to body fluids or excrement. If a PAPR will be worn, consider selecting an apron that ties behind the neck to facilitate easier removal during the doffing procedure

DOFFING PPE: OUTSIDE OF PPE IS CONTAMINATED! DO NOT TOUCH 1) PPE must be carefully removed without contaminating one’s eyes, mucous membranes, or clothing with potentially infectious materials. Use great care while doffing your PPE so as not to contaminate yourself (e.g. Do not remove your N-95 facemask or eye protection BEFORE you remove your gown). There should be a dedicated monitor to observe donning and doffing of PPE. It is very easy for personnel to contaminate themselves when doffing. A dedicated monitor should observe doffing to insure it is done correctly. Follow CDC guidance on doffing. 2) PPE must be double bagged and placed into a regulated medical waste container and disposed of in an appropriate location. 3) Appropriate PPE must be worn while decontaminating / disinfecting EMS equipment or unit. 3) Re-useable PPE should be cleaned and disinfected according to the manufacturer's reprocessing instructions. - Hand Hygiene should be performed by washing with soap and water with hand friction for a minimum of 20 seconds. - Alcohol-based hand rubs may be used if soap and water are not available. - EVEN IF AN ALCOHOL-BASED HAND RUB IS USED, WASH HANDS WITH SOAP AND WATER AS SOON AS FEASIBLE. - THE USE OF GLOVES IS NOT A SUBSTITUTE FOR HAND WASHING WITH SOAP & WATER • For any provider exposure or contamination contact on-duty Battalion Chief

Special Circumstances Protocol Section Protocol Circumstances Special • If the patient is being transported via stretcher then a disposable sheet can be placed over them.

Pearls • Transmission to another individual is the greatest after a patient develops fever. Once there is fever, the viral load in the bodily fluids appears to be very high and thus a heightened level of PPE is required. • Patient contact precautions are the most important consideration. • Incubation period 2-21 days • Ebola must be taken seriously; however using your training, protocols, procedures and proper Personal Protective Equipment (PPE), patients can be cared for safely. • When an infection does occur in humans, the virus can be spread in several ways to others. The virus is spread through direct contact (through broken skin or mucous membranes) with a sick person's blood or body fluids (urine, saliva, feces, vomit, and semen) objects (such as needles) that have been contaminated with infected body fluids. • Limit the use of needles and other sharps as much as possible. All needles and sharps should be handled with extreme care and disposed in puncture-proof, sealed containers. Safety devices must be employed immediately after use. • Ebola Information: For a complete review of Ebola go to: http://www.cdc.gov/vhf/ebola/index.html http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety- answering- points-management-patients-known-suspected-united-states.html

2020 Version 1 SC 5 Suspected Viral Hemorrhagic Fever Ebola (Decontamination Process) EMS Personal Requires Decontamination

If EMS personnel are exposed to blood, bodily fluids, secretions, or excretions from a patient with suspected or confirmed Ebola patient they should immediately: 1) Stop working and wash the affected skin surfaces with soap and water. 2) Mucous membranes (e.g., conjunctiva) should be irrigated with a large amount of water or eyewash solution

EMS Equipment / Transport Unit Requires Decontamination

1) EMS personnel performing decontamination / disinfection should wear recommended PPE SpecialCircumstances Protocol Section When performing Decontamination EMS Personnel MUST wear appropriate PPE, which includes : •Gloves (Double glove) •Fluid resistant (impervious) Tyvek Like Full length (Coveralls) •Eye protection (Goggles) •N-95 face mask •Fluid resistant (impervious)-Head covers •Fluid resistant (impervious)-Shoe / Boot covers 2) Face protection (N-95 facemask with goggles) should be worn since tasks such as liquid waste disposal can generate splashes. 3) Patient-care surfaces (including stretchers, railings, medical equipment control panels, and adjacent flooring, walls and work surfaces) are likely to become contaminated and should be decontaminated and disinfected after transport. 4) A blood spill or spill of other body fluid or substance (e.g., feces or vomit) should be managed through removal of bulk spil l matter, cleaning the site, and then disinfecting the site. For large spills, a chemical disinfectant with sufficient potency is needed to overcome the tendency of proteins in blood and other body substances to neutralize the disinfectant’s active ingredient. An EPA-registered hospital disinfectant with label claims for viruses that share some technical similarities to Ebola (such as, norovirus, rotavirus, adenovirus, poliovirus) and instructions for cleaning and decontaminating surfaces or objects soiled with blood or body fluids should be used according to those instructions. (Alternatively, a 1:10 dilution of household bleach (fina l working concentration of 500 parts per million or 0.5% hypochlorite solution) that is prepared fresh daily (i.e., within 12 hours) can be used to treat the spill before covering with absorbent material and wiping up. After the bulk waste is wiped up, the surface should be disinfected as described in the section above). 5) Contaminated reusable patient care equipment should be placed in biohazard bags (double -bagged) and labeled for decontamination and disinfection. 6) Reusable equipment should be cleaned and disinfected according to manufacturer's instructions by appropriately trained personnel wearing correct PPE. 7) Avoid contamination of reusable porous surfaces that cannot be made single use. Use only a mattress and pillow with plastic o r other covering that fluids cannot get through. 8) To reduce exposure, all potentially contaminated textiles (cloth products) should be discarded. This includes non -fluid- impermeable pillows or mattresses. They should be considered regulated medical waste and placed in biohazard red bags. They must be double-bagged prior to being placed into regulated medical waste containers.

Pearls • Ebola Information: For a complete review of Ebola EMS Vehicle Disinfection go to: http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-emergency-medical-services-systems-911-public-safety - answering-points-management-patients-known-suspected-united-states.html Disposition:

ALS: All patients

2020 Version 1 SC 5 Suspected Viral Hemorrhagic Fever Ebola (Deceased Patient)

Decedent Known or suspected carrier of HVF / Ebola Requires Transportation

Only personnel trained in handling infected human remains, and wearing full PPE, should touch, or move any Ebola-infected remains. Handling human remains should be kept to a minimum.

Donning / Doffing PPE

PPE should be in place BEFORE contact with the body PPE should be removed immediately after and discarded as 1) Prior to contact with body, postmortem care regulated medical waste. personnel must wear PPE consisting of: surgical scrub suit, surgical cap, impervious Tyvex- 1) Use caution when removing PPE as to avoid Coveralls, eye protection (e.g., face shield, goggles), contaminating the wearer. facemask, shoe covers, and double surgical gloves. 2) Hand hygiene (washing your hands thoroughly with soap 2) Additional PPE (leg coverings,) might be required in and water or an alcohol based hand rub) should be certain situations (e.g., copious amounts of blood, performed immediately following the removal of vomit, feces, or other body fluids that can PPE. If hands are visibly soiled, use soap and water. contaminate the environment).

Preparation of Body Prior to Transport

1) At the site of death, the body should be wrapped in a plastic shroud. Wrapping of the body should be done in a way that prevents contamination of the outside of the shroud. 2) Change your gown or gloves if they become heavily contaminated with blood or body fluids. 3) Leave any intravenous lines or endotracheal tubes that may be present in place. 4) Avoid washing or cleaning the body. 5) After wrapping, the body should be immediately placed in a leak-proof plastic bag not less than 150 μm thick and zippered closed The bagged body should then be placed in another leak-proof plastic bag not less than 150 μm thick and zippered closed before being transported to the morgue.

Surface Decontamination

Special Circumstances Protocol Section Protocol Circumstances Special 1) Prior to transport to the morgue, perform surface decontamination of the corpse-containing body bags by removing visible soil on outer bag surfaces with EPA-registered disinfectants which can kill a wide range of viruses. 2) Follow the product’s label instructions. Once the visible soil has been removed, reapply the disinfectant to the entire bag surface and allow to air dry. 3) Following the removal of the body, the patient room should be cleaned and disinfected. 4) Reusable equipment should be cleaned and disinfected according to standard procedures.

Transportation of VHV / Ebola Remains

PPE is required for individuals driving or riding in a vehicle carrying human remains. DO NOT handle the remains of a suspected / confirmed case of Ebola patient. The remains must be safely contained in a body bag where the outer surface of the body bag has been disinfected prior to the transport.

Pearls • Ebola Information: For a complete review of Handling Remains of Ebola Infected Patients go to: http://www.cdc.gov/vhf/ebola/hcp/guidance-safe-handling-human-remains-ebola-patients-us-hospitals-mortuaries.html

2020 Version 1 SC 5 Influenza

History Signs and Symptoms Differential • Close contact with potential exposed • Acute Fever • Influenza • Anthrax person(s) • Cough • Coronavirus • C-Diff • Close contact with laboratory • Difficulty breathing • Meningitis • MRSA confirmed case • Bodyaches • Ebola • Influenza Vaccine • Fatigue • Tuberculosis

GOALS: • Prevention of Emergency personnel exposure. • Safe transport and supportive care provided for patient

IF high risk incident identified by notification or by detection during patient contact FOLLOW Policy 3003-04 “Infectious Disease Response Plan”

Universal Patient Care Protocol; UP 1

Pre-screened Complete Current Door Jamb Survey, SpecialCircumstances Protocol Section NO YES YES by EMD Are symptom based questions Positive?

YES NO

NOTIFIED by Dispatch: Place surgical mask on patient R “P36 [ Chief Complaint ]” R R R check CAD for guidance (if tolerated by patient)

YES

EXIT to appropriate Life Threat? YES R R protocol

Airway Protocol; Respiratory Distress? YES AR 1 – 4 / PA 1 – 3 P SOB? P Respiratory Distress Protocol; AR 6 / PA 4 NO

B Patient able to assist in care? B

YES Assist patient as needed and R Transport to appropriate facility R

R Monitor and Reassess R

Notify Destination or M M Contact Medical Control

2020 Version 1 SC 6

Influenza Special Circumstances Protocol Section Protocol Circumstances Special

Pearls • Reference Policy Number: 3003-04 “Infectious Disease Response Plan” • Reference CCEMS Primer on Infectious Diseases; pg. 20 and EMS Infectious Disease Playbook; 4 -21 – 4-22 • Influenza is spread through respiratory droplets • If during door jam survey risk is identified, identify dispatch, and IMMEDIATELY back out to don appropriate PPE • If concern for Influenza, place surgical mask on patient if patient can tolerate mask. • High risk patients are anyone with underlying medical conditions such as asthma, diabetes, heart disease, lung disease, morbid obesity, or people under 5 years old, over 65 years old, or pregnant. • www.cdc.gov/flu for additional information

2020 Version 1 SC 6 Meningitis (Bacterial / Viral)

History Signs and Symptoms Differential • Close contact with potential exposed • Light sensitivity • Influenza • Anthrax person(s) • Fever • Coronavirus • C-Diff • Close contact with a lab positive person • Nuchal Rigidity (neck Stiffness) • Meningitis • MRSA • Altered Mental Status • Ebola • Seizures • Headache • Tuberculosis • Altered Mental Status GOALS: • Prevention of Emergency personnel exposure. • Safe transport and supportive care provided for patient

IF high risk incident identified by notification or by detection during patient contact FOLLOW Policy 3003-04 “Infectious Disease Response Plan”

Universal Patient Care

Protocol; UP 1 SpecialCircumstances Protocol Section

Pre-screened Complete Current Door Jamb Survey, NO YES by EMD Are symptom based questions Positive? YES

YES NO

NOTIFIED by Dispatch: MUST don CONTACT, DOPLET & R “P36 [ Chief Complaint ]” R AIRBORNE PPE check CAD for guidance

Place surgical mask on patient R (if tolerated by patient) R

EXIT to appropriate YES R Life Threat? R protocol NO

Airway Protocol; Respiratory Distress? YES AR 1 – 4 / PA 1 – 3 P SOB? P Respiratory Distress Protocol; AR 6 / PA 4

Assist patient as needed and Transport to appropriate facility with P available Negative pressure room P and appropriate isolation capabilities

Notify Destination or M M Contact Medical Control

2020 Version 1 SC 7 Meningitis (Bacterial / Viral)

Refer to Policy 3003-04 for Positive Screened patient’s via EID Surveillance Tool Don appropriate PPE: 1. N95 2. Eye protection / Face Shields 3. Long Cuff Nitrile Gloves

Donning / Doffing Sequence: Donning Sequence 1. Remove personal items (jewelry, watches, belts, etc.) and tie back long hair 2. Get appropriate sizes and inspect PPE prior to donning 3. Hand Hygiene (allow to dry) 4. Put on boot covers first then put on coverall or gown 5. Put on gloves (long nitrile gloves should be over gown or coverall wrist area) 6. Mask / Respirator 7. Eye protection / face shield 8. Perform safety check with Donning buddy Doffing Sequence 1. Insect PPE for visible contaminates, cuts, tears, etc. 2. Disinfect gloves and remove gloves discarding into red biohazard waste bag 3. Don new pair of clean gloves and perform hand hygiene 4. Remove gown or coverall and boot shoe covers (if needed) and discard 5. Disinfect gloves 6. Remove goggles/ face shield 7. Disinfect gloves 8. Remove Mask / Respirator 9. Remove gloves 10. Perform hand hygiene

Transport/ Decontamination: 1. All First responders will doff PPE outside of ambulance and place in Red Biohazard bag, if patient condition allows for time to do so. 2. Cab of ambulance will be closed off from patient care compartment. 3. Driver of ambulance will maintain appropriate respiratory protection precautions in place 4. Exhaust fan will remain ON during transport. 5. Once at destination, doors to ambulance remain open with exhaust fan running. 6. Crew notifies CCEMS communications, out of service for “DECON”

Disposal: To dispose of contaminated items, place in large RED Biohazard bag. Dispose of biohazard bag either at hospital destination or bring back to STATION 1 for proper disposal.

***DO NOT TAKE TO OUTLYING STATION*** Special Circumstances Protocol Section Protocol Circumstances Special

Pearls • Reference Policy Number: 3003-04 “Infectious Disease Response Plan • Reference CCEMS Primer on Infectious Diseases; pg. 16 /26, and EMS Infectious Disease Playbook, 4-21 – 4-26 • If during door jam survey risk is identified, identify dispatch, and IMMEDIATELY back out to don appropriate PPE • N95 mask and eye protection on prior to patient contact • Triad of symptoms include: fever (usually high), nuchal rigidity (neck stiffness), and altered mental status. • Bacterial Meningitis is usually spread by close contact with an infected person. • Viral Meningitis is commonly caused by Enterovirus. • Viral Meningitis symptoms are similar to Bacterial but are usually less severe. • Patient requires respiratory isolation • History of an upper respiratory infection is common • Nuchal rigidity test: have patient touch chin to chest, patient will not be able to do this.

2020 Version 1 SC 7 Tuberculosis ( TB )

History Signs and Symptoms Differential • Close contact with potential exposed • Productive Cough / hemoptysis • Influenza • Anthrax person(s) • Fever • Coronavirus • C-Diff • Actively being treated for Tuberculosis • Weight loss • Meningitis • MRSA • Incarcerated • Malaise • Ebola • Night Sweats • Tuberculosis

GOALS: • Prevention of Emergency personnel exposure. • Safe transport and supportive care provided for patient

IF high risk incident identified by notification or by detection during patient contact FOLLOW Policy 3003-04 “Infectious Disease Response Plan”

Universal Patient Care

Protocol; UP 1 SpecialCircumstances Protocol Section

Pre-screened Complete Current Door Jamb Survey, NO YES by EMD Are symptom based questions Positive? YES

NO NO

NOTIFIED by Dispatch: MUST don CONTACT, DOPLET & R “P36 [ Chief Complaint ]” R AIRBORNE PPE check CAD for guidance

Place surgical mask on patient R (if tolerated by patient) R

EXIT to appropriate Life Threat? YES R R protocol

Airway Protocol; Respiratory Distress? YES AR 1 – 4 / PA 1 – 3 P SOB? P Respiratory Distress Protocol; AR 6 / PA 4 NO

1. Instruct patient to Don surgical mask YES B Patient able to assist in care? B

Assist patient as needed and Transport to appropriate facility with B Patient ambulatory? B NO P available Negative pressure room P and appropriate isolation capabilities YES

Instruct patient to stay inside Notify Destination or residence until directed to walk to M M Contact Medical Control ambulance by EMS providers

2020 Version 1 SC 8 Tuberculosis ( TB )

Refer to Policy 3003-04 for Positive Screened patient’s via EID Surveillance Tool Don appropriate PPE: 1. N95 2. Eye protection / Face Shields 3. Long Cuff Nitrile Gloves 4. Gown

Donning / Doffing Sequence: Donning Sequence 1. Remove personal items (jewelry, watches, belts, etc) and tie back long hair 2. Get appropriate sizes and inspect PPE prior to donning 3. Hand Hygiene (allow to dry) 4. Put on gown / coverall and then boot covers, if available 5. Put on gloves (long nitrile gloves should be over gown or coverall wrist area) 6. Mask / Respirator 7. Eye protection / face shield 8. Perform safety check with Donning buddy Doffing Sequence 1. Insect PPE for visible contaminates, cuts, tears, etc. 2. Disinfect gloves and remove gloves discarding into red biohazard waste bag 3. Don new pair of clean gloves and perform hand hygiene 4. Remove gown or coverall and boot shoe covers (if needed) and discard 5. Disinfect gloves 6. Remove goggles/ face shield 7. Disinfect gloves 8. Remove Mask / Respirator 9. Remove gloves 10. Perform hand hygiene

Transport/ Decontamination: 1. All First responders will doff PPE outside of ambulance and place in Red Biohazard bag, if patient condition allows for time to do so. 2. Cab of ambulance will be closed off from patient care compartment. 3. Driver of ambulance will maintain appropriate respiratory protection precautions in place and doff contact isolation protection (Tyvek suit and gloves). Then driver will don a new pair of nitrile gloves prior to entering cab. 4. Exhaust fan will remain ON during transport.

Special Circumstances Protocol Section Protocol Circumstances Special 5. Once at destination, doors to ambulance remain open with exhaust fan running. 6. Crew notifies CCEMS communications, out of service for “DECON”

Pearls • Reference Policy Number: 3003-04 “Infectious Disease Response Plan • Reference CCEMS Primer on Infectious Diseases; pg 24 and EMS Infectious Disease Playbook, 5-27 – 5-32 • If during door jam survey risk is identified, identify dispatch, and IMMEDIATELY back out to don appropriate PPE • N95 mask and eye protection on prior to patient contact • High index of suspicion if patient symptomatic and has been in enclosed environments such as clinics, hospitals, prisons, or homeless shelters.

2020 Version 1 SC 8 Approved Medical Abbreviations

The following is a list of approved medical abbreviations. In general, the use of abbreviations should be limited to this list.

A & O x 3 Alert and Oriented to person, place, D-Stick Blood Glucose and time D5W 5% Dextrose in Water A & O x 4 Alert and Oriented to person, place, DKA Diabetic Ketoacidosis time, and event DNR Do Not Resuscitate A-FIB Atrial Fibrillation DOA Dead on Arrival AAA Abdominal Aortic Aneurysm DT Delirium Tremens ABC Airway, Breathing, Circulation Dx Diagnosis ABD Abdomen, abdominal ACLS Advanced Cardiac Life Support ECG Electrocardiogram AKA Above the knee amputation EEG Electroencephalogram ALS Advanced Life Support ET Endotracheal AMA Against Medical Advice ET – TUBE Endotracheal Tube AMS Altered Mental Status ETOH Ethanol (alcohol) APPROX Approximately ASA Aspirin Fx Fracture

ASSOC Associated Approved Medical Abbreviations G Grams BILAT Bilateral GI Gastrointestinal BKA Below the knee amputation GSW Gun Shot Wound BLS Basic Life Support Gtts Drops BM Bowel Movement GU Gastrourinary B/P Blood Pressure GYN Gynecology (gynecological) BVM Bag – Valve – Mask H/A Headache C-SECTION Caesarean Section HEENT Head, Eyes, Ears, Nose, Throat C-SPINE Cervical Spine HR Heart Rate (hour) C/O Complaint of (complains of) HTN Hypertension CA Cancer Hx History CABG Coronary Artery Bypass Graft ICP Intracranial Pressure CAD Coronary Artery Disease ICU Intensive Care Unit CATH Catheter IM Intramuscular CC Chief Complaint IV Intravascular CHF Congestive Heart Failure IO Intraosseous CNS Central Nervous System IN Intranasal COPD Chronic Obstructive Pulmonary Disease JVD Jugular Vein Distension

CPR Cardiopulmonary Resuscitation Kg Kilogram CSF Cerebrospinal fluid KVO Keep Vein Open CT Cat Scan CVA Cerebrovascular Accident (Stroke)

2020 APPENDIX A Approved Medical Abbreviations

L – SPINE Lumbar Spine S / P Status Post L & D Labor and Delivery SOB Shortness of Breath LAT Lateral SQ Subcutaneous Lb Pound SVT Supraventricular Tachycardia LLQ Left Lower Quadrant SZ Seizure LMP Last Menstrual Period Sinus Tach Sinus Tachycardia LOC Level of Consciousness (loss of Consciousness) T-SPINE Thoracic Spine LR Lactated Ringers TEMP Temperature LUQ Left Upper Quadrant TIA Transient Ischemic Attack TKO To keep Open (refers to IV’s MCG Microgram(s) – same as KVO) MED Medicine Tx Treatment MG Milligram(s) MI Myocardial Infarction (heart attack) URI Upper Respiratory Infection MIN Minutes / minimum UTI Urinary Tract Infection MVC Motor Vehicle Crash V-FIB Ventricular Fibrillation N/V Nausea / Vomiting V/S Vital Signs N/V/D Nausea / Vomiting / Diarrhea V-TACH Ventricular Tachycardia NAD No apparent Distress NC Nasal Cannula WAP Wandering Atrial Pacemaker NEB Nebulizer NKDA No Known Drug Allergies Y / O Years old (years of age) NRB Non-Rebreather NS Normal Saline M Male F Female OB / GYN obstetrics / gynecology ~ Approximately PALP Palpation > Greater Than PAC Premature Atrial Contraction < Less Than PE Pulmonary Embolus = Equal

PERRL Pupils Equal Round Reactive to Light Ψ Psychiatric Approved Medical Abbreviations Medical Approved PJC Premature Junctional Contraction Δ Change PO Orally PRN As Needed PT Patient PVC Premature Ventricular Contraction

RLQ Right Lower Quadrant RUQ Right Upper Quadrant Rx Medicine

2020 APPENDIX A Physiologic Effects of Sympathomimetic Agents

Receptor Activated Cardiovascular Effects Cardiac Heart DOSAGE

DRUG ALPHA BETA 1 BETA 2 DOPA Output Rate SVR < 5 mcg / kg / min 0 ↑↑↑ ↑ 0 ↑↑ ↑ ↑

Dobutamine 5 – 20 mcg / kg / min 0 ↑↑↑ ↑↑ 0 ↑↑↑ ↑↑ ↑ > 20 mcg / kg / min 0 ↑↑↑ ↑↑ 0 ↑↑↑ ↑↑↑ ↑↑ < 5 mcg / kg / min 0 ↑ ↑ ↑↑↑ ↑ ↑ 0 Dopamine 5 – 20 mcg / kg / min ↑↑↑ ↑↑↑ ↑ ↑↑↑ ↑↑ ↑↑ ↑↑↑

> 20 mcg / kg / min ↑↑↑↑ ↑↑↑ 0 ↑↑↑ ↑ ↑ ↑↑↑ ↑

< 2 mcg / min 0 ↑ 0 0 ↑ ↑ JOBAID: Physiologic Effects of Sympathomimetic Agents Epinephrine 2 – 8 mcg / min ↑↑ ↑↑↑ ↑↑ 0 ↑↑↑ ↑ ↑ 9 – 20 mcg / min ↑↑↑ ↑↑ ↑↑ 0 ↑↑ ↑↑ ↑↑ < 2 mcg / min ↑↑↑↑ ↑↑ 0 0 ↑ ↑ ↑↑↑ Norephinephrine

2 – 16 mcg / min ↑↑↑↑ ↑↑ 0 0 0 ↑ ↑↑↑↑

Receptor Stimulation Receptor Predominant Effect KEY: CO=cardiac output, HR=heart rate, α1 Peripheral Vasoconstriction ( ↑ SVR) SVR=systemic vascular resistance,

β1 Increased Contractility and HR ( ↑ CO) 0=no effect, ↑ ↑=increased [e.g., ↑=mild and ↑↑↑=strong effect]) β2 Increased Peripheral Vasodilation ( SVR) ↓=decreased (the number of arrows indicates the degree of effect DA Renal Vasodilation

2020 APPENDIX B This Page Intentionally Left Blank

2020 Version JOB AID: Blood Gas Analysis

Blood Gas Analysis: Blood Gases Blood gas analysis provides information about the patient's acid-base balance, metabolic status, and ventilatory status.

Definitions 1. pH: The negative logarithm of the concentration of H- ions. This value reflects the acid-base status of the blood. 2. Pco2: Partial pressure exerted by the carbon dioxide molecules in the blood. C02 levels are controlled by the ventilatory system. 3. Po2: Partial pressure of oxygen molecules dissolved in the blood. – – 4. HCO3 : Concentration of the bicarbonate ions in the blood. HCO 3 is a base that is excreted or retained by the kidneys as necessary. 5. So2: Percentage of hemoglobin saturated with 02. 6. O2 content: Calculated parameter that reflects the total amount of O 2 in the blood. Approximately 97% of O 2 is bound to hemoglobin. 7. Base excess/deficit: Calculated parameter that indicates the number (positive or negative) of buffering ions in the blood. – Buffering ions can be HCO3 , hemoglobin, proteins, and phosphates. Base excess is useful for detecting metabolic disorders: negative values indicate metabolic acidosis, whereas positive values indicate metabolic alkalosis or compensated respiratory

acidosis. JOBAID: Blood GasAnalysis 8. Acidemia: Condition when blood has a pH <7.35. 9. Acidosis: Process that causes acidemia. 10. Alkalemia: Condition when blood has a pH >7.45. 11. Alkalosis: Process that causes alkalemia. 12. Hypoxia: Reduced oxygen levels in air, blood, or tissue. 13. Hypoxemia: Reduced oxygen content in blood. 14. A-a Po2 gradient: Calculated parameter that indicates difference between alveolar and arterial O2 levels.

Oxygenation Status 1. Arterial oxygenation is usually considered compromised when

▪ Sao2 < 90%

▪ Pao2 < 60 mm Hg Po2 is affected by patient's age and body temperature, barometric pressure, and fraction of inspired oxygen (FIo2). 2. If a patient is receiving supplemental oxygen, Pao2 is interpreted in relation to the FIo2 delivery.

▪ Pao2/ FIo2 normal range is 286-350 (200 may be acceptable in some clinical situations).

▪ When Po2 >100 mm Hg, FIo2 should be reduced. 3. A-a Po2 gradient is also a measure of oxygenation. ▪ Normal = 10-15 min Hg

▪ Increases with increases in oxygen delivery (FIo2) ▪ Increases with increases in intrapulmonary shunting 4. Pvo2 and Svo2, indicators of venous oxygenation, are important guides for evaluating tissue oxygenation.

Normal Arterial Blood Gas Values at Sea Level Critical Normal Mixed Venous Blood Gas Values Values at Sea Level Adult Elderly Child ( > 60 yrs old) pH 7.31 - 7.41 pH 7.35 – 7.45 7.35 – 7.45 < 2yr 7.34 – 7.46; <7.25, >7.55 > 2yr 7.35 -7.45 Po2 35 – 40 mm Hg Pco2 41 – 51 mm Hg Paco , mm Hg 35-45 35 – 45 < 2yr 26 – 41; Svo , 70 – 75% 2 <20, >60 2 > 2yr 35 – 45 HCO3– 22 – 26mmol/L Base excess -2 to +2 – HCO3 ,mmol/L 21-28 21 – 28 21 - 28 <15, >40 Pao2, mm Hg 80-100 100 – (age / 3) 80 - 100 <40 Sao2, % 95-100 95 95 - 100 <76 O2 content, 15-22 15 – 22 15 - 22 %Base excess -2 to +2 - 2 to +2 -2 to +2 + / - 3

2020 APPENDIX C1 JOB AID: Blood Gas Analysis

pH PaCO2 HCO3 Compensation Common Causes ▪ Obstructive lung disease, ▪ head trauma, Respiratory HCO3- ▪ oversedation, < 7.35 > 45 ▪ general anesthesia, Acidosis > 26 mmol / L ▪ inappropriate settings for mechanical ventilation, ▪ Guillain Barré syndrome

▪ Hypoxemia ▪ nervousness/anxiety ▪ low hemoglobin level ▪ pulmonary embolus Respiratory HCO3- ▪ bacteremia > 7.45 < 35 Alkalosis > 21 mmol / L ▪ interstitial lung disease ▪ brain stem tumors ▪ response to metabolic acidosis respiratory stimulant drugs ▪ excessive mechanical ventilation

▪ Diabetic ketoacidosis starvation ▪ lactic acidosis Metabolic ▪ renal failure < 7.35 < 21 mmol / L PaCO2 < 35 mmHg Acidosis ▪ Uremia ▪ Diarrhea ▪ pancreatic drainage

▪ Vomiting ▪ prolonged nasogastric suctioning

JOB AID: Blood Gas Analysis Gas Blood AID: JOB ▪ diuretic therapy Metabolic < 7.45 > 28 mmol / L PaCO2 > 45 mmHg ▪ Hypokalemia Alkalosis ▪ massive blood transfusions containing citrate, ▪ bicarbonate administration Cushing syndrome

MIXED IMBALANCES

Blood Gas Result Coexisting Respiratory and Metabolic Alkalosis

pH < 7.34 > 7.45

PaCO2 > 45 < 35

HCO3- < 21 > 26

2020 APPENDIX C1 JOB AID: Capnography

Capnography

Definitions:

Capnography – Continuous analysis and recording of Carbon Dioxide concentrations in respiratory gasses (i.e. waveforms and numbers. Capnometry – Analysis only of the gases, no waveform.

Relationship between CO2 & RR

ETCO 2 Values

Normal 35 – 45 RR= CO2Hyperventilation

Hypoventilation > 45 RR= CO2Hypoventilation

Hyperventilation < 35

Evaluating Capnography JOBAID: Capnography

5 Characteristics Systematic Approach to Waveform Interpretation

1. Frequency 1. Is CO2 present (wave form) 2. Rhythm 2. Respiratory baseline – is there breathing? 3. Height 3. Expiratory upstroke – steep, sloping, or prolonged 4. Baseline 4. Expiratory plateau – Flat, prolonged, notched or sloping 5. Shape 5. Inspiratory downslope - steep, sloping, or prolonged 6. Read EtCO2 7. If ABG available, compare EtCO2 with PACO2 a. If within 5mm/hg of each other than the problem is ventilatory and not perfusion b. EtCO2 can be used in many cases in lieu of ABG’s

The ABC’s of Waveform Interpretation

A. Airway – look for signs of obstructed airway (steep, upsloping expiratory plateau) B. Breathing – Look at ETCO2 reading. Look for waveforms, and elevated respiratory baseline. C. Circulation – Look at trends, long and short term for increases or decreases in EtCO2 readings.

The Normal Wave Form A-B: A near zero baseline—Exhalation of CO2-free gas contained in dead space. B-C: Rapid, sharp rise—Exhalation of mixed dead space and alveolar gas. C-D: Alveolar plateau—Exhalation of mostly alveolar gas. D: End-tidal value— Peak CO2 concentration—normally at the end of exhalation. D-E: Rapid, sharp downstroke—Inhalation

2020 APPENDIX C2 JOB AID: Capnography

CAPNOGRAPHY WAVEFORMS CAPNOGRAPHY WAVEFORMS

INTUBATED - PATIENT NON-INTUBATED PATIENT JOB AID: Capnography AID: JOB

2020 APPENDIX C2 JOB AID: Ventilators

Ventilator Modes Volume Target Modes: ▪ Controlled Ventilation: delivers a preset VT and at a preset rate and provides and expected minute volume. ▪ Ventilation is maintained regardless of the patient effort. ▪ Used with patients who have no inspiratory effort or patients receiving chemical paralysis as part of the medical treatment ▪ Rarely used ▪ Assist Control Ventilation: delivers a preset VT whenever the patient exerts a negative inspiratory effort. A preset rate ensure that the patient receives adequate ventilation, regardless of spontaneous efforts and helps decrease the WOB. ▪ Example: Settings of AC rate of 10 and VT of 700, if the patient initiates 16 breaths, they will receive a VT of 700 with each breath. If the patient does not initiate breaths, they will receive 10 breaths with a VT of 700 ▪ Synchronized Intermittent Mandatory Ventilation: delivers a preset rate and preset VT and permits the patient to breathe spontaneously at his or her own respiratory rate and depth between the ventilator breaths

Pressure-Targeted Modes: ▪ Pressure-Support Ventilation: delivers a preset level of positive pressure that is applied for the duration of the spontaneous breath and allows a more even distribution of inspired gas. This mode does not have a set rate; it augments the patients spontaneous V T and decreases the WOB associated with spontaneously breathing through an artificial airway. - Can be used with IMV modes to assist spontaneous ventilations ▪ Continuous Positive Airway Pressure Ventilation: delivers positive pressure during spontaneous breaths; patient controls rate, inspiratory flow, and VT ▪ Pressure Control Ventilation: pressure controlled breaths are time triggered by a preset respiratory rate. Used in patients with severe ARDS

or those with high peak pressures JOBAID: Ventilators Trouble Shooting Ventilator Alarms: Manually ventilate the patient with a bag-valve device if you are unable to troubleshoot alarms quickly or if you suspect equipment failure. A Bag Valve device should be readily available at the bedside for every patient on a ventilator.

Low-exhaled VT: alarm sounds if the patient does not receive the preset VT ▪ A leak in the ETT or trach cuff ▪ Displacement of the ETT or trach tube ▪ Disconnection of any part of the ventilator circuit ▪ Patient stops spontaneous respirations ▪ Leak through a chest tube ▪ Decreased lung compliance ▪ Interventions include evaluation of the patient, RR, all connections, suction the airway, reconnect tubing, check the chest t ube, reposition or change the ETT

Low Inspiratory Pressure alarm ▪ A leak in the ETT or trach cuff ▪ Displacement of the ETT or trach tube ▪ Disconnection of any part of the ventilator circuit ▪ Patient stops spontaneous respirations ▪ Leak through a chest tube ▪ Decreased lung compliance ▪ Decreased resistance (decreased secretions, relief of bronchospasm, resolving Atelectasis, resolving pulmonary edema, change in position ▪ Interventions include evaluation of the patient, RR, all connections, suction the airway, reconnect tubing, check the chest t ube, reposition or change the ETT

Low Exhaled Minute Volume: ▪ Leak in the system ▪ Airway secretions ▪ Decreased lung compliance ▪ Decreased patient-triggered respiratory rate resulting from drugs, sleep, fatigue or change in neurologic status ▪ Interventions include check the patient’s respiratory rate, mental status, and WOB; evaluate the system for leaks; suction airway, assess the patient for changes in disease state

High Respiratory Rate: ▪ Increased Metabolic demands ▪ Drug administration

2020 APPENDIX C3 JOB AID: Ventilators

Trouble Shooting Ventilator Alarms: Manually ventilate the patient with a bag-valve device if you are unable to troubleshoot alarms quickly or if you suspect equipment failure. A Bag Valve device should be readily available at the bedside for every patient on a ventilator.

High Respiratory Rate: ▪ Increased Metabolic demands ▪ Drug administration ▪ Hypoxia ▪ Hypercapnia JOB AID: Ventilators AID: JOB ▪ Acidosis ▪ Shock ▪ Pain ▪ Fear, anxiety ▪ Interventions include evaluation of the patient and ABG’s and calm reassurance for them. ▪ High Pressure Limit: alarm occurs if the amount of pressure needed for ventilating a patient exceeds the preset pressure limit ▪ Excessive secretions ▪ Biting on the ETT ▪ Coughing/Gagging/Mucous plugs ▪ Attempting to talk ▪ Change in position ▪ Pneumonia ▪ Abdominal distension ▪ Pulmonary edema ▪ Bronchospasm, Pneumothorax, tension pneumothorax or hemothorax ▪ Kinks in the ventilator tubing ▪ ETT in right main stem bronchus ▪ Water from humidifier in the tubing ▪ Interventions include clearing obstruction from tubing; unkink and reposition the patient; empty water from tubing; checking breath sounds; reassure the patient and sedate if necessary; check ABG’s for hypoxemia; observe for abdominal distension; Chest XRAY; reposition the ETT; bronchodilatory therapy.

Apnea Alarms: ▪ Occurs if the ventilator does not detect spontaneous respirations within a preset interval. ▪ This alarm is very important when the patient is receiving breaths at a very low rate or the patient is receiving pressure support ventilation ▪ This alarms requires immediate attention and the nurse should assess the patient and manually ventilate the patient if necessary

2020 APPENDIX C3