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1 Air Care & Mobile Care Clinical Policies General General Patient Air Care & Mobile Care Clinical Policies General General Patient Care Guidelines for Rapid Response (CLIN68)…………………………………….4 Therapies Not Requiring Base Medical Direction (CLIN56)………………………………………..11 Use of Over the Counter Medications in Special Events (CLIN65)………………………………...14 Pronouncing Death at an Accident Scene (CLIN42)…………………………………………………16 Pronouncing Death at a Referring Facility (CLIN41)………………………………………………..18 Airway Rapid Sequence Intubation (RSI) (CLIN10)…………………………………………………………..19 Management of Nasotracheal Intubation (CLIN03)…………………………………………………25 Management of Orotracheal Intubation (CLIN09)…………………………………………………..28 Verification of Endotracheal Tube Placement (CLIN06)…………………………………………….31 Waveform Capnography (CLIN07)……………………………………………………………………34 I-Gel Supraglottic Airway (CLIN60)…………………………………………………………………..37 Use of the Airtraq Disposable Optical Laryngoscope (CLIN58)……………………………………40 Respiratory Acute Chronic Obstructive Pulmonary Disease (COPD) Exacerbation (CLIN45)………………..43 Respiratory Acute Asthma Exacerbation-Adult (CLIN50)………………………………………….46 Acute Decompensated Heart Failure/Pulmonary Edema (CLIN47)………………………………48 Respiratory Pulmonary Embolus (CLIN46)…………………………………………………………..50 Use of Non-Invasive Rescue CPAP device (CLIN66)………………………………………………..53 Care of the Ventilated Patient and Use of the 731 Ventilator (CLIN59)…………………………...56 Analgesia and Sedation Pain Management (CLIN30)…………………………………………………………………………....61 Sedation, Analgesia, and Paralysis of the Intubated Patient (CLIN49)…………………………….64 Cardiac Management of the Acute Coronary Syndrome Patient(ACS) (CLIN17)………………………….68 Management of the ST Elevation Myocardial Infarction (STEMI) Patient (CLIN20)…………….71 STEMI Limited Infusion Protocol (CLIN19)………………………………………………………….75 Cardiac Aortic Emergencies (CLIN18)………………………………………………………………...78 Cardiac Emergencies – Dysrhythmias (CLIN15)……………………………………………………..82 Transcutaneous Cardiac Pacing (CLIN21)……………………………………………………………87 Medical Management of the Shock Patient (CLIN51)………………………………………………………….89 Acute Limb Arterial Insufficiency (CLIN12)………………………………………………………….93 Gastrointestinal Bleeding (CLIN23)…………………………………………………………………...95 1 Neurologic Seizures/Status Epilepticus (CLIN25)………………………………………………………………...99 Management of Intracranial Hemorrhage (SAH, ICH) (CLIN24)………………………………...102 Management of Traumatic Brain Injury (CLIN57)………………………………………………….107 Stroke (CLIN67)………………………………………………………………………………………...111 Obstetrics Emergency Delivery (CLIN27)………………………………………………………………………..116 Pediatric Neonate Delivery at referring Facility (CLIN32)………………………………………...121 Transfer of High-Risk Obstetric (OB) Patients (CLIN26)…………………………………………..123 Vaginal Bleeding in Pregnancy (CLIN28)…………………………………………………………...125 Pediatrics Pediatric-Acute Asthma Exacerbation (CLIN31)……………………………………………………127 Cardiac Emergencies – Dysrhythmias in the Pediatric Population (CLIN16)…………………...130 Direct to OR Direct Transfer to Operating Room (CLIN29)………………………………………………………138 Blood Administration Blood Product Administration of Liquid Plasma (CLIN62)……………………………………….140 Administration of O negative PRBC or type specific PRBC for Hemorrhagic Shock (CLIN13).146 Trauma Management of Patients with Traumatic Injuries (CLIN55)………………………………………149 Spine and Spinal Cord Injury (CLIN53)……………………………………………………………..152 Management of Major Thermal Burns (CLIN14)…………………………………………………...155 Management of Amputated Body Parts (CLIN52)…………………………………………………158 Administration of Tranexamic Acid (TXA) in Trauma Patients (CLIN59)………………………161 Use of Topical Hemostatic Gauze: Kaolin-Impregnated Gauze (Combat Gauze) (CLIN54)…..165 Procedures Management of Intraosseous Access and Infusion with EZ IO Device (CLIN35)………………167 Management of Needle Cricothyrotomy (CLIN36)………………………………………………...170 Management of Surgical Cricothyrotomy (CLIN34)……………………………………………….173 Use of the Combat Application Tourniquet (CLIN33)……………………………………………..176 Hydroxocobalamin (Cyanokit) Administration (CLIN63)………………………………………...179 Field Limb Amputation (CLIN61)……………………………………………………………………183 Lateral Canthotomy and Cantholysis (CLIN64)…………………………………………………….186 Management of Pericardiocentesis (CLIN37)……………………………………………………….188 Pleural Decompression (needle and finger thoracostomy) (CLIN38)…………………………….191 Tube Thoracostomy (CLIN40)………………………………………………………………………...194 Use of the TPod Pelvic Stabilizer (CLIN43)…………………………………………………………197 2 Additional Guides & Resources Extracorporeal Membrane Oxygenation (ECMO)………………………………………………….198 Impella…………………………………………………………………………………………………..200 Intra-Aortic Balloon Pump (IABP)…………………………………………………………………...202 Left Ventricular Assist Device (LVAD)……………………………………………………………...204 My LVAD EMS Field Guide (website link) 3 General Patient Care Guidelines for Rapid Response (CLIN68) I. POLICY Air Care & Mobile Care paramedic teams will be required to respond to associates, patients and visitors in the role of a first responder or medical assistance if the need arises. In this capacity, both BLS and ALS teams will provide care within their scope of practice and according to Air Care & Mobile Care Clinical Protocols. II. PURPOSE To provide guidelines for the care of patients in the rapid response/first responder setting. The conditions mentioned are possibly the most common conditions encountered. If a condition is not addressed in this protocol, medical team will revert to ACMC Clinical Protocols. III. DEFINITIONS Rapid Response-The terminology used to identify the need for medical assistance to associates, patients or visitors who are in areas where medical coverage is limited or in areas that are not inpatient units. Paramedic Teams-Designated team who will respond to the designated areas and provide medical assistance/emergency care within their scope of practice. This could be in the configuration of two (2) paramedics, one paramedic and one EMT, or two (2) EMTs with a paramedic responding enroute. IV. PROCEDURE Paramedic teams will encounter a variety of medical conditions that need medical assistance and possible subsequent transport. Below are guidelines for the care of the most common emergent conditions. All patients will have a focus assessment, vital signs and documentation of treatment given placed in the approved electronic medical record. All patients are to be transport to UCMC for further medical care. A. Chest Pain/Cardiac Arrest 1. Provide care in a calm and reassuring manner. 2. Place the patient in a position of comfort. 3. Obtain a focused history and physical. If there is the complaint of chest pain, the history should include: onset, provoking factors, quality, radiation, severity, time and pertinent negatives. 4. Maintain airway and administer oxygen if O2 Sat is less than 94% 5. Obtain 12 Lead EKG if possible 6. Establish IV access 7. If the patient has not taken any of the above medicines medicines (Viagra, Levitra, Cialis, Staxyn, Flolan, Revatio, Adcirca) within the last 24-72 hours, the patient’s systolic blood pressure is greater than 100 mm Hg and is alert and responsive, administer nitroglycerin 4 • Nitroglycerin 0.4 mg sublingual every 3-5 minutes to a max of 3 doses only if SBP remains greater than 100 • Topical nitroglycerin (Nitropaste) may be used in lieu of sublingual nitroglycerin. Apply 1 inch of nitropaste to the anterior chest wall one time. • For chest pain not relieved by nitrates, administer either ✓ Fentanyl 25-50 micrograms IV/IO as long as systolic BP greater than 100 and pain persists. May repeat every 5 min to a total of200 micrograms. ✓ Morphine sulfate 1-5 mg IV/IO over 2 minutes as long as systolic BP greater than 100 and pain persists. May repeat every 5 minutes to a total of 10 mg. • Nausea and vomiting may be managed with ondansetron (Zofran) 4mg PO/IM/IV/IO. 8. Patients under cardiac arrest will be treated according to the most recent AHA updates for Advance Cardiac Life Support. B. Asthma/COPD 1. The patient has a history of asthma, emphysema or COPD AND complains of a worsening shortness of breath. 2. Lung exam has wheezing, rales/rhonchi, or poor air exchange. 3. Place patient on face mask to assist breathing 4. Confirm the use of any over the counter medication or prescribed inhalers 5. Assist the patient with use of inhaler if present 6. If further medication is necessary beyond the patient’s prescribed doses consider Administering Albuterol (Proventil) aerosol 2.5mg in 2.5ml normal saline via hand held nebulizer. Consider adding 1 vial Ipratropium Bromide (0.5mg of 0.017%) to the Albuterol aerosol. May substitute Duoneb (Albuterol plus Ipratropium Bromide that is premixed) for all Albuterol treatments. 7. If the patient is in impending respiratory failure, obtain IV access. 8. FOR ASTHMA: Consider epinephrine 1:1,000 solution intramuscularly (0.3 ml IM) if patient is not able to breathe in the nebulized medication. C. Allergic Reaction Assess for suspected exposure to allergen (insect sting, medications, foods, or chemicals). If patient is experiencing an anaphylaxis reaction maintain airway and administer Oxygen and Epinephrine should be administered as soon as possible. 1. Administer epinephrine 0.3 ml 1:1000 solution intramuscularly (IM). May repeat dose every 5-15 minutes as needed. 2. Monitor cardiac rhythm 3. If bronchospasm or wheezing is present, administer albuterol (Proventil) 2.5mg via nebulizer 4. Initiate IV access. If the patient is hypotensive, begin 1-liter normal saline IV wide open. 5. Administer diphenhydramine 25 -50 mg IV/IM/PO. Diphenhydramine may be used without preceding epinephrine in patients with isolated rash and no other
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