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Altered Mental Status/Coma Asthma Chest Pain CPAP Hypoglycemia Intraosseous Infusion (EZ IO) Adult Intraosseous Infusion (EZIO) Pediatric Poisoning and/or Overdose Seizure Spinal Immob. Decision Tree

Updated 1/30/14

Altered Mental Status/Coma ILS

· ABC’s Protocol · Oxygen · Assist Ventilations, as needed Possible causes: . Consider IV/IO NS · Head Injury · CVA . Detailed Assessment 1 2 · Diabetes · Seizure . Check blood sugar · Overdose · Hypotension . Consider cardiac monitor 3 . Hypertension . Poisonings · Consider ALS backup . Metabolic . Psychiatric . Sepsis

BP See SHOCK ? < 90 protocol mmHG

≥ 90 Glasgow Coma Scale mmHG Eye Spontaneous 4 Opening To Voice 3 To Pain 2 See Hypoglycemia None 1 Blood protocol Best Oriented 5 Sugar Verbal Confused 4 < 80 ? mg/dl Response Inappropriate words 3 Increased LOC ? Incomprehensible words 2 ≥ 80 None 1 mg/dl Yes Best Obeys Commands 6 No Motor Localizes Pain 5 Response Withdraws (Pain) 4 Consider Narcan 4 Flexion 3 Extension 2 None 1

Increased May repeat Narcan every 5 LOC Yes min as needed Document: ?  · Glasgow Coma Scale No · Clinical Response to Dextrose or Narcan · Blood Sugar · Transport · SpO2 · Keep patient warm · IV Fluid Totals · Monitor LOC, Vital Signs, SpO2, · Medical History & Respiratory Status · Exam · Vital Signs

1. Detailed Assessment: Document Glasgow Coma Scale. Check odor on breath. Look for Medical Alert. tags, needle tracks, and evidence of trauma. If trauma noted, consider C-spine precautions. :

. Smith Larry 2. Observe environment closely for signs of potential overdose. If suspected overdose, see overdose protocols. 3. If applicable, print a rhythm strip from the cardiac monitor for ER staff. 4. Narcan may be administered prior to Dextrose. Narcan 0.4 mg IV/IO or IM, prn (some agonist/antagonist narcotic overdoses Approved Dr may require higher doses of Narcan, i.e. methadone). Narcan via intranasal (IN) 0.8 mg - 2 mg (split the total dose between each nostril). If no response may repeat IN dose x 1. Pediatric dose: < 20 kg 0.01 mg/kg, > 20 kg 0.4 mg initial dose repeat, prn. Constricted pupils may suggest narcotic overdose. Be prepared to restrain combative patient.

Reviewed: 5/11/15 ALTERED MENTAL STATUS/COMA Revised: 5/12/15

· ABC’s · Oxygen 100% 1 · Assist Ventilations, as needed · IV/IO NS · Consider ALS backup

- Albuterol via nebulizer Resp 2 Albuterol: 2.5 mg in 2 cc NS distress Yes ? - Consider Anaphylaxis reaction

· Transport · Keep patient warm · Monitor LOC, Vital Signs, SpO2, & Respiratory Status Document:  · Airway · Breath Sounds · Skin Color · Vital Signs, SpO2 · Glasgow Coma Scale · Treatment · Response to treatment : : . Smith Larry 1. If COPD co-exists titrate Oxygen to maintain SpO2 > 90%. 2. Albuterol: may repeat continuously. Discontinue use if patient develops chest pain. Approved Dr

· ABCs . Vital Signs . Sp02 @ room air · Oxygen · Consider cardiac monitor 1 · IV/IO NS · Consider ALS backup

Consider the following treatment options: · Nitroglycerin SL 0.4 mg 2 · Aspirin PO 324 mg 3

· Transport per County “Emergency Cardiac” operating procedure · Keep patient warm · Monitor LOC, Vital Signs, SpO2 & Respiratory Status Document:  · ABCs · Medical History · Signs & Symptoms · Quality of Pulses · SpO2, VS · Glasgow Coma Scale · Color, Diaphoresis · Lung Sounds · Response to Treatment : 3 / 15 Larry Smith Larry . Dr Approved 1. Be aware that ischemic cardiac pain can present as abdominal or back pain, especially in females & older patients. 2. Nitroglycerin SL sublingual is contraindicated if systolic BP < 90 mmHg. If the patient has taken Viagra or Levitra within 24 hours, or Cialis within 48 hours do not administer Nitroglycerin. If the patient meets criteria administer 1 dose sublingual (under the tongue). Max of 3 doses total given at one dose at a time of 0.4 mg per dose every 3-5 minutes for chest pressure/pain. Recheck BP prior to each dose. 3. Aspirin is contraindicated in cases of known hypersensitivity. Aspirin may be withheld if the patient has definitely taken 324 mg of Aspirin within the last 24 hours.

Apply oxygen as indicated Possible Causes: · COPD Prepare patient for CPAP · CHF - inform them of procedure and sensation of CPAP · Pneumonia · Aspiration · Asthma Place CPAP mask and seucre to patient

If adjustable PEEP, start setting at 5 cm H2O. Increase in 2.5 cm H2O increments as needed for oxygenation 2

Assess lung sounds and vitals after placement - Give in-line nebulized medications if indicated 3 - If giving oral/sublingual medications, try to administer prior to Administer medications as indicated CPAP placement to prevent aspiration. Otherwise, remove mask to give needed medications (i.e. NTG, ASA). Allow them to be completely swallowed or dissolved. Monitor for side effects of positive pressure ventilation 4

Reassess breath sounds/vital signs frequently (slowing of heart rate is a typical sign of improvement)

For progressive respiratory failure, consider calling ALS 5

Contraindications: Notify receiving facility that the patient is arriving on CPAP · Unconscious · Vomiting · Hypotension (SBP<90 mmHg) · Trauma · Suspected Pneumothorax · Inability to seal mask · Patient unable to cooperate (this can often be mitigated with effective coaching)

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1 1. Use CPAP early or if initial round of therapy is ineffective. For example, if arriving to a COPD call and m 1

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y the patient looks poor at the initial evaluation (i.e. hypoxia, increased work of breathing) move r e r v

a quickly to CPAP with nebulized therapies. o r L p . 2. Do not increase PEEP if systolic BP is < 90 mmHg. r p A D 3. For patients with severe asthma prioritize administration of continuous albuterol. CPAP can be a useful adjunct if they are having ineffective respiratory effort or to assist in medication delivery if no improvement from albuterol treatments alone. 4. Positive pressure ventilation can cause hypotension by decreasing venous return. For dehydrated patients who have pneumonia or COPD, a small fluid bolus may be necessary to avoid hypotension once CPAP is started. Watch for gastric distension and vomiting. Remove mask if vomiting occurs. 5. If patient continues to deteriorate despite CPAP, remove CPAP and assist ventilations with 100% O2 via BVM as needed. Prepare for advance airway placement.

Reviewed: 11/18/15 Revised: 11/18/15 CPAP

Porter's EMS Protocols © Copyright 1997-2002 William Porter Hypoglycemia ILS Protocol · ABC’s · Oxygen Assist Ventilations, as needed · Check blood glucose level · Consider cardiac monitor · Consider ALS backup

Blood Ability to sugar IV/IO NS < 80 Swallow No ? mg/dl ? > 80 Dextrose 50% 2 mg/dl Yes 25g IV slowly Administer Oral Glucose 1

Repeat Blood sugar Dextrose 50% < 80 25g IV slowly ? mg/dl

> 80 mg/dl

· Transport  Document: · Keep patient warm · Airway · Monitor LOC, Vital Signs, SpO2, and · Respiratory Effort Respiratory Status · Vital Signs, SpO2 . Observe for decreased LOC 3 · Treatment · Signs & Symptoms · Glasgow Coma Scale . Blood Sugar Readings : :

. Smith Larry 1. Full glass of sweetened juice or Glucose Oral PO. Must be able to swallow. 2. Administer 0.5 g/kg Dextrose 25% in children (1-12 years). For infants (newborn – 1 year) administer 0.5 g/kg Dextrose 12.5%.

Approved Dr Recheck blood sugar following initial Dextrose dose. If blood sugar remains < 80 mg/dl, repeat initial dose. 3. Observe for decreased LOC, focal neurological findings, and hypothermia.

Reviewed: 05/12/14 HYPOGLYCEMIA

Indications: Adult EZ IO infusion is an option in unstable (altered LOC, hypotensive) patients where IV access is or is anticipated to be difficult or prolonged.

Relative Contraindications/Precautions: . Fracture of the bone selected for IO infusion (consider alternate site) . Excessive tissue at insertion site with the absence of anatomical landmarks (consider alternate site) . Previous significant orthopedic procedures (IO within 24 hours, prosthesis - consider alternate site) . Infection at the site selected for insertion (consider alternate site)

Conscious patient Unconscious patient

Initiate EZ IO access according to the Instructions for Placement 40 kg and over use Blue 25 mm 15g EZ IO needle Over 40 kg with excessive tissue over site use Yellow 45mm 15g EZ IO needle Under 40 kg use Pink 15mm 15g EZ IO needle Use IV fluids and medications as dictated per protocol.

Verifying correct IO placement with either aspiration of bone marrow or resistance free flushing with 10 ml NS via a syringe.

Set up gravity infusion or pressure infusion as needed.

Maintain fluid flow rate or administer fluids according to specific protocols

Watch for IO complications. Correct or discontinue as appropriate. ie: localized tissue edema, irritation, adverse reactions, leakage, low flow rate. h t i m S

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a Record time of IO initiation, discontinuation, and changeover to hospital IV devices and : L d

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INTRAOSSEOUS INFUSION Review: 05/12/14 (ADULTS) with the EZ IO Revised: 05/13/14 Porter's EMS Protocols © Copyright 1996-2002 William Porter Intraosseous Infusion - Pediatric ILS Protocol Indications: Pediatric EZ IO infusion is an option in unstable (altered LOC, hypotensive) patients where IV access is or is anticipated to be difficult or prolonged.

Conscious patient Unconscious patient

Verifying correct IO placement with either aspiration of bone marrow or resistance free flushing with 10 ml NS via a syringe.

Set up gravity infusion or pressure infusion as needed.

Maintain fluid flow rate or administer fluids according to specific protocols

Watch for IO complications. Correct or discontinue as appropriate. ie: localized tissue edema, irritation, adverse reactions, leakage, low flow rate. h t i m S

y r

r Record time of IO initiation, discontinuation, and changeover to hospital IV devices and

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· ABC’s Internal Contamination: · Oxygen, Assist Ventilations, as needed · What was ingested ? · Consider cardiac monitor · Time of consumption ? · Check Blood Sugar & Temperature · Amount consumed ? · Detailed Assessment · Past medical history ? · IV/IO NS External Contamination: · Protect self and crew · Consider calling Poison Control 1 · Remove contaminated clothing · Consider ALS backup · Flush contaminated skin and eyes with copious amount of water No

- S/S: mild HA, dyspnea on mild exertion, irritability, fatigue, N/V, confusion, ataxia, syncope, seizures, incontinence, respiratory Carbon Monoxide Poisoning (?) arrest, skin may be bright red in some cases Yes - Provide 100% Oxygen with a tight fitting NRB at 12-15 LPM

No - S/S: CNS and/or respiratory depression, drowsiness, N/V, pinpoint Narcotics (?) pupils, coma, cyanosis, bradycardia Yes - Consider Narcan 2

- S/S: Salivation, Lacrimation, Urination, Organophosphate Exposure (?) Defecation, Gastric emptying, Emesis (Parathion, Malathion, Pesticides & Herbicides) Yes - Consider Oxygen

· Transport · Keep patient warm · Monitor LOC, Vital Signs, SpO2, Cardiac Rhythm, Respiratory Status, CO levels 3 Document:  · Signs & Symptoms · Treatment · Clinical Response to treatment · Vital Signs, SpO2 : : · Airway Management . Smith Larry Approved Dr 1. Poison Control EMS #: 800-709-0911 2. Consider administering Narcan before supraglottic airway insertion. A brief trial of Narcan may quickly reverse the patient’s condition. Narcan may be administered prior to Dextrose. Narcan 0.4 mg IV/IO or IM, prn (some agonist/antagonist narcotic overdoses may require higher doses of Narcan, i.e. methadone). Narcan via intranasal (IN) 0.8 mg - 2 mg (split the total dose between each nostril). If no response may repeat IN dose x 1. Pediatric dose: < 20 kg 0.01 mg/kg, > 20 kg 0.4 mg initial dose repeat, prn. Constricted pupils may suggest narcotic overdose. Be prepared to restrain combative patient. 3. CO levels > 10 is consider serious.

Reviewed: 5/11/15 Revised: 5/12/15 POISONING AND/OR OVERDOSE

© Copyright 2000 William Porter Porter's EMS Protocols ILS Seizure Protocol · ABC’s . Consider C-spine precautions · Oxygen · Assist Ventilations, as needed · Detailed Assessment · Consider cardiac monitor · IV/IO NS · Consider ALS backup

Protect patient from injury during and after seizure. After seizure has stopped consider placing patient in lateral recumbent position if trauma absent.

Blood Dextrose 50% Sugar 25g IV/IO 1 ? < 80 mg/dl > 80 mg/dl

Elevated Consider external cooling methods 2 Temp Yes ?

Document:

 · ABCs · Activity During Seizure · Duration of Seizure · Postictal Phase · Transport 3

Smith · Vital Signs . · Anticipate additional seizures · SpO2 · Monitor: LOC, Vital Signs, SpO2, · Glasgow Coma Scale : : & Respiratory Status · Lung Sounds . O Larry · Color · Treatment Approved Dr · Response to Treatment · Communication with Medical Control

1. Administer 0.5 g/kg Dextrose 25% in children (1-12 years). For infants (newborn – 1 year) administer 0.5 g/kg Dextrose 12.5%. Recheck blood sugar following initial Dextrose dose. If blood sugar remains < 80 mg/dl, repeat initial dose. 2. Loosen clothing, mist and/or fan patient. 3. Provide a quiet, calm environment.

Patient conscious at time Immobilize of exam? No Yes

Patient denies LOC after Immobilize injury? No Yes

Patient Alert, Oriented x 3? Immobilize No Yes

Patient is unaffected Significant findings: Immobilize · Significant injury above clavicles by alcohol or any mind No altering substance · Loss of consciousness · Paralysis, weakness, numbness, tingling within extremities Yes · Point tenderness over spine No Patient reliable historian? Immobilize

Yes No Patient denies spinal pain? Immobilize

Yes

Patient denies spinal No tenderness on palpation? Immobilize

Yes No Patient denies neuro deficits? Immobilize  Document: Yes · Airway · Respiratory Status Patient has no other (distracting) No Immobilize · Circulation injury? · Neurologic Status · Glasgow Coma Scale Yes

: : · Detailed Assessment

. Smith Larry · Vital Signs, SpO2 ILS Provider may choose not to immobilize 1 · Treatment Approved Dr

1. Consider immobilizing if significant MOI, and/or extreme of age (<15 or >60).

Reviewed: 05/12/14 Revised: 05/13/14