2019 Protocols (Adult) Flashcards
S-120 Abdominal Discomfort BLS
- Ensure patent airway
- O2 saturation prn
- O2 and/or ventilate prn
- NPO
- Transport suspected symptomatic aortic aneurysm to facility with surgical resources immediately available
S-120 Abdominal Discomfort ALS
- Monitor EKG
- IV/IO SO adjust prn
- Treat pain as per Pain Management Protocol (S-141)
Suspected volume depletion:
-500ml fluid bolus IV/IO SO
Suspected AAA:
-500ml fluid bolus IV/IO SO for BP<80 to maintain a BP of 80, may repeat x1 SO
For nausea/vomiting:
-Zofran 4mg IV/IM/ODT SO, MR x1 q10” SO
S-121 Airway Obstruction BLS
For a conscious patient:
- Reassure, encourage coughing
- O2 prn
For inadequate airway exchange: airway maneuvers (AHA) -Abdominal thrusts -Use chest thrusts in the obese or pregnant patient
If patient becomes unconscious or is found unconscious
-Begin CPR
Once obstruction is removed:
- High flow O2, ventilate prn
- O2 saturation prn
S-121 Airway Obstruction ALS
If patient becomes unconscious or has a decreasing LOC:
- Direct laryngoscopy and Magill forceps SO MR prn
- Capnography SO prn
Once obstruction is removed:
- Monitor EKG
- IV/IO SO adjust prn
S-122 Allergic Reaction/Anaphylaxis BLS
- Ensure patent airway
- O2 Saturation prn
- O2 and/or ventilate prn
- Remove stinger/injection mechanism
- May assist patient to self-medicate with own prescribed epinephrine auto-injector or MDI ONE TIME ONLY. Base Hospital contact required prior to any repeat dose.
If available and trained:
-Epinephrine auto-injector 0.3mg IM x1
S-122 Allergic Reaction/Anaphylaxis ALS
- Monitor EKG
- IV/IO SO adjust prn
- Capnography SO prn
Hives (Urticaria):
-Benadryl 50mg IV/IM SO
Anaphylaxis:
-Epinephrine 1:1,000 0.3mg IM per SO. MR x2 q5” SO
then
-500ml fluid bolus IV/IO for systolic BP<90 SO
MR to maintain systolic BP>90 SO
-Benadryl 50mg IM/IV SO
-Albuterol 6ml 0.083% via nebulizer SO.
MR SO for respiratory involvement
-Atrovent 2.5ml 0.02% via nebulizer added to first dose of Albuterol SO for respiratory involvement.
- Epinephrine 1:10,000 0.1mg IV/IO BHO. MR x2 q3-5” BHO
- Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP>90 BHO
S-122 Allergic Reaction/Anaphylaxis/Angioedema criteria
Anaphylaxis criteria (may include any):
- Unknown exposure : Skin AND Respiratory AND/OR cardiovascular
- Likely allergen exposure (eg beesting, peanut): 2/4 systems involved (skin, GI, respiratory, cardiovascular)
- Known allergen exposure
Angioedema:
lip/tongue/face swelling/difficulty swallowing/throat tightness, hoarse voice
S-123 Altered Neurological Function BLS
- Ensure patent airway, O2 and/or ventilate prn
- O2 saturation prn
- Spinal stabilization prn
- Secretion problems, position on affected side
- Do not allow patient to walk
- Restrain prn
- Monitor blood glucose prn (if trained and available)
Symptomatic suspected opiods OD (with respiratory rate <12)*:
(Use caution with opioid dependent pain management patients)
-Naloxone nasal spray 4mg preload single dose device
-Administer full dose in one nostril
OR
-Naloxone assemble 2m syringe and atomizer
-Administer 1mg (1ml) in each nostril
Hypoglycemia (suspected) or patient’s glucometer results read <60
-If patient is awake and able to swallow, give 3 oral glucose tabs or past (15g total).
Patient may eat or drink if able.
-If patient unconscious, NPO
CVA/Stroke:
See S-144 Stroke/Transient Ischemic Attack for details.
Seizures:
Protect airway, and protect from further injury
-Treat associated injuries
Behavioral Emergencies:
(S-422 and S-142)
S-123 Altered Neurological Function ALS
- Monitor EKG
- Capnography SO prn
- IV/IO SO adjust prn
- Monitor blood glucose prn SO
Symptomatic suspected opioids OD (with respiratory rate <12):
(Use caution in opioid dependent pain management patients)
-Naloxone 2mg IN/IM/IV SO. MR SO, titrate IV dose to effect, to drive respiratory rate.
-If patient refuses transport, give additional Naloxone 2mg IM SO
Hypoglycemia: Symptomatic patient with altered LOC or unresponsive to oral glucose agents:
- D50 25Gm IV SO if BS <60
- If patient remains symptomatic and BS remains <60 MR SO
- If no IV: Glucagon 1ml IM SO if BS <60
Hyperglycemia : Symptomatic patient with diabetic history
-500ml fluid bolus IV/IO if BS >350 or reads high SO x1
Seizures:
A. Ongoing generalized seizure lasting >5 minutes (includes seizure time prior to arrival of prehospital provider) SO
B. Recurrent tonic-clonic seizures without lucid interval SO
C. Eclamptic seizure of any duration SO
-Versed IN/IM/IV/IO SO to a max dose of 5mg (d/c if seizure stops) SO MR x1 in 10 minutes SO. Max 10mg total
S-124 Burns BLS
- Move patient to a safe environment
- Break contact with causative agent
- Ensure patent airway, O2 and/or ventilate prn
- O2 saturation prn
- Treat other life threatenting injuries
- Carboxyhemoglobin monitor prn, if available
Thermal burns:
-Do not allow patient to become hypothermic
Burns of <10% body surface area:
-Stop burning with non-chilled water or saline
Burns of >10% body surface area
-Cover with dry dressing and keep warm
Toxic inhalation (CO exposure, smoke, gas, etc.):
-Move patient to safe environment
-100% O2 via mask
For suspected carbon monoxide poisoning for unconscious or pregnant patient
-Consider transport to facility with hyperbaric chamber
Chemical burns:
- Brush off dry chemicals
- Flush with copious amounts of water
Tar burns:
-Cool with water, transport; do not remove tar
S-124 Burns ALS
- Monitor EKG
- IV/IO SO adjust prn
- Treat pain per Pain Management Protocol (S-141)
For patients with >20% partial thickness or >5% full thickness burns and >15 yo:
-500ml fluid bolus IV/IO then TKO SO
In the presence of respiratory distress with bronchospasm:
-Albuterol 6ml 0.083% via nebulizer SO. MR SO
Burn Center Criteria
Patients with burns involving:
- > 20% BSA partial thickness or
- > 5% BSA full thickness
- Suspected respiratory involvement or significant smoke inhalation in a confined space
- Injury of the face, hands, feet or perenium, or circumferential
- Electrical injury due to high voltage; (>120 volts)
S-126 Discomfort/Pain Of Suspected Cardiac Origin BLS
- Ensure patent airway
- O2 saturation prn
- Only use supplemental O2 to maintain O2 saturation 94-98%
- O2 and/or ventilate prn
- Do not allow patient to walk
- If systolic BP>100, may assist patient to self-medicate own prescribed NTG SL (maximum 3 doses, including those patient has taken)
- May assist with placement of 12 lead
- May assist patient to self-medicate own prescribed Aspirin (81mg to max dose of 325mg)
S-126 Discomfort/Pain Of Suspected Cardiac Origin ALS
-Monitor EKG
-IV/IO SO adjust prn
-Obtain 12 lead EKG and transmit (if capable).
If STEMI, notify base immediately and transport to appropriate STEMI center.*
-ASA 324mg chewable PO SO
If systolic BP>100:
- NTG 0.4mg SL SO. MR q3-5” SO
- NTG ointment 1 inch SO
- Treat pain per Pain Management Protocol (S-141)
If systolic BP<100:
- NTG 0.4mg SL BHO. MR BHPO
- Treat pain per Pain Management Protocol (S-141)
Discomfort/Pain of suspected Cardiac Origin with Associated Shock:
-250ml fluid bolus IV/IO without rales SO.
MR to maintain systolic BP>90 SO
If BP refractory to second fluid bolus:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP>90 BHO
S-126 Discomfort/Pain Of Suspected Cardiac Origin Note/*Report
Note:
- If discomfort/pain is relived prior to arrival, continue treatment with NTG ointment and ASA. ASA should be given regardless of prior daily dose(s).
- If any patient has taken an erectile dysfunction medication such as Viagra, Cialis, Levitra within 48 hours, NTG is contraindicated.
- May encounter patients taking similar medication for pulmonary hypertension (Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.
- Report:
- 12 lead interpretation of STEMI
- Bundle Branch Block (LBBB, RBBB).
- Poor quality EKG, artifact, paced rhythm, atrial fibrillation or atrial flutter for consideration of false positive reading STEMI.
- Repeat the 12 lead EKG only if the original EKG interpretation is NOT ACUTE MI SUSPECTED, and patient’s condition worsens. Do not delay transport to repeat.
- Document findings on the PPR and transmit EKG if available and leave EKG with patient.
S-127 Dysrhythmias, Unstable Bradycardia BLS
BLS:
- O2 and/or ventilate prn
- O2 Sat prn
S-127 Dysrhythmias, Unstable Bradycardia ALS (Narrow complex)
Unstable Bradycardia with Pulse:
(BP<90 AND chest pain, dyspnea, or altered LOC)
Narrow Complex Bradycardia:
- Monitor EKG
- 250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
- Atropine 0.5mg IV/IO for pulse <60 SO. MR q3-5” to max 3mg SO
If rhythm refractory to a minimum of Atropine 1mg:
-External cardiac pacemaker SO**
If capture occurs and BP>100, consider medication for discomfort:
-Treat pain per Pain Management Protocol (S-141)
For discomfort related to pacing and not relieved with analgesics and BP>100:
-Midazolam 1-5mg IV/IO SO
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip, titrate to BP>90 (after max Atropine or initiation of pacing) BHO
S-127 Dysrhythmias, Unstable Bradycardia ALS (Wide complex)
Unstable Bradycardia with Pulse:
(BP<90 AND chest pain, dyspnea, or altered LOC)
Wide Complex Bradycardia:
- Monitor EKG
- 250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
- External cardiac pacemaker SO**
If capture occurs and BP>100, consider medication for discomfort:
-Treat pain per Pain Management Protocol (S-141)
For discomfort related to pacing and not relieved with analgesics and BP>100:
-Midazolam 1-5mg IV/IO SO
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip, titrate to BP>90 (after initiation of pacing) BHO
If external pacing unavailable:
-may give Atropine 0.5mg IV/IO for pulse <60 SO
MR q3-5” to max 3mg SO
S-127 Dysrythmias (Bradycardia Pacing Notes)
- *Note:
- Document rate setting, milliamps, and capture
- External pacing on standing orders should begin with minimum rate set at 60/min. Energy output should be dialed up until capture occurs, usually between 50 and 100mA. The mA should then be increased a small amount, usually about 10%, for ongoing pacing.
S-127 Dysrythmias, Supraventricular Tachycardia BLS
- O2 and/or ventilate prn
- O2 Sat prn
S-127 Dysrythmias, Supraventricular Tachycardia ALS
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-VSM SO. MR SO
-Adenosine 6mg rapid IV/IO, followed with 20ml NS rapid IV/IO SO
(Patients with history of bronchospasm or COPD BHO)
-Adenosine 12mg rapid IV/IO followed with 20ml NS rapid IV/IO SO
If no sustained rhythm change, MR x1 in 1-2” SO
If patient unstable OR rhythm refractory to treatment:
Conscious (BP<90 AND chest pain, dyspnea, or altered LOC)
-Midazolam 1-5mg IV/IO prn pre-cardioversion BHO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer’s recommended energy dose BHO, MR BHO
Unconscious:
-Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x3 SO. MR BHO
S-127 Dysrhythmias, Unstable Atrial Fibrillation/Atrial Flutter BLS
- O2 and/or ventilate prn
- O2 Sat prn
S-127 Dysrhythmias, Unstable Atrial Fibrillation/Atrial Flutter ALS
Unstable Atrial Fibrillation/Atrial Flutter:
(BP<90 AND chest pain, dyspnea, or altered LOC)
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
In presence of ventricular response with heart rate >180:
Conscious:
-Midazolam 1-5mg IV/IO prn pre-cardioversion BHPO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer’s recommended energy dose BHPO, MR BHPO
Unconscious:
Synchronized cardioversion at manufacturer’s recommended energy dose SO, MR x3 SO. MR BHO
S-127 Dysrhythmias, Ventricular Tachycardia BLS
- O2 and/or ventilate prn
- O2 Sat prn
S-127 Dysrhythmias, Ventricular Tachycardia ALS
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-Lidocaine 1.5mg/kg IV/IO SO
MR at 0.5mg/kg IV/IO q 8-10” to max 3mg/kg (including initial bolus) SO
OR
-Amiodorone 150mg in 100ml of NS over 10” IV/IO SO
MR x1 in 10” SO
If patient unstable (BP<90 AND chest pain, dyspnea, or altered LOC):
Conscious:
-Midazolam 1-5mg IV/IO prn pre-cardioversion SO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer’s recommended energy dose SO, MR x3 SO. MR BHO
Unconscious:
-Synchronized cardioversion at manufacturer’s recommended energy dose SO, MR x3 SO. MR BHO
S-127 Dysrhythmias, Reported/Witnessed >2 AICD firing, or >1 AED shock delivered (BLS/ALS)
BLS: -O2 and/or ventilate prn -O2 Sat prn ALS: -Monitor EKG -250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
If pulse >60:
-Lidocaine 1.5mg/kg IV/IO SO
MR at 0.5mg/kg IV/IO q8-10” to max 3mg/kg (including initial bolus) SO
OR
-Amiodorone 150mg in 100ml NS over 10” IV/IO SO
S-127 Dysrhythmias, VF/Pulseless VT BLS
- CPR
- 10:1 compression ratio at a rate of 110/min continuous compressions with ventilations every 6 seconds
- Rotate compressor every 2 minutes
- Metronome at rate of 110/minute for manual CPR
- Team Leader role-CPR quality, monitor, rhythm checks
- If arrest witnessed by medical personnel perform CPR until ready to defibrillate
- If unwitnessed arrest perform CPR for 2 minutes prior to rhythm check
- TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
- AED
- Assist ventilations with BVM
- Monitor O2 Sat
S-127 Dysrhythmias, VF/Pulseless VT ALS
- Monitor EKG
- Defibrillate when ready every 2 min while VF/VT persists
- Charge monitor prior to rhythm checks, do not interrupt CPR while charging defibrillation
- Capnography
- Rhythm check-minimize interruption of compressions less than 5 seconds
- IV/IO do not interrupt CPR
- Epinephrine 1:10,000 1mg IV/IO q3-5” SO
After first shock if still refractory
- Amiodorone 300mg IV/IO, MR 150mg (max of 450mg) SO
- OR*
- Lidocaine 1.5mg/kg IV/IO, MR x1 q3-5” (max 3mg/kg) SO
-Document EtCO2 during BVM, if zero do not intubate
continue ti ventilate BVM
-Intubate/PAA SO without interrupting compressions
-NG/OG prn SO
If persistent or shock refractory VF/VT after 3 rounds of drugs, contact base hospital for direction
ROSC:
- Obtain 12 lead
- Ventilate with goal of EtCO2 of 40
- Check blood pressure
- Transport to closest STEMI Center regardless of 12 lead reading SO
S-127 Dysrhythmias, VF/Pulseless VT (Notes)
- For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions.
- Do not interrupt compressions
- Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
- EtCO2 <10 = Poor survivability
- Use mechanical CPR device if available
- Do not over-ventilate
- Transport traumatic arrests to trauma centers
- Transfer monitor data to QA/QI department if able
- Consider reviewing call with crew post event
S-127 Dysrhythmias, PEA BLS
- CPR
- 10:1 compression ratio at a rate of 110/min continuous compressions with ventilations every 6 seconds
- CPR rotate compressor every 2 minutes
- Start metronome at rate of 110/minute for manual CPR
- Team Leader role-CPR quality, monitor, rhythm checks
- TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
- AED
- Assist ventilations with BVM
- Monitor O2 Sat
S-127 Dysrhythmias, PEA ALS
IF PATIENT DOES NOT MEET TOR CRITERIA:
- Monitor
- Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation
- Capnography
- Rhythm check-minimize interruption of compressions less than 5 seconds
- IV/IO do not interrupt CPR
- Epinephrine 1:10,000 1mg IV/IO MR q3-5” SO
- Document EtCO2 during BVM, if zero do not intubate, continue to ventilate with BVM
- Intubate/PAA SO without interrupting compressions
- NG/OG prn SO
- 250ml fluid bolus IV/IO
If persistent PEA after 3 rounds of Epinephrine contact Base Hospital for direction
ROSC:
- Obtain 12 lead
- Ventilate with goal of EtCO2 of 40
- Check blood pressure
- Transport to closest STEMI center regardless of 12 lead reading SO
S-127 Dysrhythmias, PEA (Notes)
- For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions
- Do not interrupt compressions
- Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
- EtCO2 <10 = Poor survivability
- Use mechanical CPR device if available
- Do not over-ventilate
- Consider reversable caises of PEA (Hyperkalemia, Hypokalemia, Hypovolemia, Hypoxia, Tamponade, Thrombosis)
- Transport traumatic arrest to trauma centers
- Transfer monitor data to QA/QI department if able
- Consider reviewing call with crew post event
S-127 Dysrhythmias, Asystole BLS
- CPR
- 10:1 compression ratio at a rate of 110 continuous compressions with ventilations every 6 seconds
- CPR rotate compressor every 2 minutes
- Start metronome @ rate of 110/minute for manual CPR
- Team leader role-CPR quality, monitor, rhythm checks
- TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
- AED
- Assist ventilation with BVM
- Monitor O2 Sat
S-127 Dysrhythmias, Asystole ALS
- Monitor EKG
- Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation
- Capnography
- Rhythm check-minimize interruption of compressions less than 5 seconds
- IV/IO do not interrupt CPR
- Epinephrine 1:10,000 1mg IV/IO MR q3-5” SO
- Document EtCO2 during BVM, if zero do not intubate continue to ventilate with BVM
- Intubate/PAA SO without interrupting compressions
- NG/OG prn SO
ROSC:
- Obtain 12 lead
- Ventilate with goal of EtCO2 of 40
- Check blood pressure
- Transport to closest STEMI Center regardless of 12 lead reading SO
S-127 Dysrhythmias, Asystole/TOR Criteria
Termination Of Resuscitation (TOR) Criteria if all these criteria have been met:
1. Victim arrest was not witnessed by EMS
AND
2. No bystander witness of collapse
AND
3. No bystander CPR
AND
4. Never received a rescue shock
AND
5. Never had a return of pulses
THEN
-If there is no improvement and patient is in asystole after continuous resuscitation of less than 20 minutes, base contact is necessary in order to terminate resuscitation BHPO
-If asystolic after 20 minutes resuscitative efforts with no improvement may cease efforts SO. Document the Time of Apparent Death and the name of the paramedic
-If all above criteria for TOR are met, Base hospital contact not required even if ALS interventions performed
S-127 Dysrhythmias, Asystole (Notes)
- This protocol only applies to asystole arrests of presumed cardiac origin. Drowning, Hypothermia, Electrocution are excluded
- Asystolic patients of cadiac origin should not be transported
- For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of AP chest diameter), allow full recoil, and minimize interruptions
- Do not interrupt compressions
- Compression rate of 110 with ventilations q 6 seconds
- EtCO2 <10 = Poor survivability
- Use mechanical CPR device if available
- Do not over-ventilate
- Transport traumatic arrests to Trauma Centers
- Transfer monitor data to QA/QI Department if able
- Consider reviewing call with crew post event
S-129 Envenomation Injuries BLS/ALS
BLS:
-O2 and/or ventilate prn
Jellyfish sting:
- Liberally rinse with salt water, for at least 30 seconds
- Scrape to remove stinger(s)
- Heat as tolerated (not to exceed 110 degrees)
Stingray or Sculpin injury:
-Heat as tolerated (not to exceed 110 degrees)
Snakebites:
- Mark proximal extent of swelling and/or tenderness
- Keep involved extremity at heart level and immobile
- Remove pre-existing constrictive device
ALS:
- IV/IO SO adjust prn
- Treat pain per Pain Management Protocol (S-141)
S-130 Environmental Exposure BLS
- Ensure patent airway
- O2 saturation prn
- O2 and/or ventilate prn
- Remove excess/wet clothing
- Obtain baseline temperature
Heat Exhaustion:
- Cool gradually
- Fanning, sponging with tepid water
- Avoid shivering
- If conscious, give small amounts of fluids
Heat Stroke:
- Rapid cooling
- Spray with cool water, fan. Avoid shivering
- Ice packs to carotid, inguinal, and axillary regions
Cold Exposure:
- Gentle warming
- Blankets, warm packs
- Dry dressings
- Avoid unnecessary movement or rubbing
- If alert, give warm liquids
- If severe, NPO
- Prolonged CPR may be indicated
Near Drowning:
-Spinal motion restriction when indicated
S-130 Environmental Exposure ALS
- Monitor EKG
- IV/IO SO adjust prn
Severe Hypothermia with Cardiac Arrest:
- Hold medications
- Continue CPR
- If defibrillation needed, limit to 1 shock maximum
Suspected Heat Exhaustion/Heat Stroke:
-500ml fluid bolus IV/IO SO, without rales. MR x1 SO
Near drowning:
-CPAP at 5-10cm H2O SO for respiratory distress
S-131 Hemodialysis Patient BLS
- Ensure patent airway
- O2 saturation prn
- Give O2
- Ventilate if necessary
S-131 Hemodialysis Patient ALS
- Monitor EKG
- Determine time of last dialysis
For immediate definitive therapy only:
- IV access in arm that does not have graft/AV fistula SO. Adjust prn
- EJ/IO access prior to accessing graft
If unable & no other medication delivery route available:
- Access Percutaneous Vas Catheter BHPO if present (apsirate 5ml PRIOR to infusion)
- OR*
- Access graft/AV fistula BHPO
Fluid overload with rales:
-Treat as per S-136 (CHF/Cardiac)
Symptomatic patient with suspected hyperkalemia (widened QRS complex or peaked T waves):
-Obtain 12 lead EKG
If >72 hours since last dialysis:
-Continuous Albuterol 6ml 0.083% via nebulizer SO
-CaCl2 500mg IV/IO per SO
-NaHCO3 1mEq/kg IV/IO x1 per SO
S-131 Hemodialysis Patient (Notes)
Note: Vas-Cath contrains concentrated dose of Heparin which must be aspirated PRIOR to infusion.
SDCPA Educational Notes:
Hyperkalemia patients may be asymptomatic or report the following
- Generalized fatigue - Paresthesias -Palpitations
-Weakness - Paralysis -Hypotension
ECG findings generally correlate with the potassium level, but potentially life-threatening arrythmias can occur without warning at almost any level of hyperkalemia
Early changes: peaked T waves, shortened QT interval, and ST segment depression. These changes are followed by bundle-branch blocks causing a widening of the QRS complex, increases in the PR interval, and decreasing amplitude of the P wave.
Late changes: P wave eventually disappears and the QRS morphology widens to resemble a sine wave. Ventricular Fibrillation or asystole follows.
S-122 Decompression Illness/Diving/Altitude Incidents BLS/ALS
BLS:
- 100% O2 and/or ventilate prn
- O2 saturation prn
- Spinal stabilization when indicated
ALS:
- Monitor EKG
- IV/IO SO adjust prn
S-122 Decompression Illness/Diving/Altitude Incidents (Presentation)
Diving victims: Any victim who has breathed sources of compressed air below the water’s surface and presents with the following:
Minor presentation: minimal localized joint pain, mottling of the skin surface, localized swelling with pain; none of which are progressive.
Major presentation: symptoms listed above that are sever and/or rapidly progressing, vertigo, altered LOC, progressive paresthesia, paralysis, severe SOB, blurred vision, crepitus, hematemesis, hemoptysis, pneumothorax, trunk pain, or girdle or brand-like burning discomfort.
Major presentation:
- All patients with a “major” presentation should be transported to UCSD-Hillcrest
- Trauma issues are secondary in the presence of a “major” presentation
- If the airway is unmanageable, divert to the closest BEF
Minor presentation:
- Major trauma candidate: catchment trauma center
- Non-military patients: routine
- Active Duty Military Personnel: transport to Military Duty Recompression Chamber
S-133 Obstetrical Emergencies BLS
Mother:
- Ensure patent airway
- O2 saturation prn
- O2 and/or ventilate prn
- If no time for transport and delivery is imminent (crowning and pushing), proceed with delivery
- If no delivery, transport on left side
Routine Delivery:
-Massage fundus if placenta delivered
(do not wait on scene)
-Clamp and cut cord between clamps following delivery (wait 60 seconds after delivery prior to clamping and cutting cord)
-Document name of person cutting cord, time cute, and address
-Place identification bands on mother and infant
Post-Partum Hemorrhage:
- Massage fundus vigorously
- Baby to breast
Eclampsia (seizures):
-Protect airway, and protect from injury
STAT transport for third trimester bleeding to facility with OB services per base hospital direction
S-133 Obstetrical Emergencies ALS
Mother:
- Monitor EKG
- IV/IO SO adjust prn
Direct to Labor/Delivery area per BHO if >20 weeks gestation
Eclampsia (seizures):
-Versed IN/IM/IV/IO SO to a max dose of 5mg (d/c if seizure stops) SO.
MR x1 in 10” SO. Max 10mg total.
S-134 Poisoning/Overdose BLS
- Ensure patent airway
- O2 saturation prn
- O2 and/or ventilate prn
- Carboxyhemoglobin monitor prn, if available
Ingestions:
-Identify substance
Skin:
- Remove clothes
- Brush off dry chemicals
- Flush with copious water
Toxic Inhalation:
- Move patient to safe environment
- 100% O2 via mask
- Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient
Symptomatic suspected opioid OD with respiratory rate <12: (use with caution in opioid dependent pain management patients)
- Naloxone nasal spray 4mg preload single dose device
- Administer full dose in one nostril
- OR*
- Naloxone assemble 2mg syringe & atomizer
- Administer 1mg into each nostril
Contamination with commercial grade (“low level”) radioactive material:
-Patients with mild injuries may be decontaminated (removal of contaminated clothing, brushing off of material) prior to treatment and transport. Decontamination proceedings SHALL NOT delay treatment and transport of patients with significant or life-threatening injuries. Treatment of significant injuries is always the priority.
S-134 Poisoning/Overdose ALS
- Monitor EKG
- IV/IO SO adjust prn
- Capnography SO prn
Ingestions:
-Charcoal 50Gm PO ingestion with any of the following within 60 minutes SO if not vomiting:
Acetaminophen, colchicine, beta blockers, calcium channel blockers, salicylates, valproate, oral anticoagulants (including rodenticides), paraquat, aminita mushrooms
-Assure patient has gag reflex and is cooperative
Symptomatic suspected opioid OD with respiratory rate <12: (use with caution in opioid dependent pain management patients)
- Naloxone 2mg IN/IM/IV SO. MR SO. titrate IV dose to effect
- If patient refuses transport, give additional Naloxone 2mg IM SO
Symptomatic Organophosphate poisoning:
-Atropine 2mg IV/IM/IO SO.
MR x2 q3-5” SO. MR q3-5” BHO
Extrapyramidal reactions:
-Benadryl 50mg slow IV/IM SO
Suspected Tricyclic OD with cardiac effects (e.g. hypotension, heart block, or widened QRS):
-NaHCO3 1mEq/kg IV/IO SO
If suspected cyanide poisoning: If cyanide kit is available on site (e.g. industrial site) may administer if patient is exhibiting significant symptoms:
- Amyl Nitrate inhalation (over 30 sec) BHPO
- Sodium Thiosulfate 25% 12.5Gm IV BHPO
- OR*
- Hydroxocobalamin (Cyanokit) 5Gm IV BHPO
S-134 Poisoning/Overdose (Hyperthermia from Suspected Stimulant Intoxication) BLS only
- Initiate cooling measures
- Obtain baseline temperature, if possible
S-134 Poisoning/Overdose (Excited Delirium) ALS only
-As soon as able: Monitor/EKG/Capnography -High flow O2 SO -Ventilate SO -500ml fluid bolus IV/IO SO. MR x1 SO. MR BHO -Versed 5mg IM/IN/IV SO MR x1 in 10" SO
S-135 Pre-Existing Medical Interventions BLS
- Proceed with transport when person responsible for operating the device (the individual or another person) is able to continue to provide this function during transport.
- Bring back up equipment/batteries as appropriate
Previously established electrolyte and/or glucose containing peripheral IV lines:
- Maintain at preset rates
- Turn off when indicated
Previously applied dermal medication delivery systems:
-Remove chest transdermal medication patches when indicated (CPR, shock) SO
Previously established IV medication delivery systems and/or other preexisting treatment modalities with preset rate:
-If the person responsible for operating the device is unable to continue to provide this function during transport, contact BH for direction.
BH may ONLY direct BLS personnel to:
1. Leave device as found OR turn the device off;
THEN
2. Transport patient OR wait for ALS arrival.
Transports to another facility of to home:
- No wait period is required after medication administration.
- If there is a central line, the tip of which lies in the central circulation, the catheter MUST be capped with a device which occludes the end.
- IV solutions with added medications OR other ALS treatment/monitoring modalities require ALS personnel (or RN/MD) in attendance during transport.
S-135 Pre-Existing Medical Interventions ALS
Maintain previously established electrolyte and/or glucose containing IV solutions:
-Adjust rate or d/c BHO
Maintain previously applied topical medication delivery systems:
-Remove dermal medications when indicated (CPR, shock) SO
Pre-existing external vascular access (considered to be IV TKO):
-To be used for definitive therapy ONLY
Maintain previously established and labeled IV medication delivery systems with preset rates and/or other preexisting treatment modalities:
-d/c BHO
If no medication label or clear identification of infusing substance:
-d/c BHO
S-136 Respiratory Distress BLS
- Ensure patent airway
- Reassurance
- O2 saturation prn
- O2 and/or ventilate prn
- May assist patient to self-medicate own prescribed MDI ONE TIME ONLY. Base hospital contact required prior to any repeat dose.
Hyperventilation:
- Coaching/reassurance
- Remove patient from causative environment
- Consider underlying medical problem
Toxic Inhalation (CO exposure, smoke gas, etc.)
- Move patient to safe environment
- 100% O2 via mask
- Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient
Respiratory Distress with croup-like cough:
-Aerosolized saline or water 5ml via oxygen powered nebulizer/mask. MR prn
S-136 Respiratory Distress ALS
- Monitor EKG
- Capnography monitoring SO prn
- IV/IO SO adjust prn
- Intubate prn
- NG/OG prn per SO
Respiratory Distress Suspected CHF/Cardiac origin: -NTG SL: If systolic BP >100 but <150: -NTG 0.4mg SL SO. MR q3-5" SO If systolic BP >150: -NTG 0.8mg SL SO. MR q3-5" SO If systolic BP >100: -NTG ointment 1 inch SO If systolic BP <100: -NTG 0.4mg SL per BHO MR BHPO
-CPAP at 5-10cm H2O SO
Respiratory Distress Suspected Non-Cardiac:
- Albuterol 6ml 0.083% via nebulizer SO. MR SO
- Atrovent 2.5ml 0.02% via nebulizer added to first dose of Albuterol SO
- CPAP 5-10cm H2O SO
If sever respiratory distress/failure or inadequate response to Albuterol/Atrovent consider:
If history of asthma or suspected allergic reaction:
-Epinephrine 0.3mg 1:1,000 IM SO
MR x2 q5” SO
If no definite history of asthma:
-Epinephrine 0.3mg 1:1,000 IM BHPO
MR x2 q5” BHPO
S-136 Respiratory Distress (Notes)
- If any patient has taken an erectile dysfunction medication such as Viagra, Cialis, and Levitra within 48 hours, NTG is contraindicated.
- May encounter patients taking similar medication for pulmonary hypertension, usually Sildenafil (trade name: Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.
- Use caution with CPAP in patients with COPD, i.e. start low and titrate pressure.
- Epinephrine IM: use caution if known cardiac history or history of hypertension or BP >150 or age >40.
- Fireline Paramedic (FEMP) without access to oxygen may use MDI delivery for Albuterol in place of nebulizer.
S-137 Sexual Assault ALS/BLS
- Ensure patent airway
- O2 and/or ventilate prn
- Advise patient not to bathe or change clothes
- Consult with law enforcement on scene for evidence collection
If the patient requires a medical evaluation:
- Transport to the closest, most appropriate facility
- Law enforcement will authorize and arrange an evidentiary exam after the patient is stabilized.
If only evidentiary exam is needed:
-Should release to law enforcement for transport to a SART facility.
S-138 Shock BLS
- O2 saturation prn
- O2 and/or ventilate prn
- Control obvious external bleeding
- Treat associated injuries
- NPO, anticipate vomiting
- Remove any transdermal patch
S-138 Shock ALS
- Monitor EKG
- IV/IO SO
- Capnography SO
Shock (suspected cardiac etiology)
-250ml fluid bolus IV/IO without rales SO
MR x1 to maintain BP >90 SO
If BP refractory to second fluid bolus:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP >90 BHO
Shock Hypovolemic (Nontraumatic): -500ml fluid bolus IV/IO SO. MR to maintain BP >90 SO
Shock Hypovolemic (suspected AAA): -500ml fluid bolus IV/IO SO. MR to maintain BP >80 SO
Shock (suspected Anaphylactic, Neurogenic):
-500ml fluid bolus IV/IO SO. MR to maintain BP >90 SO
If BP refractory to fluid boluses:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IS/Io drip. Titrate BP >90 BHO
Shock (Sepsis):
-Treat as per Sepsis Protocol (S-143)
S-138 Shock/S-139 Trauma (Notes/Shock definition)
“Shock” is defined by the following: (age>15 years):
- Systolic BP <80 mmHg OR
- Systolic BP <90 mmHg AND exhibiting any of the following signs of inadequate perfusion:
1. altered mental status (decreasing LOC, confusion, agitation)
2. tachycardia
3. pallor
4. diaphoresis
S-139 Trauma BLS
- Ensure patent airway, protecting C-Spine
- Control obvious bleeding
- Spinal stabilization prn. (Except in penetrating trauma without neurological deficits.)
- O2 saturation prn
- O2 and/or ventilate prn
- Keep warm
- Homestatic gauze
Abdominal Trauma:
-Cover eviscerated bowel with saline pads
Chest Trauma:
- Cover open chest wound with three-sided occlusive dressing; release dressing if ?tension pneumothorax develops.
- Use of chest seal
Extremity Trauma:
- Splint neurologically stable fractures as they lie
- Use traction splint as indicated
- Grossly angulated long bone fractures with neurovascular compromise may be reduced with GENTLE unidirectional traction for splinting per BHO
- Apply tourniquet in severely injured extremity when direct pressure or pressure dressing fails to control life-threatening hemorrhage.
- In Mass Casualty direct pressure not required prior to tourniquet application
Impaled Objects:
-Immobilize & leave impaled objects in place.
Remove BHPO
EXCEPTION
May remove impaled object in face/cheek or from neck if there is total airway obstruction
Neurological Trauma (head and spine injuries: -Ensure adequate oxygenation without hyperventilating patient. Goal 6-8 ventilations/minute
Pregnancy of greater than or equal to 6 months:
-Where spinal stabilization precaution is indicated, tilt on spine board 30 degrees.
Blunt Traumatic Arrest:
-Consider pronouncement at scene BHPO
S-139 Trauma ALS
- Monitor EKG
- IV/IO SO
- If MTV IV/IO en route SO
- 500ml fluid bolus IV/IO to maintain BP at 80
- Capnography SO prn
- Treat pain per Pain Management Protocol (S-141)
Crush injury with extended compression >2 hours of extremity or torso: Just prior to extremity release: -500ml fluid bolus IV/IO, then TKO SO -CaCl2 500mg IV/IO over 30 sec. BHO -NaHCO3 1mEq/kg IV/IO BHO
- Grossly angulated long bone fractures:
- Reduce with GENTLE unidirecional traction for splinting SO
Sever Respiratory Distress with unilateral diminished breath sounds and systolic BP <90:
-Needle thoracostomy SO
Blunt Traumatic Arrest:
-Consider pronouncement at scene
Penetrating Traumatic Arrest:
-Rapid transport off scene
S-141 Pain Management BLS
- Assess level of pain
- Ice, immobilize, and splint when indicated
- Elevation of extremity trauma when indicated
S-141 Pain Management ALS (MILD/MODERATE pain)
- Continue to monitor & reassess pain using standardized pain score.
- Document vitals signs before and after each medication administration
Special Considerations for All Pain Medications:
- Changing route of administration requires BHO
(e. g. IV to IM or IM to IN) - Chaning analgesic requires BHO
(e. g. changing from Fentanyl to Ketamine) - Treatment if BP <100 requires BHO
- BHPO required for:
- Isolated head injury -Acute onset sever headache
- Drug/ETOH intoxication -Major trauma with GCS <15
- Suspected active labor
For MILD pain (score 1-3) or MODERATE pain (score 4-6):
- without sever hepatic impairment or active liver disease
- Acetaminophen 1000mg IV infuse over 15”
S-141 Pain Management ALS (MODERATE/SEVERE pain)
Fentanyl
For MODERATE pain (score 4-6) or SEVERE pain (score 7-10):
-or refusal/contraindication to Acetaminophen or Ketamine
Fentanyl: If <65 years of age -Fentanyl up to 50mcg IV SO -MR 25mcg IV q5" x2 SO Maximum total SO dose 100mcg Intranasal dosing: -Fentanyl 50mcg IN q15" x2 SO -3rd dose Fentanyl 50mcg IN BHO
If >65 years of age: -Fentanyl 25mcg IV SO -MR 25mcg IV q5" x2 SO Maximum total SO dose 75mcg IV Intranasal dosing: -Fentanyl 25mcg IN q15" x2 SO -3rd dose Fentanyl 25mcg IN BHO
Special considerations for Cardiac Chest Pain & Cardiac Pacing:
-Fentanyl 25mcg IV x1 SO
S-141 Pain Management ALS (MODERATE/SEVERE pain)
Morphine
Morphine, if Fentanyl unavailable:
-Morphine 0.1mg/kg IV SO
-MR in 5” at half of initial IV dose SO
-MR in additional 5” at half of the initial IV dose BHO
Intramuscular dosing:
-Morphine 0.1mg/kg IM SO
-MR in 15” at half of the initial IM dose SO
-MR in additional 15” at half of the initial IM dose BHO
Special considerations for Cardiac Chest Pain & Cardiac Pacing:
-Administer Morphine 0.05mg/kg IV x1 SO
S-141 Pain Management ALS (MODERATE/SEVER pain)
Ketamine
Additional option for trauma, burns, or envenemation injuries:
For MODERATE-SEVERE pain (score >5):
Ketamine requirements:
- > 15 years old
- AND with GCS if 15
- AND not pregnant
- AND no known or suspected alcohol or drug intoxiation
- AND have not received opioid analgesic in past 6 hours (prior to medical arrival)
-Ketamine 0.2mg/kg in 100ml of NS SLOW IV drip over 15” SO
Maximum for any single IV dose is 20mg
-MR x1 in 15” if pain remains MODERATE or SEVERE SO
Intranasal dosing:
-Ketamine 0.5mg/kg IN (50mg/ml concentration) SO
Maximum for any single IN dose is 50mg
-MR x1 in 15” if pain remains MODERATE or SEVERE SO
S-142 Psychiatric/Behavioral Emergencies BLS
-Ensure patent airway, O2 and/or ventilate prn
-O2 saturation prn
-Treat life threatening injuries
-Attempt to determine if behavior is relayed to injury, illness, or drug use.
-Restrain only if necessary to prevent injury.
Document distal neurovascular status q15”.
Avoid unnecessary sirens.
-Consider law enforcement support and/or evaluation of the patient
-Law enforcement could remove taser barbs,
but EMS may remove bards.
S-142 Psychiatric/Behavioral Emergencies ALS+Note
- Monitor EKG
- IV SO adjust prn
- Capnography SO
For combative patient:
-Versed 5mg IM/IN/IV SO. MR x1 in 10” SO
Note:
- For combative patient IN or IM Versed is preferred route to decrease risk of injury to patient and personnel.
- Use caution when considering Versed use with ETOH intoxication. Can result in apnea.
S-142 Psychiatric/Behavioral Emergencies (Taser notes)
Consideration for patients presenting with taser barbs:
- Taser discharge for simple behavioral control is usually benign and does not require transport to BEF for evaluation.
- Patients, who are injured, appear to be under the influence of drugs, present with altered mental status, or symptoms of illness should have a medical evaluation performed by EMS personnel, and transported to a BEF.
- If barbs are impaled in an anatomically sensitive location such as the eye, face, neck, finger/hand, or genetalia do not remove the barb; the patient should be transported to a BEF.
For removal of taser barbs:
- Ensure wires are disconnected from weapon
- Stabilize/stretch skin around dart
- Grasp dart by metal body
- Remove dart in single quick/firm motion
- Clean wound with antiseptic wipe and apply dressing
S-143 Sepsis BLS
- O2 saturation prn
- O2 and/or ventilate prn
- NPO, anticipate vomiting
- Remove any transdermal patch
- Obtain baseline temperature
S-143 Sepsis ALS
- Monitor EKG
- IV/IO SO
- Capnography SO prn
Suspected Sepsis: If history suggestive of infection and two or more of the following are present, suspect sepsis and report: 1. Temperature >100.4 or <96.8 2. HR >90 3. RR >20
Administer:
-500ml fluid bolus IV/IO regardless of blood pressure or lung sounds SO
After initial fluid bolus: If BP <90
-500ml fluid bolus IV/IO regardless of lung sounds SO x1
If BP refractory to fluid boluses:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate BP >90 BHPO
S-144 Stroke and Transient Ischemic Attack BLS
- For patients with symptoms suggestive of TIA or stroke with onset of symptoms known to be <6 hours in duration:
- Expedite transport
- Make initial notification early to confirm destination
- Notify accepting stroke receiving center of potential stroke code patient en route
- Get specific last known well time in military time (hours:minutes)
- Bring witness to ED, or if witness unable to ride on ambulance obtain accurate contact number
- Allow witness to accompany patient into ED, or provide contact information to ED upon arrival
- Use supplemental O2 to maintain O2 sat at least 94%
- Keep HOB at 15 degree elevation
If trained and available:
- Obtain blood glucose, if blood glucose <60 mg/dl treat per hypoglycemia:
- If patient is awake and able to swallow, give 3 oral glucose tabs or paste (15g total). Patient may eat or drink, if able.
- Of patient is unconscious, NPO
- Use Prehospital Stroke Scale in the assessment of possible TIA or stroke patients (facial droop, arm drift, and speech abnormalities)
- Provide list of all current medications, especially anticoagulants to the ED upon arrival
- If systolic BP <120 mmHg, place head of the stretcher flat, if tolerated
S-144 Stroke and Transient Ischemic Attack ALS
- Obtain blood glucose, if blood glucose <60 mg/dl treat per hypoglycemia
- Large bore antecubital IV
- 250ml fluid bolus IV/IO without rales SO to maintain BP >120, MR SO
S-150 Nerve Agent Exposure-Auto Injector Use BLS
Upon identification of a scene involving suspected or known exposure of nerve agent:
- Isolate area
- Notify dispatch of possible Mass Casualty Incident with possible Nerve Agent involvement
- DO NOT ENTER AREA
If exposed:
- Blot off agent
- Strip off all clothing, avoiding contact with outer surfaces
- Flush affected area(s) with copious amounts of water
- Cover affected area(s)
If you begin to experience any signs/symptoms of nerve agent exposure, for example:
- Use SLUDGE pneumonic: (Salivation, Lacrimation, Urination, Defecation, Gastric complications, Emesis)
- Increased secretions (tears, saliva, runny nose, sweating)
- Diminished vision
- SOB
- Nausea, vomiting, diarrhea
- Muscle twitching/weakness
NOTIFY THE INCIDENT COMMANDER (or dispatch if no IC) immediately of your exposure and declare yourself a patient
Self Treat Immediately per the Acuity Guidelines listed under ALS
S-150 Nerve Agent Exposure-Auto Injector Use ALS
-Triage, decontaminate and treat patient based on severity of symptoms SO
Mild: miosis, rhinorrhea, increasing dyspnea, fasiculations, sweating:
- Atropine autoinjector (or 2mg) IM
- 2-PAM Cl autoinjector (or 600mg) IM
Moderate: headache, weakness, miosis, rhinorrhea, dyspnea/wheezing (if inhaled), increased secretions, generalized fasiculations, muscle weakness, GI effects:
- Atropine autoinjector (or 2mg) IM, MR x1 in 5-10”
- 2-PAM Cl autoinjector (or 600mg) IM, MR x1 in 5-10”
- Diazepam autoinjector, or Midazolam 5mg IM if Diazepam autoinjector not available
SEVERE: unconscious, seizures, muscle weakness, fatigue, flaccid, paralysis, apnea, bardycardia, heart block, or tachycardia:
Initial dosing:
-Atropine autoinjector (or 2mg) IM x3 doses in succession
-2-PAM Cl autoinjector (or 600mg) IM x3 doses in succession
-Diazepam autoinjector, or Midazolam 10mg IM if Diazepam autoinjector not available, for seizure activity
-O2/intubate
Ongoing treatment:
-Atropine autoinjector (or 2mg) IM, MR q3-5” until secretions diminish
-2-PAM Cl autoinjector (or 600mg) IM, MR x1 in 3-5”
-For continuous seizure activity, MR Midazolam 10mg IM in 10”
S-150 Nerve Agent Exposure-Auto Injector ALS
pediatric doses
Pediatric doses: Weight/Atropine/2-PAM Cl/Midazolam
<20kg = 0.5mg/100mg/2.5mg 20-39kg = 1mg/300mg/5mg >40kg = 2mg/600mg/10mg
For doses less than the amount in the autoinjector, use the medication vial and administer with a syringe.
Consider: For frail, medically compromised, hypersensitive, or renal failure patients administer half doses of Atropine and 2-PAM Cl
