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ADULT PROTOCOLS Flashcards

1
Q

CHEST PAIN (Non-Traumatic)

A
  1. ABCs, Vitals, Pulse Oximetry
  2. O2 < 95%, O2 at 4 LPM
  3. 12 Lead ECG, transmit
  4. PT < 25 yo & stable, transport non-emergent
  5. No ST elevation found, consider 15 lead
  6. IV access
  7. Aspirin 4 x 81 mg, withhold if on blood thinners
  8. if SBP > 100 and no “fil” meds taken, give Nitro up to 3 doses q. 5 minutes
  9. If no relief after 3 doses nitro, and SBP > 100, consider 2 mg Morphine IV, not to exceed 10 mg total
  10. If pain secondary to cocaine use, consider Versed 2 mg IV or 5 mg IM
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2
Q

CHEST PAIN/STEMI

A
  1. ABCs, good history of Events Leading Up
  2. Pulse Oximetry
  3. O2 via NRB at 15 LPM
  4. 12 Lead ECG, if signs of ST elevation in 2 or more contiguous leads, transmit to ER and begin emergent transport to ER
  5. Aspirin 4 x 81 mg unless allergic or on blood thinners
  6. Nitro q. 5 minutes up to 3 doses if SBP > 100, contraindicated for Right Sided involvement or for recent use of “fil” medications.
  7. If no relief after 3 doses, consider morphine 2 mg IV up to max dose of 10 mg if SBP remains above 100.
  8. If morphine contraindicated, consider Fentanyl 50 mcg with up to one additional dose
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3
Q

V-Fib/Pulseless V-Tach

A
  1. High quality CPR
  2. Defibrillate 200 Joules Biphasic
  3. Resume CPR, reassess every 2 minutes, repeat defibrillation PRN
  4. If can ventilate with BVM and oral airway, then establish IV and administer Epinephrine 1:10,000, 1 mg q. 3-5 minutes until ROSC or terminated resuscitation.
  5. Amiodarone 300 mg IV/IO. repeat half dose (150 mg) in 3-5 minutes if still in shockable rhythm.
  6. Intubate.
  7. If cannot ventilate with BVM oral airway, intubate and confirm with capnography, then administer Epi and Amiodarone.
  8. If no IV/IO, give Epi 1:10,000 2 mg and Lidocaine 3 mg/kg via ET tube. Repeat half dose if no response.
  9. Continue CPR with pulse checks every 2 minutes.
  10. Magnesium Sulfate 2 g IV/IO over 1-2 mins for Torsades de Pointes/malnourishment
  11. Consider other causes & treat
    - Hypoxia, Hypovolemia, Hydrogen Ion, Hypo/hyperkalemia, Hypothermia
    - Toxins, Trauma, Tension Pneumo, Tamponade, Thrombosis
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4
Q

BLS Cardiac Arrest MGMT

A
  1. High Quality CPR
  2. AED (expose chest, wipe dry, turn on and attach pads front and back for Peds, right midclavicular and left midaxillary for Adults)
  3. Follow AED prompts
  4. Gain IV/IO access and place supraglottic airway.
  5. Continue to follow AED prompts, prepare for ALS arrival, transport to ER if you can get there prior to ALS arrival.
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5
Q

Asystole/PEA

A
  1. High quality CPR
  2. Insert OPA and ventilate with BVM with hi-flow O2
  3. If PT can be ventilated with BVM and OPA, establish IV/IO and give Epi 1 mg (1:10,000) every 3-5 minutes, then intubate
  4. If PT cannot be ventilated with BVM and OPA, intubate first and then establish IV/IO and give Epi.
  5. If IV/IO cannot be established, give 2 mg Epi 1:10,000 via ETT
  6. Capnography < 10 mmHg = poor CPR or consider termination of resuscitation
  7. > 15 minutes resuscitation, consider termination if asystole persists
  8. Consider & treat causes:
    - Hypoxia, hypovolemia, hydrogen ion, hypo/hyperkalemia, hypothermia
    - Toxins, trauma, tension pneumo, tamponade, thrombosis
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6
Q

Post Resuscitation

A
  1. Optimize O2 and ventilation
  2. SBP < 90, administer 250 ml NS bolus (peds SBP 70 + 2x age, 20 cc/kg bolus)
  3. Check sugar, if low, titrate appropriate concentration of dextrose for PT’s age
  4. Elevate head of bed 30 degrees
  5. 12 lead EKG, transmit
  6. If anti-arrhythmic administered and PT arrests again, use second dose regimens of anti-arrhythmics (i.e. 300 mg Amiodarone for initial dose, 150 mg Amiodarone for second dose after PT arrests again)
  7. Ventilatory support to maintain ETCO2 > 20 (Adults - < 12, School Age - 20 minimum, Infant - Preschool - 30 minimum)
  8. Do not administer Sodium Bicarb unless PT is being ventilated effectively and ETCO2 is > 45 mmHg (suggesting acidosis)
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7
Q

Tachycardia - Wide Complex with a Pulse

A
  1. ABC’s, pulse oximetry, cardiac monitor, ETCO2
  2. IV access
  3. If stable, confirm V-Tach with 12 lead ECG
  4. If unstable (HR > 150 AND hypotensive, AMS, acute heart failure, chest pain), give one sedative (Versed 5 mg IV/IO or 5 mg IM) if PT is conscious and proceed to cardioversion.
  5. If Monomorphic (100 joules, 150 joules, 200 joules), if Polymorphic/Torsades de Pointes, 200 joules and administer Magnesium Sulfate 2 grams IVP.
  6. If stable, consider Amiodarone drip 150 mg IV/IO slowly over 10 minutes
  7. Reassess and transport
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8
Q

Premature Ventricular Complexes (PVCs)

A
  1. ABCs, pulse oximetry, cardiac monitor
  2. 12 Lead ECG
  3. Transport without delay
  4. IV access and O2
  5. If PVCs present after O2: consider treatment (if lightheadedness/dizziness, syncope/near syncope, chest pain are present). Lidocaine 1mg/kg IVP, may be repeated at .5 mg/kg PRN to max of 1 mg/kg (give Lidocaine drip at 2-4 mg/min if Lidocaine successful, reduce dose by half if PT over 70 y/o)
  6. If PVCs not present after O2: cardiac monitor and transport
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9
Q

Supraventricular Tachycardia (SVT)

A
  1. ABCs, pulse oximetry, cardiac monitor
  2. IV access ASAP
  3. Transport without delay
  4. PT stable:
    - 12 lead EKG (rate over 150? R-R intervals regular? QRS <= 1 mm? History/MOI suggesting compensatory tachycadia requiring fluids?)
    - Stable SVT, attempt vagal maneuvers
    - If maneuvers ineffective, 6 mg rapid IVP followed by 20 ml NS flush
    - If no change 1 min later, repeat Adenosine 12 mg rapid IVP, 20 ml NS flush (only repeat once without online med control)
  5. PT unstable:
    - HR > 150 AND hypotensive, AMS, heart failure, angina
    - if conscious, Versed 5 mg IV/IO, or 5 mg IM
    - Synchronized cardioversion (50 Joules, then 100 Joules, then 200 Joules)
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10
Q

New Onset Atrial Fibrillation / Flutter

A
  1. ABCs, pulse oximetry, cardiac monitor
  2. 12 Lead EKG
  3. IV access ASAP
  4. If Stable:
    - if rate > 130, consider Cardizem drip 10 mg IV, repeated every 5 min up to 30 mg PRN
    - Do not give Cardizem if hypotensive, HR<120, CHF/spO2<92%/rales noted, Wide complex Tachycardia, history of WPW syndrome
    - If hypotensive after Cardizem, give 1 ml Calcium Chloride (100 mg) slow IVP, give 500 ml NS bolus (may occur in dialysis/renal failure PTs)
  5. If Unstable:
    - consult Med Control for A-Fib Cardioversion
    - A-fib -> 120 Joules, 150 Joules, 200 Joules
    - A-flutter -> 50 Joules, 100 Joules, 200 Joules
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11
Q

Symptomatic Bradycardia

A
  1. ABCs, pulse oximetry, cardiac monitor
  2. Capnography
  3. IV access
  4. Stable:
    - Atropine .5 mg IV, every 3-5 min PRN to max of 3 mg
    - consider pacing if Atropine ineffective
    - if PT improves, TRANSPORT
  5. Unstable:
    - HR<60 AND hypotensive, AMS, heart failure, angina
    - if conscious, give 2 mg Versed IV/IO or 5 mg IM
    - Proceed with External Pacing @ 70 ppm, starting mA @ 10
    - May use Dopamine drip 5-10 mcg/kg/min IV as alternative or preparation for pacing
  6. Transport without delay
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12
Q

Abdominal Pain

A
  1. ABCs, pulse oximetry, cardiac monitor
  2. O2 as needed
  3. IV access
  4. Treat for shock with LR 500 ml bolus, repeat as needed (use with caution in CHF and renal failure PTs)
  5. Position of comfort and transport
  6. Treat as a Surgical Emergency in these patients: females of childbearing age, pregnant PTs, PTs with signs and symptoms of AAA, recent post op complications.
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13
Q

Nausea/Vomiting

A
  1. ABCs, airway/suction, pulse oximetry
  2. O2 as needed
  3. Cardiac monitor, rule out Acute Coronary Syndrome, esp. in female PT > 45 yrs old.
  4. 12 Lead ECG and transmit if cardiac illness suspected
  5. IV access, fluids as needed for dehydration (500 mL bolus NS or LR) to restore normotensive BP. Use caution with CHF and renal failure PTs
  6. Administer Zofran:
    - Adult > 40 kg: 4 mg IVP, IM or PO (repeat once PRN)
    - Pediatric < 40 kg: 0.1 mg/kg IVP or IM (max 4 mg)
  7. Transport as indicated
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14
Q

Dehydration

A
  1. ABCs, pulse oximetry
  2. O2 as indicated
  3. Cardiac monitor
    - dehydration->electrolyte->arrhythmias
    - tachycardia in elderly and pediatrics often associated with hypovolemia
  4. IV access:
    - Adults: LR 500 mL bolus, repeat PRN
    - use caution in CHF/renal failure PTs
    - Pediatrics: LR 20 mL/kg bolus
    - NS can be used instead of LR
    - use 10 GTT/mL IV tubing for fast delivery
  5. Transport as indicated
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15
Q

Diabetic Emergency/Hypoglycemia

A
  1. ABCs, pulse oximetry, O2 as needed
  2. Cardiac monitor
  3. IV access
  4. Check blood glucose
  5. If BG < 70 and PT is alert and has stable airway, give Oral glucose 15-30 grams PO, buccal or sublingual
  6. If BG < 70 and unresponsive or AMS:
    - EJ is preferred over IO for diabetic PT’s
    - if IV is patent, give D50%, 25 gram slow IVP (may give 250 mL of D10%)
    - Titrate to effect
    - if unable to obtain IV access after 3 attempts, give Glucagon 1 mg IM (repeat 1 mg IM in 20 min if glucose < 70 and LOC still altered)
    - If known alcoholic or malnourished, give Thiamine 100 mg IVP or IM
  7. Reassess BG in 5 minutes and repeat D50% 25 g if BG remains < 70
  8. If BG and mental status are normal, AEMT may transport. Do not delay transport to wait for medications to work.
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16
Q

Diabetic Emergency/Hyperglycemia

A
  1. ABCs, pulse oximetry, O2 as needed
  2. Cardiac monitor
  3. IV access
  4. if BG > 70 and < 400, transport as indicated
  5. if BG > 400 and STABLE, transport Non-Emergency
  6. if BG > 400 and UNSTABLE, transport emergency
  7. if BG >400, give IV fluids 500 mL NS/LR bolus (caution with CHF/renal failure PT’s)
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17
Q

Hypertensive Emergency

A
  1. ABCs, Pulse oximetry, O2 as indicated
  2. Cardiac monitor
  3. IV access
  4. if CVA/Stroke symptoms or AMS, refer to CVA/Stroke protocol
  5. If PT pregnant, refer to pre-eclampsia protocol
  6. If HTN due to pain, refer to pain management protocol
  7. If SBP >200 or DBP > 110 and SYMPTOMATIC:
    - Give Labetolol 10 mg slow IVP
    - If no change after 1st dose, give 20 mg slow IVP q. 10 min as needed
  8. Transport as indicated
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18
Q

Shock Protocol

A
  1. Assure CAB’s, pulse oximetry
  2. O2 via NRB
  3. Cardiac monitor
  4. Place supine as tolerated
  5. IV access (2 large bore preferred)
  6. 500 mL bolus, repeated PRN
    - LR preferred
    - lung sounds after each bolus
    - Pediatrics: Give 20 mL/kg bolus
  7. Determine type/cause:
    - Hypovolemic/Hemorrhagic:
    Continue IV fluids to maintain SBP 90
    mmHg
    - Anaphylactic:
    Continue fluids and go to Anaphylaxis
    protocol
    - Cardiogenic:
    Go to appropriate protocol based on
    rhythm
    After rate and rhythm normalize, if PT
    still in shock begin Epi drip 1-4 mcg/min
    titrated to effect
    - Neurogenic:
    Epinephrine drip 1-4 mcg/min titrated
    to effect
    Withhold Epi if possible multisystem
    trauma
    - Septic:
    Fluid bolus 30 ml/kg
    Vasopressors after bolus: Epi 1-4
    mcg/min
    Notify hospital of Sepsis Alert
  8. Transport Emergency
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19
Q

Sexual Assault

A
  1. ABCs
  2. Emotional support
  3. Treat all injuries
  4. Protect scene, preserve evidence
  5. Ask PT not to bathe, change clothes, urinate or douche
  6. Notify PD
  7. Place PT in open sheet, save sheet for evidence
  8. Transport w/ same gender crew member if possible
  9. Vitals may be limited to reduce emotional distress to patient
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20
Q

Sickle Cell Anemia

A
  1. Assessment
    - Hx of Sickle Cell Anemia
    - Signs of infection
    - Hypoxia
    - Dehydration
    - Painful Joints
    - Limited Joint Movement
  2. ABC’s, Vitals, Pulse oximetry
  3. O2 and airway as appropriate
  4. Supportive Care
  5. IV access, consider 20 ml/kg (LR)
  6. ECG, 12 Lead transmit
  7. If pain persists, consult with med control for pain medication
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21
Q

Psychiatric Emergencies/Restraint Protocol

A
  1. Scene safety
  2. Keep exits open
  3. ABC’s, O2 as needed
  4. Speak in calm, reassuring tone
  5. Protect PT modesty, avoid making them feel trapped
  6. Consider restraint in PT’s who may harm themselves or others:
    - ensure that adequate personnel are present
    - consider restraining to long spine board (to avoid having to detach them at the ER)
    - Place PT supine/lateral ASAP
    - Kerlix, cravats, other soft restraints may be used
    - If handcuffs used, PD must be present for transport
    - Check PMS in all restrained extremities
    - Chemical restraint: Versed 5 mg IM or 2 mg IVP. Ketamine may be considered if approved by online med control
  7. Determine Blood Glucose and treat as needed
  8. Consider hypoxia, hypoglycemia, drug/alcohol intoxication, drug overdose, brain trauma
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22
Q

Dyspnea (Adult)

A
  1. ABCs, pulse oximetry
  2. Cardiac monitor, ETCO2
  3. O2 to keep sats > 90%
  4. Check temp (consider pneumonia/sepsis)
  5. Obtain IV access (may give one neb treatment without IV access)
  6. Position upright/semi-fowlers
  7. If Hx of Asthma/COPD with wheezing or poor air movement:
    - Albuterol 2.5 mg/3 mL, Atrovent .5 mg/2.5 mL
    - Consider CPAP
    - Magnesium Sulfate (2 grams mixed in 100-150 mL NS infused over 10 minutes if severe dyspnea)
    - Solu-medrol 125 mg slow IVP or IM
    - Repeat Albuterol in 10 min if IV successfully established
    - If allergen exposure, consider anaphylaxis protocol
    - Intubate/ventilate as needed if no change
  8. If rales, known history of CHF, on diuretics, no recent fevers:
    - if wheezing, give Albuterol
    - consider CPAP
    - Nitro .4 mg SL q. 5 min up to 3 doses if SBP >= 130
    - consider Morphine 2 mg
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23
Q

AMS

A
  1. ABCs, pulse oximetry, cardiac monitor if indicated
  2. Assess temp if sepsis, hypothermia or heat illness suspected
  3. Assess CO levels if CO exposure suspected
  4. 12 Lead EKG
  5. O2 as needed
  6. IV access
  7. Check Blood Glucose and treat as indicated
  8. If malnourished or Hx alcoholism, administer Thiamine 100 mg IV/IM
  9. Hx drug abuse, constricted pupils, or resp depression, administer Narcan (up to max of 4 mg)
  10. Consider Zofran 4 mg prophylactic for N/V prior to Narcan admin
  11. If agitated/violent, consider Versed 5 mg IV/IM, repeated 2 mg doses every 5 min titrated to effect
  12. Transport as indicated
    10.
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24
Q

Stroke/CVA

A
  1. ABC’s, vital signs with manual cuff, pulse oximetry
  2. 12 Lead EKG during transport
  3. Transport Emergency (unless known onset of symptom > 6 hrs, and PT stable)
  4. O2 @ 2-4 LPM nasal cannula or 15 LPM NRB if hypoxic
  5. 12-Lead
  6. Elevate head up to 30 degrees
  7. IV access
  8. Check glucose (if < 70, treat as indicated)
  9. Obtain Hx:
    - Onset of symptoms?
    - Seizure at onset of symptoms?
    - Previous CVA?
    - Previous neurologic surgery
    - On Coumadin/Warfarin?
    - Any recent trauma, bleeding, or surgery?
  10. Cincinnati Prehospital Stroke Scale
    - Facial droop
    - Arm drift
    - Abnormal speech
  11. Do not treat HTN without consulting Med Control
  12. Notify ER of “STROKE ALERT” ASAP
  13. If Large Vessel Occlusion suspected with less than 6 hrs onset, transport to Comprehensive Stroke Center if transport time does not exceed an extra 15 minute
  14. Two or more of the following = likely LVO
    - PT states incorrect month/age
    - Gaze palsy and/or deviation
    - Arm weakness (hemiplegia/hemiparesis)
25
Q

Seizures

A
  1. ABC’s, protect PT from injury
  2. Suction as needed
  3. NPA a needed
  4. O2/assist ventilations as needed
  5. Vitals, cardiac monitor, spO2, ETCO2, temp
  6. Actively Seizing:
    - If IV established, give Versed 2 mg IVP
    - If no IV, give Versed 5 mg IM immediately
    - Determine Blood Glucose, if <70, treat accordingly
  7. No Active Seizing:
    - Determine Blood Glucose, if <70, treat accordingly
  8. If seizures continue, may repeat Versed 2 mg IV 2-3 min after initial dose up to 2 additional times. May repeat Versed IM up to one time 5 min after initial dose.
  9. If PT > 20 weeks pregnant or <2 weeks post delivery without Hx of seizures:
    - Mix 4 grams Magnesium Sulfate in 100-150 mL NS and infuse over 10-20 min
  10. Transport as indicated.
26
Q

Syncope

A
  1. ABC’s, spO2, Cardiac Monitor
  2. O2 as indicated
  3. 12 Lead EKG and treat any dysrhythmias accordingly
  4. IV access
  5. Glucose check, if < 70 treat accordingly
  6. Suction and control airway PRN
  7. Transport as indicated
27
Q

Anaphylaxis

A
  1. ABC’s, spO2, O2 via NRB, Cardiac Monitor
  2. Give Epinephrine 1:1000 IM (do not delay!), 0.01 mg/kg, up to max .3 mg per dose (use caution with over 60 yo or cardiac Hx)
  3. If wheezing present, give Albuterol 2.5 mg/3 mL NS, nebulized
  4. IV access
  5. If hypotensive, give 500 mL bolus LR or NS, repeat PRN
  6. Administer antihistamines:
    - H1 Blocker: Diphenhydramine (Benadryl) 25 mg slow IVP or 50 mg IM
    - H2 Blocker: Famotidine (Pepcid) 20 mg in 50-100 mL NS, infused over 10-15 min
  7. Give Solumedrol, 125 mg IV or IM
  8. If still in anaphylaxis after all treatments, consider Epinephrine drip, 1-4 mcg/min in Adults
  9. Transport as indicated
28
Q

Overdose

A
  1. ABCs, spO2, Cardiac Monitor
  2. Suction PRN
  3. O2 via NRB
  4. Aggressive airway control w/ ventilation if needed
  5. Intubate as needed (early Narcan admin may prevent need for intubation)
  6. IV access (bolus 1 liter NS adult, 20 ml/kg pediatric if hypotensive)
  7. Glucose Check, treat as indicated
  8. if seizing, go to seizure protocol
  9. History:
    - Type and amount of poison
    - Bring container if available
    - Route of intake
    - Time of intake
    - Hx of drug/alcohol use
  10. Stimulant Overdose: consider Versed 5 mg IVP or IM, repeat 2 mg IVP or IM q. 5 min
  11. Beta Blocker Overdose: if PT bradycardic and/or hypotensive, give Glucagon 1 mg IVP/IM
  12. Tricyclic Overdose: give Sodium Bicarb 1 amp IV
  13. Calcium Channel Blocker: if bradycardic/hypotensive, give Calcium Chloride 1 gram (10 mL) in 100 mL bag of NS over 2-5 min
  14. Narcotic Overdose: pupils small, hypotensive, decreased respirations, give Narcan .4-2 mg IV or IM, repeat PRN up to 8 mg
  15. Transport as indicated
29
Q

Poisoning/Chemical Exposure/Haz-Mat/Nerve Agents

A
  1. Suction as needed
  2. O2 via NRB
  3. Airway control with ventilation
  4. Intubate as needed
  5. Obtain IV Access (give fluid bolus if hypertensive, 1 liter for adult, 20 ml/kg peds)
  6. Glucose check
  7. If seizing, go to seizure protocol
  8. History:
    - Type and amount of poison
    - bring container with PT if possible
    - Route of intake
    - Time of intake
    - Hx of drug/alcohol use
  9. If PT agitated, possible stimulant overdose, consider Versed 5 mg IVP or IM (repeat 2 mg IVP or IM q. 5 min)
  10. If inhaled poison, remove PT from source and assess CO levels if CO exposure suspected.
  11. If dry substance, brush off chemical before irrigating
  12. Irrigate with copious amounts of water, assess or hypothermia
  13. For organophosphate/nerve agent poisoning, give Atropine 2 mg IVP every 5-15 min. If symptoms:
    - Mild: (Increased secretions, pinpoint pupil, weakness) Decontaminate, supportive care
    - Moderate: (mild symptoms, respiratory distress) give 1 Nerve Agent Antidote kit, may repeat in 5 min PRN
    - Severe: (Unconscious, convulsions, apnea) give 3 Nerve Agent Antidote kits
  14. Transport as indicated
30
Q

Alcohol Emergencies

A
  1. ABC’s, pulse oximetry, cardiac monitor
  2. O2 as indicate
  3. IV access
  4. Thiamine 100 mg IV or IM if AMS or malnourished
  5. Glucose check (treat accordingly)
  6. If significant AMS and possible drug abuse, give Narcan 0.5-4 mg IV or IM
    - Repeat PRN to a max of 4 mg
    - Narcan may be given IM if IV attempts fail
  7. Transport as indicated
31
Q

Snake Bite/Envenomation

A
  1. ABC’s
  2. Pulse oximetry, ETCO2
  3. Cardiac monitor
  4. Obtain IV access
  5. Splint extremity in a dependent position to restrict
  6. Remove jewelry from affected extremity
  7. Keep extremity below the level of the heart
  8. If PT in severe pain, see Pain MGMT protocol
  9. Bring DEAD snake to hospital or take picture
  10. Transport supine in resting position to reduce metabolism
32
Q

Near Drowning

A
  1. ABCs, C-Spine
  2. Aggressive airway control, suction as needed
  3. Pulse oximetry, ETCO2 as indicated
  4. Consider placement of gastric tube in patients suffering submersion injuries/near drowning
  5. O2 by BVM or NRB PRN
  6. Cardiac monitor
  7. IV access
  8. Consider CPAP for fresh or saltwater drowning
  9. If in cardiac arrest, go to appropriate protocol
  10. Transport as indicated
  11. All near drowning PT’s should be transported (secondary drowning still a threat to PT’s life)
33
Q

Hyperthermia / Heat Related Illness

A
  1. ABC’s
  2. Assess Temperature
  3. If Hx suggests heat exhaustion or heat stroke:
    - Move to cooler environment
    - Cool with moist sheets so PT will not shiver
  4. O2 as indicated
  5. Cardiac monitor
  6. IV access and administer LR 20 ml/kg
  7. If seizures, go to seizure protocol
  8. Transport as indicated
34
Q

Hypothermia

A
  1. ABC’s, temperature
  2. Remove wet clothing, protect against heat loss
  3. Avoid rough movement
  4. Monitor cardiac rhythm (Treat life-threatening arrhythmias only)
  5. Administer O2 and begin external warming
  6. IV access, N/S from the fluid warmers
    - Adult max of 1 liter
    - Pediatric 20 mL/kg
  7. If narcotic ingestion possible, give Narcan 0.4-4 mg IV
  8. If no pulse or breathing:
    - CPR
    - Resuscitate per ACLS protocols BUT:
    - Defibrillate 1 time maximum
    - Atropine and Lidocaine are
    generally not useful
    - Magnesium Sulfate is effective in
    pulseless V-Tach, V-Fib with
    hypothermia. Administer Magnesium
    Sulfate 2 grams IVP for these
    arrhythmias

Notes:

  • Keep ambulance doors CLOSED, heat on high, 3 layers of blankets, with a blanket between PT and spine board
  • Hypothermia as subtle as 96 degrees inhibits clotting in trauma PT’s
35
Q

Electrocution / Lightning Injuries

A
  1. Assess for signs/symptoms of electrical injury
  2. ABC’s, spO2, ETCO2, Cardiac Monitor
  3. O2 and airway maintenance appropriate to PT’s needs
  4. Spinal protection if over 1000 volt electrocution suspected or suspicion of spinal injury
  5. Control gross hemorrhage/dress wounds
  6. Treat burns per burn protocol
  7. IV/IO access as indicated
  8. Signs of shock, give 20 mL/kg bolus of fluid (peds 20 mL/kg bolus)
  9. Pain meds as indicated
  10. 12 lead EKG, transmit to ER
  11. Transport without delay
36
Q

Selective Spinal Immobilization

A
  1. Does PT have:
    - Neurological deficits
    - Neck/midline spine tenderness
    - Intoxication, head injury (blunting of senses)
  2. If NO: No immobilization needed.
  3. If YES:
    - If significant MOI, full spinal immobilization
    - If minor MOI, C-Collar
    - For pediatric, no board or collar if Low Risk Injury (fall from standing, fall from bed, MVA in car seat, neurologically normal, no apparent serious injury)
  4. Major MOI:
    - Fall onto head
    - Fall from 2 x body height
    - Death in same car
    - Intrusion into passenger compartment
    - Rollover
    - Diving injury
    - Auto v.s. Pedestrian
  5. Minor MOI:
    - Low speed MVA
    - Fall from standing
    - Penetrating trauma without motor/sensation deficits
    - Ambulatory at scene
  6. When in doubt, immobilize
37
Q

Abdominal/Pelvic Trauma

A
  1. ABC’s
  2. Pulse oximetry, ETCO2, ECG as indicated
  3. C-Spine as indicated
  4. Control life threatening hemorrhage
  5. Supportive Care
  6. Position of Comfort
  7. If Pregnant: if past 1st trimester, place PT left lateral recumbent
  8. Penetrating Object: If object not present, place supine with knees bent. If object present, stabilize
  9. Evisceration: if present, place PT supine with knees bent, cover with saline soaked trauma dressing
  10. IV access
  11. If SBP < 90, give 20 ml/kg bolus LR and titrate to maintain permissible hypotension. Consider TXA for unstable trauma PT’s.
  12. Transport without delay
38
Q

Chest Trauma

A
  1. ABC’s, pulse oximetry, stabilize as needed
  2. O2 via NRB, 12-15 LPM
  3. Cardiac monitor
  4. IV access (large bore preferred)
  5. If Open Pneumothorax:
    - place vented occlusive dressing over wound
    - monitor for tension pneumothorax
    - if tension pneumothorax develops, remove dressing, allow pressure to equal, and replace dressing
    - if using a defib pad, you can needle decompress through pad and place 3 way stop-cock to release air as needed
  6. If Tension Pneumothorax:
    - decreased breath sounds, hypotension, hypoxia
    - Needle decompression at midclavicular (preferred) or midaxillary
  7. Stabilize flail chest with bulky dressing
  8. Intubate and ventilate as indicated
  9. Pain management as indicated
  10. Transport without delay
39
Q

Burns

A
  1. Stop the Burn:
    - Remove burned/smoldering clothes
    - Cool with cool, moist, sterile towels
    - Burns involving > 10% body area should
    be covered with dry sterile dressing
    - Remove dry chemicals by brushing off,
    remove liquid chemicals by flushing with
    large amounts of water (unless
    contraindicated in ERG handbook)
  2. ABC’s and stabilize as necessary
  3. O2 via NRB, airway intervention as needed
  4. Cardiac monitor as indicated
  5. Large bore IV/IO if applicable
  6. If hypotensive (SBP<100 for adult, SBP < 70+(2 x age) in peds, administer 500 ml bolus in adults, 20 ml/kg bolus in pediatrics
  7. If normotensive/after correcting hypotension, see pain management protocols as needed (may need to give Fentanyl with Ketamine to support BP)
  8. Transport to a Vanderbilt if:
    - burns with >20% BSA of partial thickness or greater in adults
    - burns with >10% BSA of partial thickness or greater in pediatrics
    - any burns involving airway
  9. Keep PT warm, use burn sheets to prevent infection
  10. May use Watered Burn Gel on minor first degree burns (<10% BSA)

Note: Superficial/1st degree burns are not calculated into total body surface area percentage

40
Q

Eye Injuries

A
  1. ABCs
  2. Survey for additional injuries
  3. If chemical injury, flush with large amounts of sterile water and continue en route
  4. Treat and cover eye without pressure to globe (consider using rigid patches)
  5. Calm the patient
  6. Consult on-line medical direction for pain management
41
Q

Fractures (General Care)

A
  1. CABs, spO2, O2 as indicated, cardiac monitor as indicated
  2. Secondary Survey
  3. Large bore IV access
  4. Treat for shock if indicated
  5. Immobilize fracture by securing at proximal and distal end
    - Femur: traction splint or other device as indicated
    - Pelvic: stabilize with XP1, KED, sheet wrap, padding as indicated
  6. Document PMS prior to and after splinting
  7. Pain management if PT is not hypotensive/no head injury suspected
  8. Transport (do not delay transport for splinting in a critical patient)
42
Q

Head Injury (Traumatic Brain Injury)

A
  1. C-Spine Precautions
  2. ABCs, ​spO2, cardiac monitor, O2 as indicated
  3. Ventilate with 100% O2 and intubate ASAP if needed
  4. Consider RSI
  5. IV access
  6. Incline head of cot 15 degrees
  7. Restrain to spine board as needed for combative PT’s, consider chemical restraint as needed
  8. Consider pain management (document mental status before and after pain medication)
  9. Transport
43
Q

Permissive Hypotension

A
  1. Do not delay transport for IV access unless transport is delayed by extrication/entrapment
  2. If signs of shock present:
    - Tachycardia, hypotension, ETCO2 < 30 mmHg
    - administer 20 ml/kg bolus to maintain SBP of 90 mmHG or to maintain peripheral pulses
    - do not continue fluids after SBP has reached 90 mmHG
    - repeat boluses PRN up to max of 60 ml/kg
  3. If no signs of shock:
    - Not tachycardic, normotensive BP
    - reassess q. 5 minutes, establish large bore IV
  4. Considerations:
    - use warm fluids for trauma patients
    - consider IO unless injuries are prohibitive
    - humeral head IO preferred in fluid resuscitation
    - humeral head IO not permitted in peds<8 years
    - LR is preferred fluid for all PT’s receiving fluid bolus
    - consider TXA for all shock PT’s
44
Q

Trauma Destination Determination

A
  1. Vitals - IF:
    - GCS less than/equal to 13
    - and/or SBP<90mmHG
    - and/or RR < 10 or RR > 29 (or RR < 20 in infants < 1 year old)
    - THEN transport to Level I Trauma Center (or highest level available)
  2. Injuries - IF:
    - penetrating injuries to head, neck, torso, extremities proximal to elbow or knee, chest
    - and/or chest wall instability/deformity (flail chest)
    - and/or two or more proximal long bone fractures
    - and/or crushed, degloved, mangled, or pulseless extremity
    - and/or amputation proximal to wrist or ankle
    - and/or pelvic fractures
    - and/or open/depressed skull fracture
    - and/or paralysis
    - Px3 LACS (Paralysis, Pulseless, Pelvic, Long bone, Amputation, Chest, Skull)
    - THEN transport to Level I Trauma Center
  3. MOI - IF:
    - Fall of > 20 feet for adult, > 10 feet or > 2-3 x height for children
    - and/or MVA with intrusion > 12 in. occupant site, > 18 in. any site
    - and/or MVA with partial/complete ejection
    - and/or MVA with death in same passenger compartment
    - and/or MVA with vehicle telemetry indicating high risk crash
    - and/or Auto VS bicyclist/pedestrian thrown, run over, > 20 mph impact
    - and/or Motorcycle crash > 20 mph
    - THEN transport to Trauma Center (need not be the highest available depending on trauma system)
  4. Special Considerations - IF:
    - Older adults: risk increases after 55, SBP < 110 may indicated shock after age 65, low energy MOI may cause severe injury
    - Children: transport to pediatric capable trauma center when possible
    - Anticoagulants: can lead to rapid deterioration with head injury patients
    - Burns: triage to burn center if no other trauma mechanism, triage to trauma center if other trauma mechanism
    - Pregnancy > 20 weeks: EMS provider judgement
45
Q

Soft-Tissue/Crush Injuries

A
  1. ABC’s, stabilize as needed
  2. spO2, ETCO2, ECG as indicated
  3. O2 and airway management as indicated
  4. C-Spine Protection PRN
  5. Stop life-threatening hemorrhage, consider tourniquet use
  6. Splint as needed and stabilize penetrating objects
    - Splinting may prevent secondary injury from bone ends
    - Do not delay transport to splint
    - Critical PTs: place in correct anatomical position on LSB/cot and transported to a trauma center preferably
  7. Cover open fractures/lacerations, check PMS, avoid unnecessary movement
  8. Give IV NS/LR TKO
  9. Titrate fluids per permissive hypotensive protocols
  10. Transport without delay
46
Q

Spinal Injury

A
  1. ABC’s, stabilize using C-Spine precautions
  2. Pulse oximetry
  3. O2 as indicated
  4. Cardiac monitor
  5. IV access
  6. Treat for shock if present
  7. Reassure PT
  8. Transport as indicated
47
Q

Traumatic Cardiac Arrest

A

For Cardiac Arrest Secondary to Trauma:

  1. ABC’s, stabilize as needed
  2. Pulse oximetry, ETCO2 as needed
  3. Cardiac monitor as indicated
  4. O2 and airway maintenance as indicated for PT condition
  5. High quality CPR
  6. IV/IO NS give 20 ml/kg bolus
  7. Consider second IV/IO access
  8. Treat cardiac rhythms per specific protocols
  9. If suspected pneumothorax, perform needle decompression
    - bilateral may be considered
    - consider for blunt/penetrating trauma to chest/thoracic region
    - Assess for and treat EARLY in management of PT
  10. Consider viability prior to transport
  11. Consult with Med Control as needed
  12. Transport with focus on personnel safety and due regard
48
Q

Uncontrollable Extremity Bleeding/Exsanguinating Hemorrhage

A
  1. BSI/GOGGLES AND GLOVES
  2. IF bright red, heavy bleeding from arterial exposure, degloving with acute blood vessel exposure noted, or penetrating trauma with internal bleeding likely as evidenced by acute swelling, THEN:
    - Apply arterial tourniquet as proximal as possible on extremity
    - 1 TQ for upper extremity, may need 2 TQs for lower extremity (apply side by side with same pressure)
    - Strap TQ as tightly as possible, then turn windlass about 3 times, write time applied on TQ
    - Pain management ASAP, TQs are very painful
    - May use combat/Quick Clot gauze to pack junctional wounds (found in RTF Kit)
  3. IF heavy, dark red, oozing bleeding from suspected venous exposure, THEN:
    - Direct pressure
    - Elevate extremity
    - Consider tourniquet if hemorrhage is significant/refractory to previous treatment
    - May use combat/Quick Clot gauze to pack junctional wounds (found in RTF Kit)
  4. Pain management with Fentanyl and Ketamine should be considered
  5. Transport without delay to closest appropriate facility (amputations must go to Level 1 Trauma Center)
49
Q

Tranexamic Acid (TXA) Administration for Unstable Trauma PT’s

A

Indications:

  • Hypotension, and other signs of shock, associated with known or suspected BLOOD LOSS
  • Less than 3 hrs since time of injury

Contraindications:

  • Do not delay critical interventions to give TXA
  • Isolated head injury
  • Longer than 3 hrs since time of injury
Adult Dose (12 yrs and older): 1 gm to 100 mL NS (or D5W), infuse over 10 min
(If possible start maintenance dose with 1 gm to 500 mL NS w/ 10 gtt tubing at 10 gtts/minute, to give 1 gm over 8 hrs)

TRANSPORT to a facility that can maintain a TXA infusion

50
Q

START Adult Triage

A
  1. Patient able to walk?
    - IF YES, label Green (minor) for secondary triage
    - IF NO, continue to next step
  2. Breathing spontaneously?
    - IF NO, reposition airway. If breathing starts, label as RED (immediate). If still apneic, label BLACK (expectant)
    - IF YES, continue to next step
  3. Check Respiratory Rate
    - IF OVER 30, label RED
    - IF UNDER 30, continue to next step
  4. Check radial pulse/capillary refill
    - IF pulse absent/cap refill > 2 sec, label RED
    - IF pulse present/cap refill < 2 sec, continue to next step
  5. Check if PT obeys commands
    - IF PT cannot obey commands, label RED
    - IF PT can obey commands, label YELLOW (delayed)
51
Q

OB/GYN (Non-delivery or GYN only)

A

Determine:

  • Para (live births), Gravida (pregnancies)
  • Term of pregnancy (weeks), expected due date, multiple births expected, history
  • Vaginal bleeding - how long/amount
  • Possible miscarriage/products of conception
  • Prenatal problems/medications/care
  • Last menstrual cycle
  • Trauma prior to onset of complaint?
  • Lower extremity edema
  1. Position appropriately for condition
  2. O2 and airway maintenance as needed
  3. Control hemorrhage as needed
  4. IV LR TKO unless signs of shock, then 20 ml/kg bolus, consider glucose check

Abruptio Placenta:

  • Multiparity
  • Maternal hypertension
  • Trauma
  • Drug use
  • Increased maternal age
  • History of Abruptio Placenta
  • Vaginal bleeding with no increase in pain
  • No bleeding with low abdominal pain
  1. Left lateral recumbent
  2. Pregnant PT’s in 2nd-3rd trimester with blunt trauma should not refuse transport, at high risk for abruptio placenta

Placenta Previa:

  • Painless bleeding which may occur as spotting or recurrent hemorrhage
  • Bright red vaginal bleeding usually after 7th month
  • History of placenta previa
  • Multiparity
  • Increased maternal age
  • Recent sexual intercourse/vaginal exam
  • Para/gravida
  • Term of pregnancy
  • Prenatal meds, problems, care
  • Hx of bed rest
  • Placenta protruding through vagina
  1. O2 and airway maintenance appropriate to PT’s condition
  2. Position of comfort

NOTE: Any painless bleeding in the last trimester should be considered Placenta Previa until proven otherwise. If signs of imminent delivery (as diagnosed by visual presence of baby’s body part through membrane), membrane rupture is indicated followed by delivery of baby.

52
Q

Active/Imminent Delivery

A
  1. ABC’s, stabilize as needed
  2. Pulse oximetry, cardiac monitor
  3. 100% O2 via NRB
  4. Transport without delay
  5. Notify receiving facility ASAP, including pertinent history (SAMPLE + Hx of pregnancy problems, last menstrual period and due date, # of pregnancies and deliveries)
  6. 18 gauge IV access minimum, LR bolus to maintain normal BP
  7. Perineal exam:
    - If active labor with no bleeding or crowning, transport as indicated
    - If vaginal bleeding and/or signs of shock, transport emergency
  8. If delivery is imminent (contractions q. 3-5 minutes, lasting 30-60 seconds)
    - Prepare area for delivery (OB kit)
    - Keep ambulance as warm as possible
    - Prepare mother for delivery, preserve dignity
  9. Delivery:
    - Use gentle pressure to control and prevent explosive delivery
    - When head delivers, suction airway (Mouth first, then nose using bulb syringe)
    - Suction any meconium from airway ASAP
    - Check for nuchal cord and carefully remove cord from neck if present
  10. Post-Delivery
    - Dry vigorously to stimulate breaths
    - Maintain airway
    - Protect baby from fall risk
    - Protect from risk of hypothermia
    - Check APGAR 1 and 5 minutes after delivery
  11. Infant Care:
    - Keep baby at level of mother
    - Clamp umbilical cord at 8 and 10 inches, cut once between clamps
    - Consider allowing baby to nurse if mother is willing and has no Hx of drug use
  12. Allow placenta to deliver (up to 20 minutes)
    - Massage uterine fundus (lower abdomen)
    - Observe and treat signs of shock with increased delivery of O2 and IV fluids
  13. Additional:
    - Reassess for post partum hemorrhage
    - Check umbilical cord for bleeding and add additional clamp if bleeding persists
    - Check neonates Blood Glucose on heel, not finger (normal Blood Glucose is >50)
    - Refer to Neonatal Resuscitation Guidelines as needed

Notes:

  1. Greatest risk to infant are hypothermia and airway obstruction
  2. Greatest risk to mother is postpartum hemorrhage (watch for signs of shock and post partum hemorrhage)
  3. Spontaneous or induced abortions may lead to severe hemorrhage: reassure the mother, elevate legs, treat for shock, and transport
  4. Record a BP and presence or absence of edema on every pregnant PT, regardless of Chief Complaint
  5. Complete PCR on mother and child
53
Q

Abnormal/Complicated Delivery

A

Give report to receiving facility ASAP, consult with Med Control (High Risk OB Pt’s may need to go to facilities with specialty OB care such as Vandy, St. Thomas Midtown, Centennial Women’s).

Amniotic Sac Presentation:

  1. Place PT in position of comfort
  2. Amniotic Sac -
    - if no fetus visible, cover with a damp, sterile dressing
    - If head has delivered, tear sac with fingers and continue steps for delivery
  3. Contact medical control ASAP

Nuchal Cord:

  1. Carefully remove cord by slipping it over baby’s head
  2. Avoid creating a knot in the cord
  3. Prevent cord from strangulating neonate during delivery

Breech Presentation:

  1. Place PT in best possible position and transport EMERGENCY
  2. Allow delivery to progress spontaneously, do not pull
  3. Support infants head as it delivers
  4. If head delivers spontaneously, deliver infant as noted in Normal Delivery Protocol
  5. If head does not deliver in 3 minutes, insert a gloved hand into vagina to create an airway for the infant
  6. Do not remove hand until relieved by higher Medical authority
  7. Contact med control

Limb Presentation:
1. Position mother supine with head lowered and pelvis elevated and transport EMERGENCY

Meconium Staining:

  1. Do not stimulate respiratory effort before suctioning the oropharynx
  2. Suction mouth, then nose using meconium aspirator while simultaneously providing 100% O2 blow by and maintaining the PT’s airway as appropriate
  3. Obtain APGAR score after airway treatment priorities (1 and 5 minutes after delivery if possible)

Prolapsed Cord:

  1. Position mother with supine with hips elevated on pillows, knees to chest
  2. Instruct mother to pant with each contraction to prevent from bearing down
  3. Check for pulse in cord
    - if no pulse, insert gloved finger into vagina to push head off of cord and cover exposed cord with sterile damp dressing
    - if pulse present, cover exposed cord with a sterile damp dressing
  4. Contact med control ASAP
54
Q

APGAR

A 
Appearance: 
0 = blue all over
1 = blue on extremities
2 = no blue
Pulse:
0 = No pulse
1 = < 100 BPM
2 = > 100 BPM
Grimace:
0 = No response to stimulation
1 = Grimace or feeble cry
2 = sneezing/coughing/pulling away when stimulated
Activity:
0 = No movement
1 = Some movement
2 = Active movement
Respiration:
0 = No breathing
1 = Slow/irregular breathing
2 = Strong cry

0 - 3, resuscitate!!!
4 - 7, stabilize!
7 - 10, stable condition, treat as indicated

55
Q

Neonatal Resuscitation

A

Applies to term and preterm infants who do not respond adequately to stimulation. Applies to infants from 0-1 month.

Within first 30 seconds:

  1. Vigorously stimulate and warm infant as soon as the infant is born (Heat, blanket)
  2. Sniffing position/open airway
  3. Clamp and cut cord per protocol
  4. If excessive secretions AND respiratory compromise, then suction with bulb syringe
    - Routine suctioning no longer recommended
  5. If meconium staining present AND newborn is not vigorous (weak/absent respiratory effort, weak/absent muscle tone, HR<100), consider tracheal suctioning
  6. Stimulate breathing by rubbing infants back/flicking soles of feet

Assess respirations:

  1. If inadequate/gasping, assist ventilations at 40-60/minute with 100% O2 and infant BVM
    - If infant is premature, titrate O2 flow, start on room air and do not exceed 65% FiO2 (6 LPM)
  2. If respirations are shallow or slow, attempt 1 minute of stimulation while giving blow by O2
    - If respirations do not increase, begin ventilation as noted above

Assess pulse:

  1. If HR < 60 beats/min, initiate compressions, ventilate with 100% FiO2
    - Compression to ventilation ratio of 3:1, compress at 120/min
    - Discontinue compressions when HR > 60 with a pulse

Advanced Resuscitation:

  1. Consider advanced airway (one attempt only) for
    - Persistent apnea
    - Central cyanosis
    - Bradycardia (HR<100)
  2. If HR consistently under 60
    - Continue CPR
    - Initiate IV/IO saline
    - Administer 1:10,000 Epinephrine, .01 mg/kg (.1 ml/kg), IV/IO every 3-5 minutes as needed
  3. Obtain blood glucose (heel stick). If <50, give Dextrose 10% 2-4 ml/kg IV/IO
  4. Consider isotonic fluid administration at 10 ml/kg as needed
56
Q

Pre-Eclampsia/Eclampsia

A
  1. ABC’s, stabilize as needed
  2. Pulse oximetry
  3. Signs and symptoms:
    - Headache
    - seeing spots/double vision
    - BP > 140/90
    - Generalized swelling of face, arms, legs
  4. Give O2 and begin external warming
  5. Monitor cardiac rhythm, treat only life-threatening rhythms
  6. IV access, 2 lines if possible
  7. Encourage PT to relax as much as possible
  8. IF SBP > 140 or DBP > 90, THEN
    - If PT is > 20 weeks pregnant, or < 2 weeks post delivery without a history of seizures, then mix 4 grams Magnesium Sulfate in a 100 or 150 mL bag of NS and infuse over 10-20 minutes (can give in conjunction with Versed if seizures begin)
    - If not, give Labetalol 10 mg slow IVP, may repeat 20 mg slow IVP q. 10 minutes as needed
    - Transport as indicated
  9. IF SBP < 140 or DBP < 90, THEN
    - Transport as indicated
57
Q

Maternal ACLS/Cardiac Arrest in Pregnancy

A

Management of Unstable Pregnant Patients:

  1. Place in full left lateral decubitus position to relieve aortocaval pressure
  2. Establish IV access above the diaphragm to prevent obstruction of IV therapy by gravid uterus
  3. Investigate and treat precipitating factors
  4. Pregnant PT’s at higher risk for aspiration, hypoxemia and pulmonary edema
  5. Systemic hypotension can overwhelm compensatory mechanisms, which attempt to maintain uterine blood flow

Chest Compressions:

  1. Hand placement, compression rates, ventilation ratios are the same as with non-pregnant PT’s
  2. Keep supine, implement Left Uterine Displacement technique (pull uterus the the PT’s left side)
  3. Mechanical CPR devices not recommended at this time

Transport/Operations:

  1. Transport to facility that can perform a cesarean delivery when indicated
  2. If possible, transport to facility that can perform a Perimortem Cesarean Delivery (PMCD)

Defibrillation:

  1. Use standard defibrillation protocols
  2. Place pad under breast tissue when possible

Breathing/Airway Management in Pregnancy:

  1. O2 reserves lower, metabolic demands higher in pregnancy. Earlier ventilatory support may be indicated.
  2. Intubation with 6-7 mm inner diameter tube recommended
  3. Upper airway edema and friability (weakening of tissue) occur due to hormonal changes, may reduce visibility during laryngoscopy and increase risk of bleeding.
  4. Renal blood flow increases, stressing kidneys and increasing tendency for pulmonary edema to develop

ACLS Medications in Pregnancy:

  1. In cardiac arrest, no medication should be withheld due to concerns of fetal teratogenicity
  2. Use standard drugs and doses when indicated
58
Q

Field Determination of Death

A

Do not begin or continue resuscitation if the following are present:

  1. Rigor mortis
  2. Dependent lividity
  3. Decomposition of body tissues
  4. Devastating, non-survivable injuries incompatible with life such as decapitation, incineration, brain matter visible

Resuscitation may not be continued or initiated if:

  1. A valid DNR, advanced directive, P.O.S.T, P.O.L.S.T., P.O.A., or patient advocacy paperwork is presented & PT is in full cardiac arrest
    - If family states PT has a DNR, but cannot produce paperwork, call Medical Control to terminate CPR
  2. On scene physician who properly identifies themself/Medical Control issues orders to stop CPR
  3. Blunt traumatic cardiac arrest, patient in asystole
  4. Unwitnessed arrest, unknown downtime, asystole in 2 or more leads
  5. Medic may choose not to perform EKG if obvious death to preserve evidence in a crime scene
  6. If family members/bystanders want resuscitative efforts started, then begin and transport
  7. When in doubt, start CPR

Advanced EMT Class (15 decks)

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