EMS SOG > EMS > Flashcards
EMS Flashcards
Consent and competency
Withholding consent for treatment
Mentally competent:
-Awake, alert, and fully oriented to _________,______,_____ and _____
-No significant ________(alcohol, drugs, head injury,significant illness)
-Not at risk for ____, ____, _______
-Awake, alert, and fully oriented to person,place,time and event
-No significant mental impairment(alcohol, drugs, head injury,significant illness)
-Not at risk for self harm, suicide, homicide
A ______ shall be defined as a person who presents with subjective and/or objective signs and/or symptoms or a complaint which results in evaluation and/or treatment.
Patient
A ___________ does not require treatment, transport, or cooperation from the patient.
Patient encounter
Controlled substance
Responsibility
_____________ will disperse controlled substances to individual ALS Companies through ___________ as directed by the __________ and _____________.
Logistical support will disperse controlled substances to individual ALS companies through the rescue district/battalion chiefs as directed by the division chief of rescue and the JFRD medical director
Controlled substance
Inventory and documentation
Each controlled substance page has a serial number that denotes ___________, ________, and _________.
Year
Unit
Page number
Below is the ONLY approved JFRD format for your PCR narrative
-_______
-_______
-_______
-_______
-_______
Below is the ONLY approved JFRD format for your PCR narrative
-CC (Chief Complaint)
-HPI (History of Present Illness)
-PE (Physical Exam)
-TX (Treatment)
-NOTE
Transports of unstable patients should begin within ___ minutes when possible.
10 minutes
Miniature horses generally range in height from ___ inches to ___ inches measured to the shoulders and generally weigh between ___ and ____ pounds.
24 inches to 34 inches
60 and 100 pounds
JFRD members should provide examination and treatment of the incapacitated or incompetent patient in accordance with this SOG and Florida statute _______
Florida statute 401.445
Florida statute ______-emergency medical care or treatment to minors without parental consent
Florida statute 743.064
If medical personnel are concerned for the safety of a minor and the parent or legal guardian refuses treatment and transport, contact the ________ and _____ for guidance.
Rescue district/battalion chief
Law enforcement
Florida statute ______-emergency examination and treatment of incapacitated persons.
Florida statute 401.445
If JFRD members feel that a baker act is warranted, ____ must be contacted.
Law enforcement
Medication errors and reactions while the patient is under the care of JFRD shall be reported immediately to the ______ and the ______. The ——-shall then notify the ____ and the _____ within ___hours.
Receiving physician and the APPROPRIATE district/battalion chief
District/battalion chief
JFRD medical director and the division chief of rescue
Within 24 hours
Dispensed to a company
The dispensing will be documented on the JFRD controlled substance checklist annotating:(7)
Date/time of dispensing
Total quantity of each controlled substance
Inspect the controlled substance for expiration date and damage
Seal number
Printed name/ signature of RESCUE district/battalion chief dispersing the controlled substance
Printed name/signature of Paramedic officer in charge of the ALS company(or paramedic if officer is not)
Explanation: dispensing to appropriate company
Daily inspection
If the seal is not broken:(5)
Date/time
Seal number
Name/signature of medic OIC or medic assigned
Name/signature of witness
Explanation: daily seal inspection
Daily inspection
If the seal is broken:(7)
Date/time
Inspect the controlled substances for expiration date/damage
Total quantity for each controlled substance
Seal number
Printed name/signature of medic OIC or medic assigned
Witness printed name/signature
Explanation:as appropriate
Daily inspections
The ______ and _____ signature is verification that all shifts have accurately completed the daily controlled substance log.
Company captains and chiefs signature
ALS companies
Discrepancies
Reported to____
Recorded in______
Documented in _____
Investigated by ______and_____with a discrepancy report provided to ____and______
reported to rescue district/bat chief
Recorded in company logbook
Documented in explanation section of jfrd controlled substance daily checklist
Quality improvement officer and rescue district/battalion chief
Division chief of rescue and JFRD medical director
Restocking should occur when:(4)
Minimum ALS engine inventory reached
Minimum rescue inventory reached
Prior to expiration date
Prior to holiday or weekend when stock is close to minimum rescue inventory
Each time a controlled substance is restocked:(3,7)
Controlled substance inventory will be checked and documented on the JFRD controlled substance daily checklist
Inspect the controlled substances for expiration date and damage
Restocking will be documented on the JFRD controlled substance daily checklist annotating:
Date/time
Total quantity of each controlled substance
Earliest expiration date of each controlled substance
Seal number
Printed name/signature of medic OIC or medic assigned
Witness printed name and signature
Explanation: restocking from (R103, etc)
Until returned, any expired or damaged controlled substances will be labeled _______ and will remain in the locked safe. Note will be made in the ____section of the controlled substance log
“DO NOT USE”
Comments
Approved methods of restraint:
Law enforcement:(3)
JFRD personnel:(3)
LE:
Handcuffs
Plastic ties
Hobble restraints
JFRD:
Soft limb restraints
Stretcher straps/harness
Wide cloth restraints
When restraints are in use, circulation to the extremities shall be evaluated ____________.
AT LEAST every 5 minutes
Documentation of the use of restraints on the EMS field copy report and PCR shall include:(3)
Patients behavior necessitating placement of restraints
Type of restraint used
Status of circulation distal to restraints
The primary purpose of a PCR is to document the _______ provided to a patient
Clinical care
The rescue officer will provide the ____ EMS field copy to the hospital.
White
Transport documentation
Parent/guardian information must be added in the ____section under _____ for all pediatric patients
Billing section under “responsible party”
Transport documentation
All transport reports require a legible signature from EITHER the _______ OR a ____________.
Responsible party OR a hospital representative
Transport documentation
If the laptop is not functioning following a transport, the appropriate signatures must be captured on paper.
The paper signature form must be delivered to the_____ who will then scan the copy and email it to _______________.
Rescue district/battalion chief
JFRDQI@coj.net
Transport documentation
When executing a PUTS report, a _______ must sign the report in addition to the _____. (_______ counts as signature).
Representative of the receiving ER/facility
JFRD provider
PIN
Non-Transport documentation (AMA refusal & non emergency)
Document on the patient care report:(4)
Details concerning the assessment of competency
The following statement in the narrative section-
At least one set of vital signs for each patient (or justify reason)
Any improvement from initial complaint
Non-Transport documentation (AMA refusal & non emergency)
Refusal signature requirements
-Obtain signature of patient
-_____ can sign for a legally competent adult patient
No one else
Non-Transport documentation (AMA refusal & non emergency)
Refusal signature requirements:
Appropriate witnesses in order of preference:(5)
Spouses, relatives, law enforcement, friends, other fire/rescue personnel
Non-Transport documentation (AMA refusal & non emergency)
Refusal signature requirements:
If a laptop technical issue occurs:
______ on the field copy must be completed
Ensure signature on the back of form is in _______
Include an explanation of the technical issue in the _____
Witness ___and ____
Signed refusals on the EMS field copy(laptop failure only) will be completed and filed at ________
___________, completed paper refusals will be forwarded to the _____ office.
Every field
Appropriate area
Narrative
Name and signature
The station
Monthly
Quality improvement office
The ___________of __________is to promote practices that will provide the highest quality, prehospital emergency care by utilizing the most well-trained, courteous employees for the benefit of all residents and visitors of the Jacksonville area.
Purpose
Quality improvement
The authority for the continuous quality improvement program comes from the _____in addition to the _____ as mandated by F.S. 401 and F.A.C. 64J-1
Director/fire chief
Medical director
Quality improvement
The program will review present standards of practice ______ so that they reflect currently accepted medical practices that are of the highest quality.
AT LEAST annually
Administration of the continuous quality improvement program will be the responsibility of the :(4)
Medical director
Division chief of rescue
Deputy division chief/rescue
Quality improvement officer
The _______ will appoint the quality improvement officer after receiving recommendations from _______.
Director/fire chief
Division chief of rescue
The medical director and quality improvement officer will communicate on a ______ basis.
Weekly
The quality improvement program will be a dynamic process, changing with the identified needs of the department and consisting of the following three aspects:
Proactive
Concurrent
Retrospective
____ quality improvement will consist of evaluation and training of practices that promote high quality patient care, prior to the delivery of patient care by JFRD personnel.
The ___,_____, and _____ will apply an accepted standard of care with benchmarks based upon JFRD rules, this emergency medical services SOG and national standards.
Proactive quality improvement
Quality improvement officer, division chief of rescue, and medical director
_____quality improvement will consist of supervision and evaluation of practices for quality during the delivery of patient care by JFRD personnel. This will be accomplished by the ____and _____.
Concurrent
Rescue district/battalion chiefs and the medical director
______quality improvement will consist of the evaluation of practices for quality after the deliver of patient care by JFRD personnel.
The ______ will appoint select individuals to the quality improvement review committee. The community will meet ______.
Retrospective
Division chief of rescue
As needed
The primary purpose of a _____ is to verify that the clinical care provided to the patient meets the established standards set forth in this SOG.
Patient care report review
A _____ is defined as one who, due to their age or disability, may be unable to adequately provide for their own care or protection.
Vulnerable adult
-
-
In addition to the above, the patient shall meet at least one of the following criteria:(6)
-L
-D
-R
-B
-D
-B
Unresponsive
Apneic
Pulseless
Patient has lividity
Body decay or visible decomposition
Patient has rigor mortis
Patient has an open cranium with exposed brain matter
Patient is decapitated or has a severed trunk
Patient has full thickness burns to the entire body
Blunt chest trauma or multi system trauma patients meeting the following criteria shall be considered DOS:(3)
-A
-P
-If cardiac rhythm is ___________ or rhythm of ______ or less without a
pulse, document time and pronounce death
Apneic
Pulseless
Asystole
wide complex ventricular rhythm
30 or less
Acutely hypothermic patients in cardiac arrest shall be treated and transported
Includes submersion victims <__________minutes
<60 minutes
Control of death scenes is the responsibility of __________. Generally, law enforcement officers voluntarily defer to the EMS provider for resuscitation decisions; however, ultimate responsibility for control of death scenes rests with _____________. If a law enforcement officer denies you access to the scene, they are assuming _________________ and acting within the law to preserve _____________. You must obtain the law enforcement officer’s ______________, explaining to them that you are required to document in the patient care report that they assumed the responsibility for the __________________ and that they denied you access to the scene.
Law enforcement x2
Full responsibility
Evidence
Name and ID number
Pronouncement of death
Patient identification device is a miniature version of _______ and is incorporated by reference as part of the DNRO form.
DH Form 1896
DNRO
According to the Florida department of health, the form shall be printed on __________ and have the words ____ printed in black and displayed across the top of the form. DH Form 1896 may be duplicated, provided that the content of the form is _________, the reproduction is of _________, and it is duplicated on ____________. The _____________ does not have to be an exact duplicate
• __________________is a miniature version of DH Form 1896 and is incorporated by reference as part of the DNRO form. Use of the patient identification device, which is defined by the state of Florida as the bottom ____________ portion of the official DNRO form as notated on the following page, is _________ and is intended to provide a _______________ and ________ DNRO which travels with the patient
• The DNRO form and patient identification device must be signed by the ______________
• During each transport, the EMS provider shall ensure that a copy of the DNRO form or the patient identification device accompanies the live patient
• The EMS provider shall provide ___________, ____________ and any other _________, short of _________ or ________________
• A DNRO may be revoked at any time by the __________, if signed by the patient, or the patient’s ____________, or __________or court appointed ___________or person acting pursuant to a ____________
Yellow paper
“DO NOT RESUSCITATE ORDER”
Unaltered
Good quality
Yellow paper
Shade of yellow
Patient identification device
Detachable
Voluntary
Convenient and portable
Patients physician
Comforting, pain relief, and any other medically indicated care
Respiratory or cardiac resuscitation
Patient
Health care surrogate
Proxy
Guardian
Durable power of attorney
Transport/destination
All patients will be transported based on _______ in the most appropriate manner consistent with their condition. _____will be documented on the patient care report. In those situations where extraordinary circumstances exist, as in multiple patient incidents, the _____, or designee, may elect to deviate from existing guidelines in determining destination of patients.
patient assessment
Deviations
Incident commander
The ______ may waive the maximum of two patients per rescue company in extenuating circumstances.
District/battalion chief
Stable pediatric with a complex complaint and/or medical history: Transport to ___ or _____.
Baptist downtown or UF health Jacksonville
Emergency inter-facility transfer procedures
The ____ will determine the transport destination.
Transferring physician
Arrival at receiving facility
If patient not assessed by medical staff within 15 minutes of arrival, consult with charge nurse or nurse manager for guidance; if there is an issue contact ____________.
Your district/battalion chief
Transports to more distant emergency departments may occur after consult with the __________.
Rescue district/battalion chief
The regulations set out four assessment factors to assist entities in determining whether miniature horses can be accommodated in their facility. The assessment factors are:
- Whether the miniature horse is housebroken
- Whether the miniature horse is under the owners control
- Whether the facility can accommodate the miniature horses type, size, and weight
- Whether or not the miniature horses presence will compromise legitimate safety requirements necessary for safe operation of the facility
For each EMS call, FRCC shall obtain the following information:(5)
Address or location of incident
Nature of emergency
-# of patients
-type/severity of injuries
Type of location(house,apt,street,hwy)
Complainants name
Complainants phone number
Using the computer aided dispatch (CAD) system, the _____ shall ensure dispatch of the closest available ALS Unit
Emergency medical dispatcher
JFRD personnel will issue a trauma alert using the words _____, ______, and ________.
“Trauma Alert”, state the criteria, and announce the destination
Infants and children ____pounds, use pedi immobilizer for spinal immobilizations
LESS THAN 60 pounds
Patients with multi-system involvement may _______. ____ is a priority.
Deteriorate rapidly
Load and go
Chest trauma patients may ____. ____ is a priority.
Deteriorate rapidly
Load and go
______ is the most important indicator of abdominal trauma. The best treatment for the patient with severe abdominal trauma is _____.
Mechanism of injury
Rapid transport
Taser trauma
Only ____ are permitted to remove probes
Law enforcement officers
Burns are classified according to type(___,___, and ___) and ______.
Type (thermal, electrical, and chemical) and thickness
Multi system
Bleeding from the nose/ears should not be _____ but a ______ should be placed over the nose and ears.
Should not be stopped
Sterile dressing
Scope
These guidelines have been written to cover all medical emergencies; however, the Medical Director realizes that unforeseen scenarios or situations may arise. In these cases, JFRD personnel should attempt to follow the most appropriate intervention and contact ___________for treatment recommendations outside the scope of these guidelines.
online medical control (receiving physician)
_____________will perform those procedures they are credentialed and/or have been trained to perform such as blood pressure check, CPR, glucose check, spinal immobilization, tourniquet application, splinting, etc.
First responders
Comply with the patient care report (PCR) signature requirements as set forth by the ________________
Centers for Medicare & Medicaid Services (CMS)
In the case of children under the care of a parent or legal guardian, consent must be obtained from the parent or legal guardian. If consent cannot be obtained, follow Florida Statute _________.
Florida Statute 743.064
A _____________is an individual authorized to make medical decisions on behalf of an incapacitated patient
Health care agent
Approved Health Care Agents
There are three types (as listed below) recognized by the State of Florida which may impact JFRD operations. If any unusual circumstances arise, contact ____________for guidance.
The rescue district/battalion chief
A _________________form authorizes a designated individual to handle affairs and conduct business on a patient’s behalf.
A Durable Power of Attorney form
A ____________form authorizes a designated individual to make health care decisions on a patient’s behalf
A Healthcare Surrogate form
A Durable Power of Attorney form is completed in advance of____________.
a patient
becoming incapacitated
A Healthcare Surrogate form is completed in advance of____________.
a patient becoming incapacitated
If an individual is incapacitated and did not previously complete an advance directive (as listed above), decisions regarding the patient’s medical treatment are made by a __________________.
Designated Proxy
Regardless, any of the following individuals, in order of priority, may make health care decisions on the patient’s behalf:8
• The judicially appointed guardian of the patient
• The patient’s spouse
• An adult child of the patient, or if the patient has more than one adult child, a majority of the adult children who are reasonably available for consultation
• A parent of the patient
• The adult sibling of the patient or, if the patient has more than one sibling, a majority of the adult siblings who are reasonably available for consultation
• An adult relative of the patient who has exhibited special care and concern for the patient and who has maintained regular contact with the patient and who is familiar with the patient’s activities, health, and religious or moral beliefs
• A close friend of the patient
• A clinical social worker licensed pursuant to chapter 491
Florida Patient’s Bill of Rights – Information Request
In accordance with Florida Statute 381.026, a patient has the right to know the _________, __________, and ____________of each health care provider who is providing medical services to the patient. JFRD members must provide such information when requested.
Name, function, and qualifications
The ___________will be responsible for the procurement, storage, dispensing and disposal of controlled substances._____________ will disperse controlled substances to individual ALS companies through the ______________as directed by the_________and___________.
The Logistical Support Facility
Logistical Support
Rescue District/Battalion Chiefs
Division Chief of Rescue and the JFRD Medical Director
Controlled Substance Inventories:
• May be amended based on_________
• ALS Suppression Units
• Minimum
• Midazolam - ______
• Rescue Units • Minimum
• Etomidate/Amidate - _____
• Fentanyl - _____
• Ketamine - ______
• Midazolam - ____
• Rescue District/Battalion Chiefs
• As determined and authorized by ________________
drug availability (i.e., national backorder)
5 mg
60 mg
200 mcg
500 mg
15 mg
the Division Chief of Rescue and the Medical Director
Completed JFRD Controlled Substance Daily Checklists will remain with the notebook until collected by the ____________and forwarded to the__________ .
• Each controlled substance page has a serial number that denotes the________, __________, and ______________. Therefore, a page should not be removed
District/Battalion Chiefs
Quality Improvement Officer
year, unit, and page number
JFRD Controlled Substance Daily Checklist
Do not write “_____________” in the log
“SEALED”
If seal is broken
Explanation:________
As appropriate
If a stocked spare unit is not staffed for the day, the Officer-in-Charge or Paramedic assigned to a______________ will, with a witness present, verify that the numbered seal is intact, and document accordingly as listed above. If the seal is broken, contact the appropriate Rescue District/Battalion Chief
staffed ALS unit within the station
• The_______and ________ signature is verification that all shifts have accurately completed the daily controlled substance log.
company Captain’s and Chief’s
_____________Inspection
• Inspect inventory to verify accuracy of controlled substances prior to submitting completed logs to QI
End of Year (12/31)
______________Inspection
• Inspect inventory to verify accuracy of document counts and expiration dates
First of Year (1/1)
• ALS apparatus may also restock each other____________. (What circumstances?)
in cases of emergency
Until returned any expired or damaged controlled substances will be labeled “__________”, remain in ___________, and be included in the ______________• A note will be made in the comment section of the____________ indicating the amount and name of the expired medication
labeled “DO NOT USE”, remain in the locked safe, and be included in the total count
Controlled substance log
Rescue District/Battalion Chiefs
• Storage
• Controlled substances will be stored at all times in a locked safe in a ________
controlled location
Climate
Access to the Rescue Chiefs’ safes require concurrent use of a______and______. A seal on the _______ of the safe must be broken to remove the _______. The _______and required ________must be replaced each time the safe requires access
key and PIN
Hinge
Key
Seal
Key
Rescue District/battalion chiefs
• Discrepancies
• Discrepancies concerning controlled substances will be:
• Reported to the__________and _________
• Investigated by the ___________and ________with a discrepancy report provided to the_________and__________
-Division Chief of Rescue and the JFRD Medical Director
-Quality Improvement Officer and the Assistant Chief of
Rescue
-Division Chief of Rescue and the JFRD Medical Director
• Rescue District/Battalion Chiefs do not include ____________controlled substances in their total count. ____________controlled substances have a separate log and are secured in a separate location inside the safe. ________ or ___________controlled substances will be turned in to the Logistical Support Facility during normal business hours
Expired
Expired
Expired or damaged
Controlled substance
Rescue and Suppression District/Battalion Chiefs
• Monthly chief inspection of ALS companies:Dates?
23rd, 24th, 25th
Additions to the inventory of IV fluids and medications will be procured from the___________________ in amounts authorized by the Division Chief of Rescue and JFRD Medical Director.
Logistical Support Facility Manager
Patients in police custody
• Competent patients in police custody can still make decisions about their medical treatment and sign an AMA Refusal or Non-Emergency/Non-Transport Waiver if___________________. If Law enforcement refuses to remove the handcuffs to allow the patient to sign, document in the__________ section of the PCR that the patient verbalized a refusal of treatment. Select “Not Signed – In Law Enforcement Custody” under the Signature Type tab when selecting Refusal of Assessment/Care/Transport. Have the law enforcement officer sign the Witness signature in the PCR. Also include the officer’s ____________.
• Transport Destination
• If the patient is unstable (includes any Alert), transport to ________________.
• If the patient is stable,______________ will dictate the hospital destination
allowed by law enforcement
Narrative
officer’s ID number
The closest most appropriate hospital
Law enforcement
Blood draw on patients being transported
The following process shall be followed for blood draw requests on patients being transported by Rescue:
• ___________medical care as per the appropriate guideline
• Do not delay transport of ______________patient to perform a blood draw
• Draw blood per instructions in the blood draw kit
• All items except ___________will be returned to the kit with the Betadine prep pad being sealed in the plastic bag provided
• The ____________ will seal the blood collection kit, maintain the chain of custody and complete the documentation
• In your report, record the _________ printed on the blood draw kit and the________________
Initiate
An unstable patient
The needle
Investigating officer
Date
investigating officer’s name and ID number
Blood draw on patients not transported
The following process shall be followed for blood draw requests on patients who refuse treatment and/or transport:
• A ______________ patient may refuse the test
• If_______and________ to the test, draw blood per instructions in blood draw kit
• A______________ must be completed
• Capture a refusal signature as necessary and have the investigating officer witness the refusal. If patient refuses to sign, follow Guideline 1090 for documentation requirements
Competent
mentally competent and agreeable
full patient care report
__________and___________are critically important in both transport and non-transport reports.
Accurate and legible signatures
• All patient care reports SHOULD be completed ____________ and are ALWAYS required to be completed _______________.
• All chief officers and captains must review E-Pro ____________ for outstanding reports to ensure that all reports have been completed on time
• The Suppression Officer will provide the completed EMS field copy to the Rescue Officer
• The Rescue Officer will ensure the EMS field copy is completed and provide the ___________copy to the hospital
• All EMS field copies must be shredded after _____________.
• The Emergency Pro report system is designed to recognize the ___________as the lead crew member. The proper procedure is for all ____________to ensure their name is listed in the first (top) position on the sign-in roster
• Anytime an ALS procedure is performed, the paramedic that performed the
procedure must be listed in the ____________.
• Avoid phrases that ___________
• Always document ______________.
As soon as possible
By the end of the shift
Daily
White copy
Completion of the electronic PCR
Report writer x2
Flow sheet
Do not add value
Objectively
Radio reports to the receiving hospital should be transmitted according to the following format within _______minute:
• Unit ____
• Any applicable “________” that were called
• Patient’s _____
•_________ for pediatrics
• Gender
• Chief complaint
• Brief history of the present illness
• Vital signs (e.g., pulse, respiratory rate, blood pressure, pulse oximetry, BGL, cardiac
rhythm and GCS for all trauma patients).
• General _________ that includes level of consciousness and pertinent physical
findings
• Pertinent care provided
• If applicable, request for physician orders
• Provide ETA
One minute
Unit identification
Alerts
Age
BroselowTM tape color
Appearance
Radio report
If requested by receiving hospital, the patient’s __________and______shall be provided.
Name and date of birth
The _____________ of Quality Improvement will be to train. The program will identify individual and system weaknesses and will develop plans to improve patient care.
Intention
Quality improvement
Practices, which deviate from the SOG or the ASC, will be identified by:
_______ database queries
Concerns regarding the delivery of____________
__________reports from area hospitals
Patient care ___________
• PCR database queries
• Concerns regarding the delivery of patient care
• Patient outcome reports from area hospitals
• Patient care complaints
Rescue Captains
• Must review the following reports monthly:
• _______PCRs per month to include a sampling from all report authors assigned to that unit during the month, either permanently or temporarily, with an emphasis on ________ and calls of _________
20 PCRs
Refusals and calls of a critical nature
Rescue District/Battalion Chiefs
• Must review all of the following reports monthly, if not________________:
• All__________ reports
• All_____________
• All____________
• Minimum of _______ PCRs per month to include a sampling from all report authors assigned to their district. This number of reviews may have already been accomplished with criteria above
• Specific reports identified by _______________
already reviewed by a Captain
Cardiac/Trauma Arrest
“Alerts” (Trauma, STEMI, Stroke, etc.)
Advanced airways
30 PCRs
The medical director
As part of ongoing and continuous improvement in EMS documentation, the Quality Improvement (QI) Office will conduct ____________audits of Emergency-Pro patient care reports (PCR) to ensure that the documentation satisfies the legal and billing processes required, up to and including the presence of a legal and legible responsibility ____________ captured ___________ to departing the medical facility (as noted by the time stamp in the PCR).
Daily
Signature
PRIOR
The QI Office receives automated _________queries of Emergency-Pro PCRs that have a responsibility signature timestamp notated ________ the transport unit has gone available from the medical facility.
Daily
AFTER
The QI Office will subsequently forward any PCR populated in the automated daily query to the ____________for notification with the _____________copied. All PCRs populated in the automated daily query will also be forwarded to the_______________ and will not be processed for billing/reimbursement until such time confirmation is received by the QI Office that the PCR contains explicit documentation in the narrative section that the following occurred…..
Report author
District/Battalion chief
JFRD EMS Billing Manager
If, after review of the PCR by the QI Office, there is no documentation or notation in the narrative by the report author that the Rescue unit returned to the medical facility to legally obtain an appropriate signature on the PCR AND the AVL data confirms that the Rescue unit was not at the medical facility when the responsibility signature time-stamp was captured on the PCR, a formal request for investigation will be immediately forwarded to_____________, with Rule Infraction Charges to follow when necessary. Copies of the PCR and supporting AVL data shall be forwarded to__________________ to assist with their investigation.
the appropriate District/Battalion chief x2
_________________permanently assigned to the Rescue Division shall receive formal EMS Documentation Training taught by the QI Office. This mandatory training will be in addition to the initial Emergency-Pro PCR Navigation class. Rescue personnel are not permitted to author an Emergency-Pro PCR without first receiving______________.
EMS Documentation Training shall be comprehensive in nature covering all medical-legal aspects of proper, accurate, and legible documentation on the PCR.____________ training will be required to be completed via_____________.
ALL paramedics
Both classes
Annual refresher
TargetSolutions
A vulnerable adult is defined as one who, due to their _______or______, may be unable to adequately provide for their own ________or__________.
Age or disability
Care or protection
All employees are required to report known or suspected child or vulnerable adult abuse, abandonment, or neglect. Anyone who knowingly and willfully fails to do so, or who knowingly and willfully prevents another person from doing so,commits______________, punishable as provided in Florida Statutes.
Anyone who knowingly and willfully makes a false report of child or vulnerable adult abuse, abandonment, or neglect, or who advises another to make a false report, is guilty of _________________, punishable as provided in Florida Statutes.
Anyone making a report who is acting in___________ is immune from any liability per FL Statute.
commits a felony of the third degree x2
Acting in good faith
When JFRD personnel suspect that abuse or neglect to a child or vulnerable adult has taken place, they shall initiate the following:
•______________
•_______________
• If transport is refused:
• Request___________
• Stay with patient until_____________
• Notify the_____________
Treat related injuries
Transport all suspected cases
Request law enforcement at scene
Law enforcement arrival
Rescue District/Battalion Chief
JFRD personnel shall also report the abuse/neglect according to the following procedure:
•_______________ report the actual or suspected child abuse, neglect or
abandonment to the central abuse hotline maintained by_____________
• The_________ shall make the initial verbal report by calling the statewide toll-free number (1-800-962-2873). Obtain________and_____ from the contact person
• Report suspicions to_______________
• Notify the______________
• Notify the______________via___________within______ hours indicating that you have reported the case to the FL Abuse/Neglect Registry, including ONLY the________and__________ of the contact person. Do not provide any patient information in the email (HIPAA concern)
• Document in the _____________ the circumstances and reporting of abuse
Immediately
The Department of Children and Family Services (DCF)
Officer-in-charge
Name and ID Number
Emergency department physician
Rescue District/Battalion Chief
Division Chief of Rescue via email within 24 hours
First name (agency gives a first name only) and ID number
PCR narrative
Radio reports to the receiving hospital should be transmitted according to the following format within one minute: 12
-U_____
-A____
-A_____
-B______
-G______
-C_______
-H________
-V__________
-G_________
-C________
-O________
-E__________
-Unit identification
• Any applicable “Alerts” that were called
• Patient’s age
• BroselowTM tape color for pediatrics
• Gender
• Chief complaint
• Brief history of the present illness
• Vital signs (e.g., pulse, respiratory rate, blood pressure, pulse oximetry, BGL, cardiac
rhythm and GCS for all trauma patients).
• General appearance that includes level of consciousness and pertinent physical
findings
• Pertinent care provided
• If applicable, request for physician orders
• Provide ETA
Resuscitation efforts may be terminated only when all the following criteria exist:
• Patient is at a ___________facility
• Arrest was _______________
• _______________ provided prior to JFRD arrival or at any time during the resuscitation
• Patient is____________years old
• Rhythm remains _____________ after providing ______ rounds of full ACLS
• ________________ in place (endotracheal intubation is preferred)
Long term care medical facility
Not witnessed
No shocks
Greater than 18 years old
Asystole
3 rounds
Advanced airway in place
An order not to resuscitate, to be valid, must be on the form adopted by rule of the department. The form must be signed by the patient’s _________ and by the __________ or, if the patient is incapacitated, the patient’s______________ or _________ as provided in chapter 765, court-appointed __________as provided in chapter 744, or attorney in fact under a ______________ as provided in chapter 609. The court-appointed guardian or attorney in fact must have been delegated authority to make ______________ on behalf of the patient.
The patient’s physician
The patient
Health care surrogate
Proxy
Guardian
Durable power of attorney
Health care decisions
Transportation to the appropriate facility of those patients requiring further medical care is the final step in assuring the continuity of patient care. _________and _________must be the overriding consideration in every case.
Patient care and well being
All patients will be transported based on patient_________in the most appropriate manner consistent with their _______. Deviations will be documented on the ________________.
Patient assessment
Their condition
Patient care report
Transportation and destination must be determined from specific guidelines and free from the influence of ability to pay, social status, convenience of personnel or other discriminatory factors. In those situations where extraordinary circumstances exist, as in multiple patient incidents, the _____________ or _____________, may elect to deviate from existing guidelines in determining destination of patients.
Incident commander
Transport officer
Patients who will be transported by rescue (with proper consent) The following situations require transport:
• Life-threatening emergencies and those situations which could become life- threatening
• Chest pain/cardiac signs and symptoms/epigastric discomfort
• Systolic B/P greater than_____mmHg OR Diastolic B/P greater than____mmHg
• Systolic B/P less than ____mmHg
• Abdominal pain
• Reported loss of consciousness
• Report of blood in stool or vomit
• Severe sudden onset headache, light intolerance and/or neck stiffness
• Difficulty breathing
• Pregnancy
• Diabetic emergencies
• Altered mental status
• Suspected or known overdoses
• Suicidal (attempted or suspected) patients unless _________
• All non-fatal________ patients
• Patients who meet Trauma, STEMI, or Stroke Alert status
• Patients who require or have received Advanced Life Support treatment and/or
medications
• Patient’s injury or condition that might be exacerbated by improper handling or
transport by privately owned vehicle (POV) or other means of transportation
• Pediatric patients ______years of age or less who are __________
• Exceptions are _________injuries when a competent parent or legal guardian is on-scene OR documented__________of ______________
• Elderly patients _____years of age or greater
• Exceptions are ______________, _________patients without a documented _______________ or documented ______________ of ______________
Systolic B/P greater than 180 mmHg OR Diastolic B/P greater than 110 mmHg
Systolic B/P less than 90 mmHg
Unless transported by law enforcement
Non-fatal drowning
15 years of age or less who are symptomatic
Exceptions are superficial injuries when a competent parent or legal guardian is on-scene OR documented signed refusal of treatment/transportation
65 years of age or greater
Exceptions are non-symptomatic competent patients without a documented chief
complaint or documented signed refusal of treatment/transportation
Non-transport situations
The following situations will not require transportation of the patient to the hospital by Rescue: (Complete signed AMA or non-emergency/non-transport refusal when appropriate).
• Situations where _________exists
• Injuries of a _______ or ________ nature
• Situations where transport would _________________rescue crew members
• Patients, otherwise stable, who require transport to______________
• Situations where patient requests _________ or _____________
• ______________will not be transported
• Patients who ______________
No emergency
Superficial or minor
Endanger the safety of
Mental health resource or detox facility
Private provider or private vehicle transportation
DOS victims
Refuse transport
• Each time a controlled substance is administered
• The controlled substance inventory will be _______and __________ on the JFRD Controlled Substance Daily Checklist
• Inspect the controlled substances for ________ and__________
• The administration will be documented on the JFRD Controlled Substance Daily
Checklist, annotating:
• ___________ of administration
• ____________ of each controlled substance
• __________ of each controlled substance
• ____________Number
• Printed name and ________________ of the Paramedic Officer-in-Charge or paramedic
assigned to the ALS company
• Witness’ ________ and__________
• Explanation: ________ Number, ___________, Amount ________, Amount __________
Checked and documented
Expiration date and damage
Date/time
Total quantity
Earliest expiration date
New seal number
Printed name and signature of the Paramedic Officer-in-Charge or paramedic
assigned to the ALS company
• Witness’ printed name and signature
Explanation: CCR Number, Medication, Amount Administered, Amount Wasted
• Below is the ONLY approved JFRD format for your PCR Narrative
• CC: (Chief Complaint)
• The patient’s __________
• HPI: (History of Present Illness)
• Exactly how the patient was__________ to JFRD personnel
• Complete of ____________the patient called 911 (e.g. onset of symptoms
and activity related to the complaint)
• Include a detailed description of the _______________
• PE: (Physical Exam)
• Evaluate ______________ findings through observation, palpation,
percussion, and auscultation
• For any complaints of pain, document: _________________
• Include any associated ___________that relate to the present illness
• List any pertinent _________and________findings
• TX: (Treatment)
• Document how the patient was _______________and that a hospital staff member was _________upon patient transfer
• Any changes in __________that occurred during transport and transfer of care at the hospital
• NOTE:
• This section should be used for any _____________that occur during
the entire duration of the incident.
Main complaint
Presented
Description of why
Patients complaints
Objective anatomic
Onset, Provocation, Quality, Radiation, Severity and Time (OPQRST)
Signs or symptoms
Pertinent positive and negative
Moved to the stretcher
At the bedside
Patient condition
Unusual circumstances (e.g., patient contact delays, scene delays, patient/family issues, equipment issues, transfer of care issues, etc.)
Various circumstances (i.e., elderly spouse, medical POA, etc.) warrant consideration for allowing passengers to accompany the patient during transport, utilizing __________and a ________approach. However, transport of passengers is at the sole discretion of the _________________.
• Exceptions
• Pediatric patients requiring a parent or guardian
• _____________when a parent or guardian is not available
• _____________patients requiring a guardian or caregiver
• Patients with __________________
• Patients with_______________
Common sense and a customer service approach
Officer in charge of the rescue unit
School representative
Geriatric patients
Language barriers requiring a Translator
speech disabilities requiring someone proficient in sign language
Many times, JFRD personnel are faced with the situation of transporting more than one patient to the hospital via one Rescue Company. In these situations, no patient shall be left unattended in the back of the rescue unit, ________________________.
Under any circumstances
When transporting more than one patient to the hospital, the__________ will provide personnel to ride along to assist in ____________ and __________the patient until they can be taken into the emergency room.
The ___________________may wave the maximum of two patients per Rescue Company in extenuating circumstances.
Transports of unstable patients should begin within ______minutes when possible.
Officer-in-Charge of the Suppression Company
Patient care and monitor
District/Battalion chief
Within 10 minutes
Adult destination determination policy
The _________will determine the transport destination after considering the following:
• Refer to the most recent Hospital Capabilities Chart for JFRD as needed to assist with
determining a hospital’s capabilities
• Patients who are unstable or in cardiac arrest will be transported to the __________ emergency department
• Patients who are stable will generally be transported to ______________;
however, patients who have recently been discharged from the hospital should be
encouraged to ______________
Officer in charge
Closest most appropriate
Their hospital of choice
Return to that same hospital
Pediatric destination determination policy
The ___________ will determine the transport destination after considering the following:
• Adhere to the facility’s specific_______________
• Pediatric patients who are unstable or in cardiac arrest should be transported to _________.
• Transport to an alternate hospital should only take place if______and___________
• Patients who are stable should be transported to____________
• Stable pediatric with a simple injury or complaint and no hospital affiliation:transport to _________
• Stable pediatric with a complex complaint and/or medical history (e.g., congenital cardiac, neurologic, or endocrine abnormalities): Transport to___________
Officer in charge
Pediatric coverage hours
Closest approved pediatric emergency department
that hospital is closer to the scene of the incident and the patient’s immediate condition is such that the patient’s life will be endangered if care is delayed by proceeding directly to an approved pediatric emergency department
the hospital where the patient is usually seen and has the patient’s medical records
Transport to the closest approved Pediatric Emergency Department
Baptist Downtown or UF Health Jacksonville
Pediatrics should be secured to the stretcher with the______or_______
• Exceptions may be made for __________ and/or _________.
Pediatric Restraint Device (Appendix L) (if size appropriate) or their own car seat
Level of distress and/or treatment.
• Inter-facility transfers should be taken to the _______________, with rare exception. The ______________ will determine the hospital destination
• _____________ and/or__________ be requested from the transferring facility
Emergency department
Transferring physician
Equipment and/or staff
Most patients can be transported to a Stand-alone ED. Exceptions include:
• Those patients ______________or________________
• Chest pain
• STEMI Alert
• Stroke Alert
• __________Alert
• Pediatric (except___________)
• Pregnancy
• Baker Act
• Post-Cardiac Arrest with ROSC
• Trauma Alert
• Trauma Red
• Baker Act
Expected to be admitted or require specialized services
COVID Alert
Except during designated hours as defined on the Hospital Capabilities Chart
Arrival at receiving facility
• If patient not assessed by staff within ____ minutes of arrival, consult with _______or _________for guidance; if there is an issue contact __________
• Rescue personnel will transfer patient to the hospital stretcher in a ______ and ________ manner. If the transfer is delayed more than ___ minutes notify _________
• Once inside the emergency department, the patient will not _________.
Within 15 minutes
Charge Nurse or Nurse Manager
District/Battalion chief
Timely and expedient manner
More than 30 minutes notify FRCC
Will not be removed
Approved Adult Hospitals
• Baptist Medical Center - 8 locations,4 are stand-alone
• Ed Fraser Memorial Hospital
• Mayo Clinic Hospital - Jacksonville
• Memorial Hospital-4 locations, 3 are stand alone
• NAS Naval Hospital - Jacksonville
• Normandy Park (Orange Park Medical Center) - Stand-alone Emergency Department
• Orange Park Medical Center
• Park West (Orange Park Medical Center) - Stand-alone Emergency Department
• UF Health Hospital Jacksonville
• UF Health Hospital North
• St. Vincent’s Medical Center-5 locations, 2 are stand alone
Approved Adult Hospitals
• Baptist Medical Center - Beaches
• Baptist Medical Center - Clay County - Stand-alone Emergency Department
• Baptist Medical Center - Downtown
• Baptist Medical Center - Nassau
• Baptist Medical Center - North - Stand-alone Emergency Department
• Baptist Medical Center - Oakleaf - Stand-alone Emergency Department
• Baptist Medical Center - South
• Baptist Medical Center - Towncenter - Stand-alone Emergency Department
• Ed Fraser Memorial Hospital
• Mayo Clinic Hospital - Jacksonville
• Memorial Hospital Jacksonville
• Memorial Hospital Atlantic - Stand-alone Emergency Department
• Memorial Hospital Julington Creek - Stand-alone Emergency Department
• Memorial Hospital Mandarin - Stand-alone Emergency Department
• NAS Naval Hospital - Jacksonville
• Normandy Park (Orange Park Medical Center) - Stand-alone Emergency Department
• Orange Park Medical Center
• Park West (Orange Park Medical Center) - Stand-alone Emergency Department
• UF Health Hospital Jacksonville
• UF Health Hospital North
• St. Vincent’s Medical Center - Arlington - Stand-alone Emergency Department
• St. Vincent’s Medical Center - Clay
• St. Vincent’s Medical Center - Riverside
• St. Vincent’s Medical Center - Southside
• St. Vincent’s Medical Center - Westside - Stand-alone Emergency Department
Approved Pediatric Hospitals - ______________ may vary at some hospitals. See most recent Hospital Capabilities Chart for JFRD.
• 5 main hospitals and 4 stand alones
Approved Pediatric Hospitals - Hours may vary at some hospitals. See most recent Hospital Capabilities Chart for JFRD.
• Wolfson Children’s Hospital
• UF Health Hospital Jacksonville
• Memorial Hospital Jacksonville
• Orange Park Medical Center
• Baptist Medical Center - Clay
• Baptist Medical Center - North
• Baptist Medical Center - Oakleaf
• Baptist Medical Center - South
• Baptist Medical Center - Towncenter
Transports to more distant Emergency Departments may occur after consult with the ______________.
Deviations from the transportation guidelines must be ___________ and ___________on the _________report.
Rescue District/Battalion chief
Documented and justified on the patient care report
Air transport units
• Air Transport Units (ATU) should be considered for _______ or ________ patients any time ground transport time to the closest appropriate hospital exceeds ____ minutes
• An ATU for direct flight to UF Gainesville’s Burn Center should also be considered for
Isolated burns without ___________ when:
• ______degree burns greater than 20% of the total body substance area (TBSA)
• _______degree burns greater than 5% of the TBSA
• ________degree burns with the threat of _________or __________impairment to the
face, hands, feet, genitalia, perineum, or major joint
• Patients in _________ or _____________ are not appropriate for an ATU
Critically ill or injured
Exceeds 20 minutes
Isolated burns without other significant trauma
2nd and 3rd degree burns greater than 20%
3rd degree burns greater than 5%
2nd and 3rd degree burns with the threat of functional or cosmetic impairment to the
face, hands, feet, genitalia, perineum, or major joint
Cardiac or trauma arrest
Service animals are defined as dogs that are individually trained to ________ or ________ for people with disabilities. Examples of such work or tasks include guiding people who are blind, alerting people who are deaf, pulling a wheelchair, alerting and protecting a person who is having a seizure, reminding a person with mental illness to take prescribed medications, calming a person with Post Traumatic Stress Disorder (PTSD) during an anxiety attack, or performing other duties. Service animals are working animals, not pets. The work or task a dog has been trained to provide must be _______________to the person’s disability. Dogs whose sole function is to provide ____________or __________ do not qualify as service animals under the ADA. This definition does not affect or limit the broader definition of “__________” under the _____________ Act or the broader definition of “_____________” under the __________Act
Do work or perform tasks
Directly related to the person’s disability
Comfort or emotional support
ADA
“Assistance animal” under the Fair Housing Act
“Service animal” under the Air Carrier Access Act
Under the ADA, service animals must be ___________, ___________, or ____________, unless these devices interfere with the service animal’s _________ or the individual’s ____________prevents using these devices. In that case, the individual must ______________ of the animal through voice, signal, or other effective controls.
Harnessed, leashed, or tethered
Work
Disability
Maintain control
A service animal, utilized by a patient for a disability, shall be permitted to accompany a ________ or ___________ in the rescue unless the presence of the service animal will _______________, the patient is ___________ or there is some basis for the crew members to believe that the ___________, __________ or___________ would be compromised by the presence of the service animal in the rescue.
• ___________ may be considered threatening behavior in which case the service animal may be transported by other means. _______may also be considered threatening; however, specific service animals are required to _____ to get their owner’s attention
Patient or guardian of a minor patient
Disrupt patient care
Unstable
Safety of the crew, the patient, or others
Growling
Barking
Bark
When transporting a patient with a service animal, every effort should be made to do so in a _____manner for the patient, the animal, and the crew members. If possible, the animal should be _______ in some manner to prevent _______ to either the animal or the crew during transport. The _______ should be loaded into the rescue first, and then the _________. Whenever possible, the _____________ should be notified that you are en route with a service animal.
Safe
Secured
Injury
Patient
Service animal
Receiving hospital
When the presence of a service animal in the rescue might interfere with __________, jeopardize ___________, personnel should make other arrangements for __________ transport of the service animal to the receiving facility.
• Acceptable alternative methods of transporting a service animal to the receiving facility include, but are not limited to, ___________, ___________, or ____________ of the patient, _____________, a _______________, or a ______________
Interfere with Patient care
Jeopardize the safety of the crew, the patient, or others
Simultaneous
Family members, friends, or neighbors of the patient, animal control, a District/Battalion Chief, or a law enforcement official
Personnel should document on the Patient Care Report (PCR) instances where the patient or guardian accompanying a minor patient utilize a service animal and note whether the service animal was _____________. If the service animal was not transported__________________, the PCR should contain the___________and ________________.
Transported with the patient
Transported in the rescue with the patient
Reason(s) and how the animal was transported
When it is _____________ what service an animal provides, only limited inquiries are allowed.
Personnel may ask only two questions:
1. Is the dog _________________________?
2. What _______________________________?
Personnel cannot ask about ________________, require _______________documentation, require a special _____________ or _______________ documentation for the dog, or ask that the dog demonstrate its ability to ______________.
__________and__________ are not valid reasons for denying access or refusing service to people using service animals.
Not obvious
Is the dog a service animal because of a disability?
What work or task is the dog trained to perform?
The person’s disability, require medical documentation, require a special identification card or training documentation for the dog, or ask that the dog demonstrate its ability to perform the work or task.
Allergies and fear of dogs
In addition to the provisions about service dogs, the Department’s revised ADA regulations have a new, ________________ about miniature horses that have been individually trained to do work or perform tasks for people with disabilities. (Miniature horses generally range in height from ____inches to ____inches measured to the shoulders and generally weigh between ___ and _____ pounds.) Entities covered by the ADA must _______________ to permit miniature horses where reasonable. The regulations set out four assessment factors to assist entities in determining whether miniature horses can be accommodated in their facility. The assessment factors are (1) whether the miniature horse is ____________; (2) whether the miniature horse is _____________; (3) whether the facility can accommodate the miniature horse’s _____, __________, and __________; and (4) whether or not the miniature horse’s presence will compromise legitimate _______________ necessary for __________ of the facility.
Separate provision
24 inches to 34 inches
60 and 100 pounds
Modify their policies
Housebroken
Under the owner’s control
Type, size, and weight
Compromise legitimate safety requirements necessary for safe operation of the facility
As authorized by Florida Statute, Chapter 401.254, JFRD may provide ________ and ______of injured “police canines.” F.S. 401.254 also states, “A paramedic or an emergency medical technician who acts in ___________ to provide emergency medical care to an injured police canine (K-9) is immune from _____________.”
Under no circumstances are JFRD _________and/or______________ authorized to transport any other animal (domestic house pet, etc.) outside the scope of this specific statutory authority.
Treatment and transport
Good faith
Criminal or civil liability
Personnel and/or units
Police Canine Defined (per F.S. 401.254)
“Any canine that is _______, or the service of which is __________, by a federal, state, or local _____________, a fire __________, a special ________, or the State_________ for the principal purpose of aiding in the detection of __________activity, __________ materials, or missing ________; the enforcement of _______; the investigation of __________; or the apprehension of ______________.”
Owned
Employed
Law enforcement agency
Fire department
Special fire district
State Fire Marshal
Detection of criminal activity
Flammable materials
Missing person
Enforcement of laws
Investigation of fires
Apprehension of offenders
Transport of Injured Police Canines (K9)
Treatment
Initial priority must be given to the _____,_________,and____________ of any _____________ on the scene.
JFRD personnel must operate within these guidelines and only initiate treatment within their __________, which includes basic medical procedures such as __________administration, _________application (must be _____________), splinting, and bandaging.
The canine handler may possess additional specialized veterinary training. JFRD personnel shall allow such treatment and ____________ when necessary.
Examination, treatment, and transport
Injured persons
Scope of practice
Oxygen administration
Tourniquet application (must be high on the extremity)
May assist when necessary
When possible, the canine should be __________________ with the handler sitting ___________. The handler will place a _______________ on the dog when necessary.
The transport destination shall be selected from either of the two clinics listed below as they provide ________________ and are also __________________. As soon as _________, on-scene personnel should notify the receiving clinic of the in- bound injured canine and ________________.
• BluePearl Pet Hospital (____________ location) - 275 Corporate Way, Ste. 100 • (904) 278-0287
• BluePearl Pet Hospital (______________location) - 3444 Southside Blvd, Ste. 103 • (904) 646-1287
Secured to the stretcher
Alongside on the bench
Safety muzzle
24/7 emergency veterinarian care
Contracted by the Jacksonville Sheriff’s Office
As soon as feasible
Approximate ETA
Orange Park location
Southside location
Communications Procedures
For each _________, Fire Rescue Communications Center (FRCC) shall obtain the following information:
• __________of the incident
• ___________ emergency
• ___________of patients
• ________ and_______ of injury(s)
• Type of _________
• Complainant’s ________
• Complainant’s _________
EMS call
-Address or location of the incident
-Nature of emergency
Number of patients
Type and severity of injuries
-Type of location (house, apartment, street, or highway, etc.)
Complainant’s name
Complainant’s phone number
Using the Computer Aided Dispatch (CAD) system, the Emergency Medical Dispatcher (EMD) shall ensure dispatch of the ________ _______ ALS unit. The CAD system will display the _________ that normally responds to the listed address in _____________.
Closest available
Appropriate apparatus
Order of priority
Outside Agency Assistance
While at the scene of an emergency, personnel may request assistance from other emergency response agencies (Air Transport Unit, law enforcement, etc.) by contacting FRCC via _______or________ . FRCC will forward the request to the appropriate agency and advise on-scene personnel of the______________________and ___________________.
Via radio or telephone
Disposition of the request and ETA of the required agency
Pre-hospital Procedures
Upon arrival at the location of the incident, the EMT or Paramedic shall assess the condition of each trauma patient using the Trauma Scorecard Methodology as outlined in F.A.C. 64J-2.004 for _______ and F.A.C. 64J-2.005 for __________ to determine if the patient meets “Trauma Alert” criteria. ________ of trauma patients shall be determined by this assessment.
Adults
Pediatrics
Transport destination
Assessing ADULT Trauma Patients:
The EMT or Paramedic shall assess all adult trauma patients using the following Trauma Scorecard Methodology in the ______________. If any ONE of the following conditions is identified, the patient shall be considered a trauma alert patient:
• Airway – The patient receives ___________ beyond the administration of O2
• Circulation –
• The patient lacks a ___________ with a sustained heart rate greater than ____ beats per minute
• Has a_________ blood pressure of less than ___ mmHg
• Best Motor Response (BMR) – The patient exhibits a score of ______or less on the
______ assessment component of the Glasgow Coma Scale
• Spinal – There is the presence of __________; or loss of _________; or there is the
suspicion ______________
• Cutaneous –
• The patient has ___ or ____ degree burns to _____ or more of total body surface area
• Amputation proximal to the _______or_______
• Any ___________- injury to the _________________(excluding superficial wounds
where the depth of the wound can be determined)
• Long bone Fracture – The patient reveals signs or symptoms of ____or more long bone fracture sites (humerus, radius, ulna, femur, tibia, or fibula)
In the order presented
Active airway assistance
Radial pulse
GREATER THAN 120 beats per minute
Systolic blood pressure of LESS THAN 90 mm Hg
Four OR LESS on the motor assessment component of GCS
Presence of paralysis, or loss of sensation, or there is suspicion of a spinal cord injury
2nd or 3rd degree burn to 15% OR MORE
Proximal to the wrist or ankle
Penetrating injury to the head, neck, or torso
2 OR MORE long bone fracture sites
Assessing ADULT Trauma Patients
Considered a trauma alert patient when any TWO of the following conditions are identified:
• Airway – The patient has a respiratory rate of _______or greater
• Circulation – The patient has a sustained heart rate of _____ beats per minute or greater
• BMR – The patient has a BMR of ___ on the motor component of the Glasgow Coma
Scale
• Cutaneous –
• The patient has a soft tissue loss from either a ________ injury or a major flap
avulsion greater than ______inches
• Sustained a __________ to the extremities of the body
• Long bone Fracture –
• The patient reveals signs or symptoms of a __________ fracture resulting from a________
• Fall from an elevation of ___feet or greater
• Age – The patient is____years of age or older
• Mechanism of Injury –
• The patient has been ejected from a motor vehicle (excluding any _______, moped, _________, bicycle, or the _____________)
• The driver of the motor vehicle has impacted with the steering wheel causing ____________
30 OR GREATER
120 beats per minute OR GREATER
BMR of 5 on the motor component
Major degloving injury
Flap avulsion GREATER THAN 5 inches
Gunshot wound to the extremities
Single long bone fracture resulting from a motor vehicle collision
10 feet OR GREATER
55 years of age OR OLDER
Motorcycle, all terrain vehicle, open body of a pickup truck
Causing steering wheel deformity
If, after evaluating the patient using the previous criteria, the patient is not identified as a trauma alert patient, they will be evaluated using all elements of the ________________. If the patient’s score is __________, the patient shall be considered a trauma alert patient (excluding patients whose normal Glasgow Coma Scale Score is 12 or less, as established by the patient’s _____________ or preexisting medical __________when known).
If the patient meets none of the aforementioned trauma alert criteria, the EMT or Paramedic can call a trauma alert if, in his or her judgment, the patient’s condition warrants such action. Where EMT or Paramedic judgment is used as the basis for calling a trauma alert, it shall be _________ as required in section F.A.C. 64J-2.002(5).
Glasgow Coma Scale
12 OR LESS
Medical history
Condition
Documented
Assessing PEDIATRIC Trauma Patients:
Trauma patients with the anatomical and physical characteristics of a person _________years of age or less will be assessed as pediatric patients using the following Trauma Scorecard Methodology. If any ONE of the following conditions are identified, the patient shall be considered a pediatric trauma alert patient:
• Airway – In order to maintain _________________, the patient is _________; or the patient’s breathing is _______ through such measures as ______________,______suction , or through the use of____________ to assist ventilatory efforts
• Circulation –
• The patient has a faint or non palpable _________ or _______ pulse
• The patient has a ________ blood pressure of less than ____ mmHg
• Consciousness – The patient exhibits _____________ that includes _____, __________, the inability to __________, unresponsiveness to ________, totally ______________, or is in ________
• Spinal – There is the presence of _________; or loss of________; or there is the suspicion of__________
• Fracture – There is evidence of __________ (humerus, radius, ulna, femur, tibia, or fibula) fracture; or there are multiple __________ or multiple __________ (except for isolated_________ or _______ fractures or dislocations)
• Cutaneous –
• The patient has a major soft tissue disruption including ___________ injury or
___________
• ____ or _____ degree burns to ____ or more of the total body surface area
• Amputation proximal to the _______or______
• ____________ injury to the head, neck, or torso (excluding superficial wounds where
the depth of the wound can be determined)
Fifteen years of age OR LESS
Maintain optimal ventilation
Intubated
Assisted
Manual jaw thrust, continuous suctioning, other adjuncts
Faint or non-palpable carotid or femoral pulse
Systolic blood pressure of LESS THAN 50 mm Hg
An altered mental status
Drowsiness, lethargy, the inability to follow commands, unresponsiveness to voice, totally unresponsive, or is in a coma
Paralysis, sensation, spinal cord injury
An Open long bone fracture, multiple fracture sites or multiple dislocations
Wrist or ankle
Major degloving injury or major flap avulsion
2nd or 3rd degree burns to 10% OR MORE
Proximal to the wrist or ankle
Penetrating injury to the head, neck, or torso
Assessing PEDIATRIC Trauma Patients
Considered a pediatric trauma alert patient when any TWO of the following conditions are identified
• Consciousness – The patient exhibits symptoms of _________; or there is _____________
• Circulation –
• The __________or__________pulse is palpable, but the ________or_______ pulses are not
palpable
• The _______ blood pressure is less than _____ mmHg
• Fracture – The patient reveals signs or symptoms of a ___________ fracture (does not include isolated _______or______ fractures)
• Size – Pediatric trauma patients weighing ______ kilograms or less, or the body length is equivalent to this weight on a ____________ tape (the equivalent of ____ inches in measurement or less)
If the patient meets none of the aforementioned trauma alert criteria, the EMT or Paramedic can call a trauma alert if, in his or her judgment, the patient’s condition warrants such action. Where EMT or Paramedic judgment is used as the basis for calling a trauma alert, it shall be ________ as required in section F.A.C. 64J-2.002(5).
Amnesia
Loss of consciousness
Carotid or femoral
Radial or pedal
Systolic blood pressure is LESS THAN 90 mm Hg
Single closed long bone fracture
Wrist or ankle
11 kilograms OR LESS
Pediatric length and weight emergency tape
33 inches in measurement OR LESS
Documented
Issuing a Trauma Alert:
Upon determining that a trauma patient meets either Adult or Pediatric Trauma Scorecard Methodology, that patient will be classified as a “Trauma Alert” patient. JFRD personnel will issue a trauma alert using the words “_____________,” state the_______, and announce the _______. ________shall notify the State-Approved Trauma Center (SATC), State-Approved Pediatric Trauma Center (SAPTC), or receiving hospital that they will be receiving a “Trauma Alert” patient.
_______________ or _______________________, are the only people authorized to change the trauma alert status, as documented in F.A.C. 64J-2.002(5).
“Trauma Alert”
State the criteria
Announce the destination
FRCC
The Medical Director of the EMS provider issuing the trauma alert
The physician at the receiving trauma center or hospital
Documentation of Trauma Patients
JFRD personnel will provide required trauma information to the receiving facility in accordance with F.A.C. 64J-2.004 for _________ and F.A.C. 64J-2.005 for ______________, and F.A.C. 64J-2.002(5).
A ___________________ will be completed as required in F.A.C. 64J-1.014 (3).
Adults
Pediatrics
JFRD EMS patient care record
Transporting to SATC or SAPTC
_______ patients meeting Adult or Pediatric Trauma Scorecard Methodology will be transported by______________ transport to a SATC or SAPTC nearest to the location of the incident
When the _________or _____________ deems that rapid transport is necessary (e.g., distance, severity of injury, traffic conditions, etc.), _______________ unit should be considered.
All
JFRD ground transport
Officer in charge or Incident Commander
An air transport unit
Receiving Facilities
A receiving facility is one which is identified in these guidelines and which meets the requirements of F.A.C. 64J-2.002.
• State-Approved Trauma Centers (SATC)
• ____________ Jacksonville
• ____________Hospital
• _____________Medical Center
• State-Approved Pediatric Trauma Centers (SAPTC)
• ______________ Jacksonville
• ___________Hospital
UF Health Hospital Jacksonville
Memorial Hospital
Orange Park Medical Center
UF Health Hospital Jacksonville
Wolfson Children’s Hospital
Transporting to Other Than SATC or SAPTC
A trauma alert patient may be transported to a receiving facility other than a SATC or SAPTC under the conditions listed below. Such variances must be documented in ____________ in the “______ section of the __________Tab.” Under “_____________” select “____________.”
• Transport to a SATC or SAPTC is ___________ due to __________ events (MCI, natural disaster, or another catastrophic event, etc.)
• The patient’s immediate condition is such that the patient’s life may be endangered if care is ______ by proceeding directly to a SATC or SAPTC
• If, after __________ patient of the _________guidelines, the patient _____________ on transport to another facility, transport will proceed according to ______________.
• In this rare circumstance, ______________ with the appropriate _______________ must occur
• In the ____________________, document that the __________________ protocols
were explained to the patient, the patient ____________ understanding of the protocols and _______________ to the trauma center
Emergency-Pro
Trauma section of the Incident Tab
Trauma Protocol Exception
Yes
Impractical due to unforeseen events
Delayed
Informing
State
Still insists
Patients wishes
Immediate consult with the appropriate District/Battalion Rescue Chief
Narrative of the PCR
JFRD Trauma Transport Protocols
Verbalized understanding
Refused transport
Adult Glasgow Coma Scale
EVM 456
Eye Opening
4-____________
3 -To________
2-To______
1-None
Best Verbal Response
5-_________
4-__________
3-_________words
2-_________sounds
1-None
Best Motor Response
6-__________
5-_________
4-_________
3- Abnormal__________
2- Abnormal__________
1-None
Eye Opening
4-Spontaneous
3-To Speech
2-To Pain
1-None
Best Verbal Response
5-Oriented
4-Confused
3-Inappropriate words
2-Incomprehensible sound
1-None
Best Motor Respons
6-Obeys
5-Localizes
4-Withdraws
3-Abnormal flexion
2-Abnormal extension
1-None
Adolescent Glasgow Coma Scale
EVM 456
Eye Opening
4-____________
3 -To________
2-To______
1-None
Best Verbal Response
5-_________
4-__________
3-_________words
2-_________sounds
1-None
Best Motor Response
6-__________
5-_________
4-_________
3- Abnormal__________
2- Abnormal__________
1-None
Eye Opening
4-Spontaneous
3-To Speech
2-To Pain
1-None
Best Verbal Response
5-Oriented
4-Confused
3-Inappropriate words
2-Incomprehensible sound
1-None
Best Motor Respons
6-Obeys
5-Localizes
4-Withdraws
3-Abnormal flexion
2-Abnormal extension
1-None
Child Glasgow Coma Scale
EVM 456
Eye Opening
4-_____
3-To____
2-To______
1-None
Best Verbal Response
5-____, _____
4-________
3-______words
2-______words or _____sounds
1-None
Best Motor Response
6-______ ______
5-_____ _____ stimulus
4-_____in response to______
3-_____in response to _____
2-______in response to______
1-None
Child Glasgow Coma Scale
EVM 456
Eye Opening
4-Spontaneous
3-To speech
2-To pain
1-None
Best Verbal Response
5- Oriented, appropriate
4-Confused
3-Inappropriate words
2-Incomprehensible words or nonspecific sounds
1-None
Best Motor Response
6-Obeys commands
5-Localizes painful stimulus
4-Withdraws in response to pain
3-Flexion in response to pain
2-Extension in response to pain
1-None
Infant Glasgow Coma Scale
EVM 456
Eye Opening
4-_____
3-To_____
2-To_____
1-None
Best Verbal Response
5-_____and_____
4-_____, _____
3-_____in response to pain
2-_____ in response to pain
1-None
Best Motor Response
6-Moves ____and______
5-______in response to ______
4-_____in response to_____
3-Abnormal ______in response to _____
2-Abnormal ________in response to _____
1-None
Infant Glasgow Coma Scale
EVM 456
Eye Opening
4-Spontaneous
3-To speech
2-To pain
1-None
Best Verbal Response
5-Coos and babbles
4- Irritable, cries
3-Cries in response to pain
2-Moans in response to pain
1-None
Best Motor Response
6-Moves spontaneously and purposely
5-Withdraws in response to touch
4-Withdraws in response to pain
3-Abnormal flexion in response to pain
2-Abnormal extension in response to pain
1-None
Trauma Arrest
TREATMENT
• __________ and examine patient to perform a complete assessment
• Maintain _________
• Increase _________ in patient compartment and consider __________
• The Lucas Device is ____________in trauma
• Control __________
• Penetrating chest trauma
• _________________ procedure (Appendix J) on ____________side(s)
• Refer to appropriate medical _____________ and _______________ guidelines
• Provide ___________________ if indicated
Expose and examine
Maintain body warmth
Increase temperature
Consider warm IV fluids
Needle decompression procedure
Affected side(s)
Medical cardiac arrest and advanced airway guidelines
Spinal immobilization
If patient does not meet unquestionable death criteria as listed in Guideline 1130, follow this guideline.
Trauma Arrest guideline
Multi-System Trauma
Patients with ____________ involvement may deteriorate rapidly, _________ is a priority.
TREATMENT
• __________ and examine patient to perform a complete assessment
• Maintain body _______
• Increase _________ in patient compartment and consider __________fluids
• Provide ___________
• Infants and children less than ______ lbs., use ___________
• Airway/breathing management
• Administer O2 via __________ to maintain adequate oxygen saturation of ___% or
greater
• Tension pneumothorax
• ______________ procedure (Appendix J)
• Refer to Advanced Airway Guideline 9020 as indicated
• Consider __________________ (Appendix N) for pelvic fractures
• _____________ impaled objects in place unless the object must be removed to _______the______
• Control ___________
• Bleeding from the nose and/or ears should ___________, but a __________ should
be placed over the nose and/or ears
• Initiate cardiac monitoring
• Establish IV/IO Access
• Up to _____mL/kg intravenous fluids to achieve ________ BP of _____ mmHg; maximum ____L
• Therapeutic goal is _________mm/Hg
• If IO used for access, the _________ is the preferred site
• Determine Blood Glucose Level
Multi-system trauma
Load and go
Expose
Warmth
Increase Temperature
Warm IV Fluids
PROVIDE spinal immobilization
LESS THAN 60 lbs
Pedi-Immobilizer
Proper adjunct
95% OR GREATER
Needle decompression
SAM pelvic splint
Immobilize
Stabilize the airway
Bleeding
Should not be stopped
Sterile dressing
UP TO 20mL/kg
Systolic BP of 90 mm Hg; maximum 2L
Systolic 90 mm Hg
Humerus
Head Trauma
TREATMENT
• Maintain body warmth
• Provide spinal immobilization _____________ (Appendix ____)
• Infants and children less than ____ lbs., use Pedi-ImmobilizerTM
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9020 as indicated
• The head injured patient with a ______________ is more likely to suffer airway compromise than the standard trauma patient
• Immobilize impaled objects in place unless the object must be removed to stabilize the airway
• Control bleeding
• Bleeding from the nose and/or ears should not be stopped, but a sterile dressing should
be placed over the nose and/or ears
• Establish IV/IO Access
• Up to ___mL/kg intravenous fluids; maximum ____L
• It is ___________ to avoid __________ in a head trauma patient
• Initiate cardiac monitoring
• Determine Blood Glucose Level
• _____________helmets should be removed
• Sporting helmet removal
• The ____________should always be removed for airway access
• Helmet and shoulder pads should be left in place except in the following situations:
• Helmet in place and no __________
• __________ trauma
• __________ cannot be removed
• _____________ regions are unstable because the helmet fits_________
• ____________cannot be achieved with just face mask removal
• Patient is in ___________ (requires removal of __________)
• If the helmet is removed, the shoulder pads also need to be removed. It is an “_____________” principle
• Refer to Appendix _____for Sports Helmet Removal Procedure
If indicated
Appendix O
LESS THAN 60 lbs
Decreased LOC
UP TO 20mL/kg intravenous fluids; maximum 2L
Critically important to avoid hypotension
Protective helmets
Face mask
No shoulder pads
Head/facial trauma
Face mask
Cervical/spinal
Fits poorly
Airway management
Cardiac arrest
Shoulder pads
“All or nothing”
Appendix Q
Spinal Trauma
In cases of ____________ spinal injuries, ______ is less critical and care should be taken in performing proper spinal immobilization.
TREATMENT
• Provide spinal immobilization ___________(Appendix _______)
• Expose and examine patient to perform a complete assessment
• Maintain body warmth
• Protective (e.g., motorcycle, bicycle) helmets should be removed
• Sporting helmet removal
• The face mask should always be removed for _________
• Helmets and shoulder pads should be ________ except in the following situations:
• Helmet in place and no shoulder pads
• Head/facial trauma
• Face mask cannot be removed
• Cervical/spinal regions are ________ because the helmet fits poorly
• Airway management cannot be achieved with just face mask removal
• Patient is in cardiac arrest (requires removal of shoulder pads)
• If the helmet is removed, the shoulder pads also need to be removed. It’s an “all or nothing” principle
• Refer to Appendix _____for Sports Helmet Removal Procedure
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• ___________ injury may cause _______
• Refer to Advanced Airway Guideline ______ as indicated
• Consider SAM pelvic splint (Appendix N) for pelvic fractures
• Establish IV/IO Access
• Up to ___ mL/kg intravenous fluids; maximum ___L
• If IO used for access, the humerus is the preferred site
• If _________ persists after _____L and ____________ shock is suspected, administer
________________ mcg/kg/min IV/IO
• Contraindications
• ___________ shock
• _____/______ with ______(Rhythm)
• ________(Rhythm)
• Initiate cardiac monitoring
• Immobilize impaled objects in place unless the object must be removed to stabilize the airway
Isolated spinal injuries, scene time
If indicated(Appendix O)
Airway access
Left in place
Unstable
Appendix Q
High cervical injury may cause apnea
Advanced airway guideline 9020
UP TO 20mL/kg maximum 2L
Hypotension persists after 1L and neurogenic shock is suspected
Dopamine 5-10 mcg/kg/min IV/IO
Hypovolemic shock
A-Fib/A-Flutter with RVR
V-Tach
Chest Trauma
Chest Trauma patients may deteriorate rapidly. Load and go is a priority.
TREATMENT
Expose and examine patient to perform a complete assessment
Maintain body warmth
Transport to a Trauma Center when __________, severe ___________, __________, respiratory ________, or decreased _________ are present. __________patients on ___________ should also be transported to a Trauma Center
• Consider Trauma Alert based on __________
Provide spinal immobilization if indicated (Appendix O)
Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9020 as indicated
Immobilize impaled objects in place
Control bleeding
Treatments based on injuries:
• Sucking Chest Wound
• Apply ____________________ if available (currently contained in the ________________ Bags carried in _______________vehicles)
• Otherwise, apply _______________dressing(s) to cover the wound(s)
• Cover the occlusive dressing with ___________
• Tape the dressing on _________ sides
• Tension Pneumothorax
• _____________ or ___________breath sounds with severe ____________or signs/symptoms of tension pneumothorax such as _________, ____________, and _________
• Needle decompression procedure (Appendix ______)
Establish IV/IO Access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Therapeutic goal is Systolic 90 mm/Hg
• If IO used for access, the humerus is the preferred site
Initiate cardiac monitoring
Discoloration, severe tenderness, crepitus, respiratory distress, or decreased breath sounds are present
Elderly patients on anti coagulants
EMT/Paramedic judgement
Vented Halo chest seal
Advanced Trauma Care Bags carried in all Field Chief vehicles
Vaseline-type occlusive dressings
Sterile 4x4s
Three sides
Unilateral absent or decreased breath sounds WITH severe respiratory distress
Hypotension, Tachycardia, and hypoxia
Appendix J
Chest Trauma patients may ___________. ___________ is a priority.
Deteriorate rapidly
Load and go
___________________ is the most important indicator of abdominal trauma. The best treatment for the patient with severe abdominal trauma is ________________.
Mechanism of injury
Rapid transport
Abdominal Trauma
TREATMENT
Expose and examine patient to perform a complete assessment
Maintain body warmth
Transport to a Trauma Center when:
• _______ and/or ____________ are present
• Patient is ___________ and on ______________
Consider Trauma Alert based on EMT/Paramedic judgement
Provide spinal immobilization if indicated (Appendix O)
Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9020 as indicated
Immobilize impaled objects in place
Control bleeding
Refer to Hemorrhage Control Guideline 2140 if applicable for uncontrolled hemorrhage
• Apply _______________ if available (currently contained in the __________________Bags carried in_________ vehicles) for _____________hemorrhage
Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Therapeutic goal is Systolic 90 mm/Hg
• If IO used for access, the humerus is the preferred site
Initiate cardiac monitoring
Abdominal Evisceration
• Never __________abdominal viscera
• Cover with _________ and __________ with __________ fluid (may need to periodically _________)
• ______________ dressing in place if possible
Discoloration AND/OR severe tenderness
Elderly AND on anticoagulants
Hemostatic gauze
Advanced Trauma Care Bags carried in ALL FIELD Chief vehicles
Life-threatening hemorrhage
Never replace abdominal viscera
Sterile dressing and moisten with Intravenous fluid
Periodically remoisten
Secure the wet dressing in place if possible
Trauma Pregnancy
Signs and symptoms of shock may be ________ due to ____________________.
Delayed due to increased maternal blood volume
Trauma Pregnancy
TREATMENT
Expose and examine patient to perform a complete assessment
Maintain body warmth
Provide spinal immobilization if indicated (Appendix O)
• Immobilizing a pregnant patient greater than ________weeks may cause __________
syndrome from pressure on the __________ and may also impair ________ as the fetus and the uterus press against the __________
• After immobilization is__________ and patient is _________, elevate the patient’s __________
of the LSB _______________inches. This will displace the uterus and fetus to the ______
side and off of the inferior vena cava
• If the long spine board (LSB) cannot be elevated, ______________ the uterus to the
_________ as much as possible without _______________ and maintain this displacement throughout _____
Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9020 as indicated
Immobilize impaled objects in place
Control bleeding
Refer to Hemorrhage Control Guideline 2140 if applicable for uncontrolled hemorrhage
• Apply _______________ if available (currently contained in the Advanced Trauma
Care Bags carried in all field chief vehicles) for ___________hemorrhage
Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Therapeutic goal is Systolic 90 mm/Hg
• If IO used for access, the humerus is the preferred site
Initiate cardiac monitoring Determine Blood Glucose Level
Greater than 20 weeks
Supine Hypotension Syndrome
Inferior Vena Cava
Ventilation
Diaphragm
Complete and the patient is secure
Right side of the LSB approximately 6 inches
Left side
Manually displace
Left as much as possible without causing spinal movement
Throughout the transport
Hemostatic gauze
Life threatening hemorrhage
_______________Trauma
This guideline does NOT apply to a multi-system trauma patient
Extremity Trauma
Extremity Trauma
TREATMENT
• Expose and examine patient to perform a complete assessment
• Maintain body warmth
• Transport to a Trauma Center when__________ are present
• Provide spinal immobilization if indicated (Appendix ___)
• Infants and children less than 60 lbs., use Pedi-ImmobilizerTM
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider SAM pelvic splint (Appendix N) for pelvic fractures
• Immobilize impaled objects in place
• Control bleeding
• Splint all areas of tenderness or deformity
• May consider pain management prior to patient _______or ________.
• Splint ___________ and _________ injuries in the position found
• Consider _________ to reduce _______ and _______
• Reduce fractures (_______or ______) by ____________ if absence of _________________
• Consider traction splint for presumed _________ fracture
• __________ the extremity when practical
• __________, __________, and __________ distal pulses before and after ____________. ___________ and
__________ before and after splinting
• Amputation
• Place the amputated part in __________, ___________ with intravenous fluids
• Keep amputated part __________
• Dress and splint partial amputations in __________ with the extremity, being careful to
avoid ____________
• Do not __________
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Therapeutic goal is Systolic 90 mm/Hg
• If IO used for access, the humerus is the preferred site
• Assess patient for injuries and provide pain management, if appropriate
• Adult and pediatric, _____________mcg/kg (Maximum single dose ________ mcg) _______only
• May be repeated every _______ minutes
• Total maximum dose _______mcg
• Contraindications
• ___________ (systolic blood pressure ______________ mmHg)
• ______________
• Precaution
• Rapid administration may cause ________________
Open fractures
Appendix O
Prior to patient movement or splinting
Dislocations and joint injuries
Ice pack to reduce swelling and pain
Open or closed by axial traction
Distal pulses
Femur fracture
Elevate
Locate, mark, and monitor
Splinting
RECORD Sensation and motor function
Sterile gauze, moisten
Cool
In alignment with the extremity
Avoid torsion
Do not clamp vessels
Fentanyl 1 mcg/kg (Maximum single dose 100mcg)
SLOW IVP Only
Every 5-10 minutes
200 mcg
Hypotension (Systolic BP less than 90 mmHg)
Respiratory depression
Chest wall rigidity
Crush injury
The patient’s____________ status, total amount of ________________, ___________of the entrapment and __________of the object dictate the extent of the symptoms. Crush injury is to be distinguished from a _____________________.
Patients overall health status
Total amount of entrapped body surface area
Length of the entrapment
Weight of the object
Simple entrapment
Crush Injury
TREATMENT
Expose and examine patient to perform a complete assessment
Maintain body warmth
Provide spinal immobilization if indicated (Appendix O)
Airway/breathing management
Control bleeding
Initiate cardiac monitoring
• Perform __________. The receiving hospital must receive a _______ of the 12 lead ECG
Establish IV/IO access
• Adult - _____mL/kg IV/IO intravenous fluids; maximum __L
• Include _______mEq/kg of ________________with the initial _______of intravenous fluid ________to removing the compressive force
• If IO used for access, the humerus is the preferred site
• Pediatric – _____mL/kg IV/IO intravenous fluids; maximum ___L
• Include ___mEq/kg of __________ (Maximum dose ____mEq) with the initial ________ of intravenous fluid ______to removing the compressive force
• Life threatening _________, _____________waves or ____________complex
• ________________ mg/kg (Maximum dose ______mg) IV/IO over _______minutes
• Precaution
• Possible ___________ when mixed with ________
• Administer additional bolus of _______________ IV/IO
• Adult - ____mEq/kg of ___________
• Pediatric - __ mEq/kg of ___________ (Maximum dose ______mEq
• Adult and pediatric pain management
• _________ ______ mcg/kg (Maximum single dose ______ mcg). ______only
• May be repeated every _____ minutes
• Total Maximum dose _______ mcg
• Contraindications
• ___________ (systolic blood pressure less than ______mmHg)
• ____________
• Precaution
• Rapid administration may cause ___________
Perform 12 lead ECG
Hard copy
**20mL/kg IV/IO intravenous fluids; max 2L
Include 1 mEq/kg of Sodium Bicarbonate with the initial liter of IV fluid PRIOR to removing the compressive force
**20mL/kg IV/IO intravenous fluids; maximum 2L
Include 1 mEq/kg of Sodium Bicarbonate (maximum dose 50 mEq) with the initial liter of intravenous fluids PRIOR to removing the compressive force
Life threatening dysrhythmias, peaked T waves, or widening QRS complex
Calcium chloride 5 mg/kg
Maximum dose 500 mg
IV/IO over 2 minutes
Possible crystallization when mixed with Sodium Bicarbonate
Sodium Bicarbonate IV/IO
1 mEq/kg of Sodium Bicarbonate
1 mEq/kg of Sodium Bicarbonate (maximum dose 50 mEq
Fentanyl 1 mcg/kg (maximum single dose 100mcg) SLOW IV/IO only
May be repeated every 5-10 minutes
Total maximum dose 200 mcg
Hypotension (systolic blood pressure less than 90mm Hg)
Respiratory depression
May cause chest wall rigidity
Patient Transport
• The patient should be transported to the hospital if any of the following underlying circumstances apply:
• History of delirium, mania, or irrational bizarre behavior ___________ being tased
• Abnormal ________
• History or physical findings consistent with ____________ or __________ drug use
• Cardiac history
• Altered _________________ or _________________, violent behavior including resistance to
evaluation
• Evidence of ________________
• JSO _________ or _____________to remove probe(s)
• Any patient that meets the ________________criteria
TREATMENT
Provide spinal immobilization if indicated
Airway/breathing management
Immobilize impaled objects in place unless the object must be removed to stabilize the
airway
Control bleeding
Initiate cardiac monitoring
Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
Determine ___________ Level
Before being tased
Abnormal vital signs
Amphetamine or hallucinogenic drug use
Altered level of consciousness or aggressive, violent behavior
Evidence of hyperthermia
JSO unable or unwilling to
JFRD transport criteria
Blood glucose level
Rule of Nines
Torso
Adult-____
Toddler-____
Infant-_______
Arms
Adult-____
Toddler-____
Infant-______
Groin
Adult-____
Toddler-____
Infant-____
Head
Adult-______
Toddler-_____
Infant-_______
Legs
Adult—_____
Toddler-______
Infant-________
Rule of Nines
Torso
Adult- 18% front 18% back
Toddler-18% front 18% back
Infant-18% front 18% back
Arms
Adult- each arm 9%
Toddler-each arm 9%
Infant-each arm 9%
Groin
Adult-1%
Toddler-1%
Infant-1%
Head
Adult-9%
Toddler-18%
Infant-18%
Legs
Adult-each leg 18%
Toddler-each leg 13.5%
Infant-each leg 13.5%
Burns
Burns are classified according to_______and _______. Use the ________ or the “______________” (________________ is 1% of body surface area) to estimate burn area.
ASSESSMENT
Burn Trauma Alert Criteria: • Adult
• _____________burns equal to or greater than ______%of the BSA
• Pediatric
• _________burns equal to or greater than ____% of the BSA
According to type (Thermal, Electrical, and Chemical) and thickness
Rule of Nines or the “palm of hand method” (palm of the patient’s hand is 1% of body surface area)
Partial/full thickness (2nd/3rd degree) EQUAL TO OR GREATER THAN 15%
Partial/full thickness (2nd/3rd degree) EQUAL TO OR GREATER THAN 10%
Burns
TREATMENT
• Expose and examine patient to perform a complete assessment
• Maintain body warmth
• Airway/breathing management
• Patients with known ____________injury or with signs of potential _________ burns who are in
________ _______ should be ____________early to prevent airway collapse
• Initiate cardiac monitoring
• Establish IV/IO Access
• For _________ thickness (_____ degree) burns GREATER THAN OR EQUAL TO______% body surface area (BSA), ____mL/kg intravenous fluids; maximum ___L
• Remove all _________, ________ or _________ items from the burned area unless __________to the _______.
• Request __________ when appropriate
• Treatment
• __________ burns (not involving ________, ___________ Acid, ___________ Acid, Solid ___________ or
______________ metals)
• __________ with intravenous fluid for ________minutes
• Chemical burns involving ______, ___________ Acid, ________ Acid, Solid ________ or _________ metals
• Do not ________wounds with ________, ___________ fluids, sterile __________, etc.
• Contact ____________ for treatment
• _____________ burns
• Apply ________ if needed
• ______________ burns
• Apply __________ dressing(s)
• Leave _______intact
• Adult and pediatric pain management
• ________________ mcg/kg (Maximum single dose ____ mcg). ______________ only
• May be repeated every ________ minutes
• Total maximum dose _____ mcg
• Contraindications
-____________
-_____________
• Precaution
• ______________ may cause chest wall rigidity
Known inhalation injury or with signs of potential airway burns
Respiratory distress should be intubated early
partial/full thickness (2nd/3rd degree) burns GREATER THAN OR EQUAL TO 20% body surface area (BSA)
***2mL/kg intravenous fluids; maximum 2L
Clothing, jewelry, or constricting items
Unless adhered to the patient
HAZMAT Team
Lime, Carbolic Acid, Sulfuric Acid, Solid Potassium or Sodium metals
Irrigate with IV fluid for 20 minutes
Lime, Carbolic Acid, Sulfuric Acid, Solid Potassium or Sodium metals
Do not flush wounds with water, IV fluids, sterile water, etc.
Receiving physician
Superficial burns
Burn gel dressing
Partial-thickness/full thickness
Dry, sterile dressings
Leave blisters intact
Fentanyl 1-2 mcg/kg (maximum single dose 100 mcg) SLOW IV/IO only
May be repeated every 5-10 minutes
Maximum dose 400 mcg
Hypotension
Respiratory depression
Rapid administration
Electrical Trauma
______ experiences more lightning strikes than any other state in the nation, which increases the risk of exposure to ___________injuries.
Florida
Electrical injuries
Electrical Trauma
TREATMENT
• Expose and examine patient to perform a complete assessment
• Maintain body warmth
• Provide spinal immobilization if indicated
• Airway/breathing management
• Initiate cardiac monitoring
• Perform ___________. The receiving hospital must receive a ________ of the 12 lead
ECG
• Establish IV/IO Access
• ***20 mL/kg intravenous fluids; maximum 2L
• On _____________ scenes where there are multiple patients, __________ shall be applied
and patients in cardiac arrest shall be worked ___________
• Assess patient for injuries and provide pain management, if appropriate
• _____________mcg/kg (Maximum single dose ___ mcg) ___________ only
• May be repeated every _______minutes
• Total Maximum dose_______ mcg
• Contraindications
•______________
•______________
• Precaution
• _____________________ may cause chest wall rigidity
12 lead ECG
A hard copy
Lightning strike scenes
Reverse triage
First
Fentanyl 1-2 mcg/kg
Maximum single dose 100 mcg
SLOW IV/IO Only
5-10 minutes
Total maximum dose 400mcg
Hypotension
Respiratory depression
Rapid administration
Eye Trauma
TREATMENT
• Airway/breathing management
• Immobilize impaled objects in place unless the object must be removed to stabilize the airway
• Transport to a Trauma Center when ____________trauma is present
• Remove ___________ when applicable
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess nature of ophthalmologic emergency
•
________ Trauma
• Patch _________gently without __________ to the _______
• Maintain patient in _________position to reduce _____of_________ from the eye
• If blood is noted in _______________, place the patient in ________
• _________ any impaled object and _______________
• __________ for patient comfort
• ________/________ Exposure
• ________-___drops to each eye before and after __________
• May be repeated every _____minutes •
Contraindications
• _________trauma
• Irrigate __________with intravenous fluids during ________
• Apply _________dressings to both eyes
• Dim lights for ___________
• Atraumatic
•____________gently without pressure to the globes
• Dim lights for patient comfort
Penetrating eye trauma
Remove contact lenses when applicable
Direct trauma
Patch both eyes gently without pressure to the globes
Supine position
Reduce leakage of fluids from the eye
Anterior chamber, place the patient in semi-Fowler’s
Stabilize any impaled object and cover both eyes
Dim lights for patient comfort
Chemical/Irritant Exposure (e.g., pepper spray, tear gas)
Tetracaine 2 drops to each eye before and after irrigation
Every 10 minutes
Open ocular trauma
Affected eye
During transport
Dry, sterile dressings
Patient comfort
Patch both eyes
______________and ______________ of hemorrhage can mean the difference between life and death.
Early and aggressive management
JFRD STEMI ALERT POLICY
CRITERIA #1
Zoll _________ or _________ message
CRITERIA #2
The patient has symptoms consistent with ______________syndrome such as active /recent _______/____________, unexplained _______________, unexplained _____________, ____________, near-____________, _____________, _____________or ___________ and/or ____________ AND also has 12 lead ECG with a ______mm or greater ST Segment elevation present in at least ______________________leads performed by JFRD.
If the patient meets either of the above criteria:
• Identify a STEMI approved hospital destination
• See most recent Hospital Capabilities Chart for JFRD
• Notify FRCC of “___________,” destination and ETA
• Transmit 12 lead ECG to receiving facility with the _____________entered
• Other ______________ or ____________ECGs may also be transmitted
Zoll ACUTE MI or STEMI message
An Acute Coronary Syndrome
Chest pain/discomfort, unexplained difficulty breathing, unexplained weakness, syncope, near syncope, dizziness, diaphoresis, or nausea and/or vomiting AND
2mm OR GREATER AT LEAST Two anatomically contiguous leads
“STEMI Alert”, destination, and ETA
Patients name
Life threatening or questionable
Chest Pain
TREATMENT
• Vitals should be obtained before and in between each administration of nitroglycerin
• If life-threatening arrhythmias are present, refer to appropriate guideline
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. Repeat as necessary if pain persists despite interventions, cases
of clinical deterioration, or ECG changes
• The receiving hospital must receive a hard copy of any 12 lead ECG that is
performed. The patient’s name must be entered on the ECG
• No medications except O2 and aspirin should be given prior to the completion of the 12
lead ECG
• In the presence of Inferior STEMI (ST elevation in leads II, III, aVF), consider performing
V4R (Appendix C). However, do not delay transport
• Establish IV access
• In the setting of Inferior STEMI, initiate 20 mL/kg intravenous fluids prior to considering
NTG; maximum 2L • Treatment situations:
• Patients presenting with chest pain should receive Aspirin unless contraindicated or
previously taken within 2 hours
• Aspirin 324 mg PO
• Pregnancy patients will only be given ASA in the presence of a STEMI
• Contraindications
• Allergies to salicylates
• Active GI bleeding
• Aspirin 81 mg PO
• History of GI bleeding
• Use of anticoagulants
• Normotensive (SBP>100 mmHg) and evidence of Acute Coronary Syndrome
• First dose of NTG can be given without IV access when systolic >140 mmHg
• Additional doses of NTG require IV access
• NTG 0.4 mg SL every 5 minutes until pain is resolved or systolic BP drops below
100 mmHg
• Contraindications
• Systolic BP less than 100 mmHg
• Hypovolemia
• Precaution
• Consider withholding for patients 30 years of age and younger without Acute Coronary Syndrome symptoms
• In the setting of an Inferior MI (ST elevation in leads II, III, aVF), NTG administration may result in hypotension
• If hypotension develops be prepared to administer a fluid challenge and elevate the patient’s legs. Patient must be closely monitored
• A drop in the systolic BP of 20 mmHg or more, consider withholding repeat doses
• If the patient has used erectile dysfunction medications (Viagra, Levitra, Cialis) within 24 to 72 hours
• Pain management for STEMI patients only, Fentanyl 1 mcg/kg Slow IVP only (Maximum single dose 100 mcg)
• May be repeated every 5-10 minutes
• Total maximum dose 200 mcg
• Contraindications
• Hypotension (systolic blood pressure less than 90 mmHg)
• Respiratory depression
• Precaution
• Rapid administration may cause chest wall rigidity
Page 2 of 4
Chest Pain
Medical Director Review Date 11-1-2020
3010
• Hypotensive (SBP<90 mmHg)
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If patient develops pulmonary edema stop IV fluid administration and administer, Dopamine 5-10 mcg/kg/min IV and titrate to effect
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
JFRD STROKE ALERT POLICY
1. Assess patient using the BE-FAST algorithm to IDENTIFY the presence of a stroke
• Balance – Sudden dizziness, loss of balance or coordination
• Eyes – Sudden trouble seeing out of one or both eyes
• Face – Facial Weakness, uneven smile
• Arm – Weakness, unable to raise both arms evenly
• Speech – Impaired, slurred, difficulty repeating simple phrases
• Time - Last seen normal?
2. Perform the Los Angeles Motor Scale (LAMS) assessment to determine the SEVERITY of the stroke. LAMS of 3, 4, or 5 are indicative of a potential large vessel occlusion that requires mechanical thrombectomy. 3. If the patient’s blood glucose is > 60 mg/dL, proceed with assessment. Otherwise, administer 12.5 grams of Dextrose IV/IO. If stroke symptoms persist despite treatment, continue with assessment.
Page 1 of 4
Acute Stroke
Medical Director Review Date 11-1-2020
3020
4. After identifying stroke alert criteria, determine closest, most appropriate Stroke Center per parameters below. If symptoms present > 24 hours, any hospital is appropriate.
• Comprehensive Stroke Center
• All LAMS score of 3, 4, or 5 with onset up to 24 hours
• LAMS score of 0, 1, or 2 when that facility is the closest Stroke Center
• All suspected strokes with onset greater than 3 hours and less than 24 hours
• Patient wakes up with stroke symptoms
• Suspicion of subarachnoid hemorrhage/intracranial hemorrhage, sudden severe
headache (“Thunderclap Headache”) or sudden decrease in LOC
• Current or recent GI bleeding
• Trauma, surgery, or invasive procedure within past 3 months
• Currently on anticoagulants
• Bleeding disorders (e.g., low platelets, cirrhosis)
• Primary Stroke Center
• LAMS score of 0, 1, or 2 with onset up to 3 hours when that facility is the closest
Stroke Center
Notify FRCC of Stroke Alert, destination, LAMS score, onset time, and ETA. Comprehensive Stroke Centers
• See most recent Hospital Capabilities Chart for JFRD Primary Stroke Centers
• See most recent Hospital Capabilities Chart for JFRD
Bleeding to extremity
• Life-threatening (Signs/Symptoms include _____________, profuse _________bleeding, blood soaking through ______________ and signs of ________ with ____________ bleeding)
• immediately apply ____________ (Appendix M)
• Non-life-threatening
1. Control with _________ to bleeding area or vessel
2. Apply ________________
3. Apply _____________________ any previously applied dressing
Bleeding to Head, Neck, or Torso
• Life-threatening
1. Control with _____________ to bleeding area or vessel
2. Apply ________ if available. Otherwise, apply_____________
3. Apply _________________ any previously applied dressing
• Non-life threatening
1. Control with ______________ to bleeding area or vessel
2. Apply ____________
3. Apply _______________ on top of any previously applied dressing
Advanced Trauma Care Bags (Appendix R) are carried on ______________. These bags contain an assortment of ____________________ for use at _________________ incidents.
Amputation, profuse pulsating bleeding, blood soaking through pressure bandage, and signs of shock with continuous bleeding
Tourniquet
Direct pressure
Trauma dressing
Pressure bandage on top of
Direct pressure
Hemostatic gauze
Apply trauma dressing
Apply Pressure bandage on top of
Direct pressure
Trauma dressing
Pressure bandage
ALL FIELD Chief vehicles
Hemorrhage control supplies
Multi-casualty patient incidents
JFRD STEMI ALERT POLICY
CRITERIA #1
Zoll ___________ or __________ message
CRITERIA #2
The patient has___________ consistent with an Acute Coronary Syndrome such as active/recent
chest pain/discomfort, unexplained difficulty breathing, unexplained weakness, syncope, near- syncope, dizziness, diaphoresis or nausea and/or vomiting AND also has 12 lead ECG with a _______ or greater ST Segment elevation present in at least ________ anatomically contiguous leads performed by JFRD.
If the patient meets either of the above criteria:
• Identify a STEMI approved hospital destination
• See most recent Hospital Capabilities Chart for JFRD
• Notify FRCC of “STEMI Alert,” _________ and _______
• Transmit 12 lead ECG to receiving facility with the patient’s ________ entered
• Other life-threatening or ________ ECGs may also be transmitted
Zoll ACUTE MI or STEMI message
symptoms
2mm or greater ST Segment elevation
at least two anatomically contiguous leads
destination and ETA name
questionable
Chest Pain
TREATMENT
• Vitals should be obtained _______ and _________ each administration of nitroglycerin
• If ____________ arrhythmias are present, refer to appropriate guideline
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. Repeat as necessary if _______ persists despite interventions, cases
of clinical ________, or ECG __________
• The receiving hospital must receive a hard copy of _________ 12 lead ECG that is
performed. The patient’s name must be entered on the ECG
• No medications except _____ and __________ should be given prior to the completion of the 12
lead ECG
• In the presence of _______________, consider performing
______ __________. However, do not delay transport
• Establish IV access
• In the setting of ____________STEMI, initiate _______ mL/kg intravenous fluids prior to considering NTG; maximum 2L
• Treatment situations:
• Patients presenting with chest pain should receive ________ unless contraindicated or
previously taken within ______ hours
• Aspirin _______ mg PO
• __________ patients will only be given ASA in the presence of a STEMI
• Contraindications
• Allergies to _________
• ________ GI bleeding
• Aspirin ____ mg PO
• __________ GI bleeding
• Use of _______________
• Normotensive (SBP>100 mmHg) and evidence of Acute Coronary Syndrome
• First dose of NTG can be given without IV access when systolic ______ mmHg
• Additional doses of NTG require _________
• NTG ______ mg SL every _______ minutes until pain is resolved or systolic BP drops below
_______ mmHg
• Contraindications
• Systolic BP less than _____ mmHg
• _____________
• Precaution
• Consider withholding for patients ______ years of age and younger without Acute Coronary Syndrome __________
• In the setting of an ___________ MI (ST elevation in leads II, III, aVF), NTG administration may result in ____________
• If hypotension develops be prepared to administer a ___________ and _______ the patient’s legs. Patient must be closely monitored
• A drop in the systolic BP of _____ mmHg or more, consider _______ repeat doses
• If the patient has used _______ medications (Viagra, Levitra, Cialis) within ___ to ___ hours
• Pain management for STEMI patients only, ________ ___ mcg/kg Slow IVP only (Maximum single dose _____ mcg)
• May be repeated every _____ minutes
• Total maximum dose ____ mcg
• Contraindications
• Hypotension (systolic blood pressure less than _____ mmHg)
• Respiratory __________
• Precaution
• _______________may cause chest wall rigidity
• Hypotensive (SBP_____mmHg)
• Up to _____ mL/kg intravenous fluids; maximum 2L
• If patient develops _____________ stop IV fluid administration and administer, __________ _______ mcg/kg/min IV and titrate to effect
• Contraindications
• ____________ shock
• ________ with ______
• _________
before and in between
life-threatening
persists despite interventions, cases of clinical deterioration, or ECG changes
any 12 lead ECG that is performed
O2 and aspirin
Inferior STEMI (ST elevation in leads II, III, aVF)
V4R
Inferior STEMI, initiate 20 mL/kg intravenous fluids prior to considering NTG
Aspirin
within 2 hours
324 mg PO
Pregnancy
salicylates
Active GI bleeding
81 mg PO
History of GI bleeding
Use of anticoagulants
systolic >=140 mmHg
IV access
0.4 mg SL every 5 minutes
100 mmHg
less than 100 mmHg
Hypovolemia
30 years of age and younger
symptoms
Inferior MI (ST elevation in leads II, III, aVF), NTG administration may result in hypotension fluid challenge and elevate the patient’s legs
systolic BP of 20 mmHg or more, consider withholding repeat doses
erectile dysfunction medications (Viagra, Levitra, Cialis) within 24 to 72 hours
Fentanyl 1 mcg/kg Slow IVP only (Maximum single dose 100 mcg) repeated every 5-10 minutes
200 mcg
less than 90 mmHg)
Respiratory depression
Rapid administration
SBP<90 mmHg
Up to 20 mL/kg
pulmonary edema
Dopamine 5-10 mcg/kg/min IV and titrate to effect
Hypovolemic shock
A-Fib/A-Flutter with RVR
V-Tach
JFRD STROKE ALERT POLICY
- Assess patient using the BE-FAST algorithm to ________ the presence of a stroke
• Balance – Sudden ________, loss of _________ or coordination
• Eyes – Sudden trouble __________ out of one or both eyes
• Face – Facial __________, uneven ___________
• Arm – Weakness, unable to ________ both arms evenly
• Speech – Impaired, __________, difficulty repeating ________ phrases
• Time - Last seen ___________?
- Perform the Los Angeles Motor Scale (LAMS) assessment to determine the _________ of the stroke. LAMS of __________are indicative of a potential ________ vessel occlusion that requires __________ thrombectomy.
LAMS
FACE
0-Both sides move normally
1-One side is ________ or flaccid
ARM
0-Both sides move normally
1-One side is _______
2-One side is flaccid/_______
GRIP
0-Both sides move normally
1-One side is _________
2-One side is _________/doesn’t move
TOTAL
1-5
- If the patient’s blood glucose is > =______ mg/dL, proceed with assessment. Otherwise, administer ________ grams of __________ IV/IO. If stroke symptoms persist despite treatment, continue with assessment.
- After identifying stroke alert criteria, determine closest, most appropriate Stroke Center per parameters below. If symptoms present > =_______ hours, _____ hospital is appropriate.
• Comprehensive Stroke Center
• All LAMS score of ______ with onset up to _____ hours
• LAMS score of ______ when that facility is the _______ Stroke Center
• All suspected strokes with onset greater than ___ hours and less than ____ hours
• Patient _______ with stroke symptoms
• Suspicion of ___________ hemorrhage/_________ hemorrhage, sudden severe
Headache (“_____________ Headache”) or sudden ________ in _______
• ________ or __________ GI bleeding
• Trauma, surgery, or invasive procedure within past _______ months
• Currently on __________
• ___________ disorders
• Primary Stroke Center
• LAMS score of _________ with onset up to ______ hours when that facility is the _________
Stroke Center
Notify FRCC of _______, _________, ____________, ____________, and __________.
Comprehensive Stroke Centers
• See most recent Hospital Capabilities Chart for JFRD
Primary Stroke Centers
• See most recent Hospital Capabilities Chart for JFRD
IDENTIFY
Sudden dizziness, loss of balance or coordination
Sudden trouble seeing out of one or both eyes
Facial Weakness, uneven smile
Weakness, unable to raise both arms evenly
Impaired, slurred, difficulty repeating simple phrases
Last seen normal?
SEVERITY
3, 4, or 5
large vessel occlusion
mechanical thrombectomy
weak or flaccid
weak
doesn’t move
weak
flaccid
> =60
12.5 grams of Dextrose IV/IO
> =24 hours, any hospital is appropriate
LAMS score of 3, 4, or 5 with onset up to 24 hours
LAMS score of 0, 1, or 2 when that facility is the closest Stroke Center
greater than 3 hours and less than 24 hours
wakes up
subarachnoid hemorrhage/intracranial hemorrhage
(“Thunderclap Headache”) or sudden decrease in LOC
Current or recent GI bleeding
3 months
anticoagulants
Bleeding disorders (e.g., low platelets, cirrhosis)
LAMS score of 0, 1, or 2 with onset up to 3 hours when that facility is the closest
Stroke Center
Stroke Alert, destination, LAMS score, onset time, and ETA.
Acute Stroke
TREATMENT
• Place patient on the stretcher in__________ position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Establish IV/IO access
• ______ gauge in the _________ if possible
• The _________ side is preferred but the ________ side may be used
• Up to____ mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of__________ is present
• Initiate cardiac monitoring
• Perform 12 lead ECG (do not delay_________). The receiving hospital must receive a hard copy of the 12 lead ECG
• Determine Blood Glucose Level
• Treat if indicated (should be performed________ issuing Stroke Alert)
• Hypoglycemia (<___mg/dL)
• __________ ____ grams IV/IO. Repeat BGL by finger stick in ______ minutes
• If no improvement and BGL <____ mg/dL, repeat _______ _____ grams
• Without IV/IO access
• ________ ____ mg IM (repeat BGL after _____ minutes)
• Considerations
• Onset in ___ minute with a peak onset time of _____ minutes
• The hypoglycemic patient will usually awaken within _____ minutes
semi-Fowler’s 18 gauge in the antecubital if possible The unaffected side is preferred but the affected side may be used Up to 20 mL/kg intravenous fluids; maximum 2L pulmonary edema transport BEFORE <60 Dextrose 12.5 grams IV/IO. Repeat BGL by finger stick in 5 minutes <60 Dextrose 12.5 grams Glucagon 1 mg IM (repeat BGL after 15 minutes) Onset in 1 minute with a peak onset time of 30 minutes The hypoglycemic patient will usually awaken within 15 minutes
Acute Heart Failure
Pulmonary Edema
TREATMENT
• Place the patient in ____________ position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider early use of the _______ to treat pulmonary _____
• Refer to Advanced Airway Guideline 9010 as indicated
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Establish ______ access
• Treatment situations:
• Normotensive (SBP >_____ mmHg) or ___________
• NTG ____ mg SL every ___ minutes until systolic BP drops below ______ mmHg
• First dose of NTG can be given without _________ when systolic > ______mmHg
• _________ doses of NTG require IV/IO access
• If possible, administer NTG SL _______ to CPAP application
• If CPAP in place, apply ___ inch of Nitropaste to the patient’s _________ chest
• Contraindications
• Systolic BP <______ mmHg
• __________
•Precaution
• In the setting of an ___________ STEMI (ST elevation in leads ___________), NTG
administration may result in _________
• If hypotension develops be prepared to administer a _________ and elevate
the patient’s _______. Patient must be closely monitored
• A drop in the systolic BP of ________ mmHg or more, consider withholding ________
doses of NTG
• If the patient has used ____________ medications (Viagra, Levitra, Cialis)
within ____ to ______ hours
• If patient becomes hypotensive after applying Nitropaste, _____________
•Hypotensive (SBP<_______ mmHg) may indicate _____________
•__________ ________mcg/kg/min IV/IO and titrate to effect
• Contraindications
• ____________ shock
•______ with ______
• __________
TREATMENT
• Place the patient in full Fowler’s position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider early use of the CPAP (Appendix H) to treat pulmonary edema
• Refer to Advanced Airway Guideline 9010 as indicated
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Establish IV/IO access
• Treatment situations:
• Normotensive (SBP >=100 mmHg) or hypertensive
• NTG 0.4 mg SL every 5 minutes until systolic BP drops below 100 mmHg
• First dose of NTG can be given without IV/IO access when systolic >=140 mmHg
• Additional doses of NTG require IV/IO access
• If possible, administer NTG SL prior to CPAP application
• If CPAP in place, apply 1 inch of Nitropaste to the patient’s left anterior chest
• Contraindications
• Systolic BP <100 mmHg
• Hypovolemia
•Precaution
• In the setting of an Inferior STEMI (ST elevation in leads II, III, aVF), NTG
administration may result in hypotension
• If hypotension develops be prepared to administer a fluid challenge and elevate
the patient’s legs. Patient must be closely monitored
• A drop in the systolic BP of 20 mmHg or more, consider withholding repeat
doses of NTG
• If the patient has used erectile dysfunction medications (Viagra, Levitra, Cialis)
within 24 to 72 hours
• If patient becomes hypotensive after applying Nitropaste, wipe away paste
•Hypotensive (SBP<90 mmHg) may indicate cardiogenic shock
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to effect
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
Hypertension
Hypertensive ___________ (systolic BP greater than ______ mmHg and diastolic BP greater than _______ mmHg) can present ________ or ________ symptoms. If stroke, cardiovascular, or
respiratory _________ are present with an abnormally ________ BP, refer to the appropriate guideline.
TREATMENT
• Place patient in __________ position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Establish _____ access
Hypertensive Urgency (systolic BP greater than 220 mmHg and diastolic BP greater than 120 mmHg) can present with or without symptoms. If stroke, cardiovascular, or
respiratory symptoms are present with an abnormally elevated BP, refer to the appropriate guideline.
TREATMENT
• Place patient in semi-Fowler’s position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Establish IV access
V-Fib/Pulseless V-Tach
The emphasis should be placed on early __________ of cardiac arrest with continuous well-performed _______ and ___________.
TREATMENT
• Check _________, check for __________, check for ________ (Should not take more than ____ seconds)
• If NO pulse present, proceed with _______ and treatment modalities as listed in Appendix S
• If the provider is alone, the use of a BVM in single rescuer CPR is _________ recommended. Continuous, _______ chest compressions with pauses for ______ application/use only until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible and ________ when appropriate
• Airway/breathing management
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after ______ attempts, with minimal interruptions to chest compressions, insert _________ airway
• Utilize __________when indicated
• Establish _____ access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the ______ is the preferred site
• Determine Blood Glucose Level
• Administer Epinephrine ______ mg (1:________) IV/IO
• After administration of Epinephrine, circulate for _______ minutes before rhythm and pulse
check
• Precaution
• Do not _____ with any other drug
• Repeat Epinephrine every ________minutes
• Administer Amiodarone ________ mg IV/IO
• Repeat Amiodarone ______ at ________ mg IV/IO at _______ minutes for refractory _______
rhythm
• If rhythm was ________ with defibrillation prior to administering initial Amiodarone dose, _____ mg Amiodarone in ______ intravenous fluid bag (___-_____) over _____ mins. _______ bag is preferred
• This includes AED shocks by ___________
• For Torsades de Pointes, ____________VT, or refractory ______
• Give Magnesium Sulfate _____ grams IV/IO
• Magnesium Sulfate is to be used as the _______ antiarrhythmic of choice in Torsades
(polymorphic VT)
• Consider the following less common causes of cardiac arrest, H’s and T’s, and their appropriate treatments:
• Hyperkalemia - _______ patients
• Calcium Chloride ______ _____/kg IV/IO (Maximum dose ______ mg) over _____ minutes
• Precaution
• Possible crystallization when mixed with _______
• Hypovolemia- _________ with ______ maximum
• Hypoxia- provide 100% O2 with use of _______ and appropriate _________
• Hydrogen Ion = __________
• Sodium Bicarbonate ______ ________/kg IV/IO
• Contraindications
• ________ in Asystole/Pulseless Electrical Activity
• Precaution
• Do not mix with _________ and ________ after injecting
• Inactivates ___________ when mixed
• Inactivates _________ when mixed
• Hyperthermia/Hypothermia- _______ or _______ as needed
• __________ pneumothorax
• Needle decompression procedure (Appendix J)
• Toxins/Tablets
• Suspected ________ overdose - Narcan _______ IV/IO
• Calcium Channel blocker overdose
• Calcium Chloride _______/kg IV/IO (Maximum dose ________ mg) over _____ minutes
• Precaution
• Possible __________ when mixed with Sodium Bicarbonate
The emphasis should be placed on early identification of cardiac arrest with continuous well-performed compressions and defibrillation.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (Should not take more than 10 seconds)
• If NO pulse present, proceed with CPR and treatment modalities as listed in Appendix S
• If the provider is alone, the use of a BVM in single rescuer CPR is no longer recommended. Continuous, uninterrupted chest compressions with pauses for AED application/use only until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible and rapidly defibrillate when appropriate
• Airway/breathing management
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, with minimal interruptions to chest compressions, insert supraglottic airway (Appendix D)
• Utilize Lucas CPR device (Appendix A) when indicated
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the tibia is the preferred site
• Determine Blood Glucose Level
• Administer Epinephrine 1 mg (1:10,000) IV/IO
• After administration of Epinephrine, circulate for two minutes before rhythm and pulse
check
• Precaution
• Do not mix with any other drug
• Repeat Epinephrine every 3 to 5 minutes
• Administer Amiodarone 300 mg IV/IO
• Repeat Amiodarone once at 150 mg IV/IO at 5 minutes for refractory shockable
rhythm
• If rhythm was converted with defibrillation prior to administering initial Amiodarone dose, 150 mg Amiodarone in small intravenous fluid bag (100-250cc) over 10 mins. Smaller bag is preferred
• This includes AED shocks by bystanders
• For Torsades de Pointes, Polymorphic VT, or refractory VF/VT
• Give Magnesium Sulfate 2 grams IV/IO
• Magnesium Sulfate is to be used as the FIRST antiarrhythmic of choice in Torsades
(polymorphic VT)
• Consider the following less common causes of cardiac arrest, H’s and T’s, and their appropriate treatments:
• Hyperkalemia - Dialysis patients
• Calcium Chloride 5 mg/kg IV/IO (Maximum dose 500 mg) over 2 minutes
• Precaution
• Possible crystallization when mixed with Sodium Bicarbonate
• Hypovolemia- fluid challenge with 2L maximum
• Hypoxia- provide 100% O2 with use of BVM and appropriate airway adjunct
• Hydrogen Ion = acidosis
• Sodium Bicarbonate 1 mEq/kg IV/IO
• Contraindications
• None in Asystole/Pulseless Electrical Activity
•Precaution
• Do not mix with other drugs and flush line well after injecting
• Inactivates Epinephrine when mixed
• Inactivates Dopamine when mixed
• Hyperthermia/Hypothermia- cool or warm as needed
• Tension pneumothorax
• Needle decompression procedure (Appendix J)
• Toxins/Tablets
• Suspected narcotic overdose - Narcan 4mg IV/IO
• Calcium Channel blocker overdose
• Calcium Chloride 5 mg/kg IV/IO (Maximum dose 500 mg) over 2 minutes
• Precaution
• Possible crystallization when mixed with Sodium Bicarbonate
Asystole/Pulseless Electrical Activity
The emphasis should be placed on early _______ of cardiac arrest with continuous well-performed _________.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (should not take more than 10 seconds)
• If NO pulse present, proceed with CPR and treatment modalities as listed in Appendix T
• If the provider is alone, the use of a BVM in single rescuer CPR is no longer ________. Continuous, uninterrupted ___________with pauses for AED application/use only until ________ units arrive
• Apply monitor/defibrillator pads as soon as __________
• Airway/breathing management
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after _____ attempts, with minimal interruptions to chest compressions, insert _________ airway (Appendix D)
• Utilize ___________ (Appendix A) when indicated
• Establish ______ access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the ______ is the preferred site
• Determine Blood Glucose Level
• Administer Epinephrine _____ mg (1:______) IV/IO
• After administration of Epinephrine, ________ for _____ minutes before rhythm and pulse
check
• Precaution
• Do not ______ with any other drug
• Repeat Epinephrine every ________ minutes
• If shockable rhythm, refer to _________ treatment
• Consider the following less common causes of cardiac arrest, H’s and T’s, and their appropriate treatments:
• _________ - Dialysis patients
• __________ ___ mg/kg IV/IO (Maximum dose _____ mg) over _____ minutes
• Precaution
• Possible ________ when mixed with Sodium Bicarbonate
• ___________- fluid challenge with 2L maximum
• _________- provide 100% O2 with use of BVM and appropriate airway adjunct
• __________ = acidosis
• Sodium Bicarbonate _____ mEq/kg IV/IO
• Contraindications
• None in __________
• Precaution
• Do not _______ with other drugs and flush line well after _______
• ________ Epinephrine when mixed
• ________ Dopamine when mixed
• _________________- cool or warm as needed
• Tension pneumothorax
• ___________ decompression procedure (Appendix J)
• Toxins/Tablets
• Suspected _________ overdose - Narcan _______ IV/IO
• Calcium Channel blocker _________
• Calcium Chloride ________/kg IV/IO (Maximum dose ________) over ______ minutes
• Precaution
• Possible crystallization when mixed with Sodium Bicarbonate
The emphasis should be placed on early identification of cardiac arrest with continuous well-performed compressions.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (should not take more than 10 seconds)
• If NO pulse present, proceed with CPR and treatment modalities as listed in Appendix T
• If the provider is alone, the use of a BVM in single rescuer CPR is no longer recommended. Continuous, uninterrupted chest compressions with pauses for AED application/use only until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible
• Airway/breathing management
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, with minimal interruptions to chest compressions, insert supraglottic airway (Appendix D)
• Utilize Lucas CPR device (Appendix A) when indicated
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the tibia is the preferred site
• Determine Blood Glucose Level
• Administer Epinephrine 1 mg (1:10,000) IV/IO
• After administration of Epinephrine, circulate for two minutes before rhythm and pulse
check
• Precaution
• Do not mix with any other drug
• Repeat Epinephrine every 3 to 5 minutes
• If shockable rhythm, refer to V-Fib/Pulseless V-Tach treatment
• Consider the following less common causes of cardiac arrest, H’s and T’s, and their appropriate treatments:
• Hyperkalemia - Dialysis patients
• Calcium Chloride 5 mg/kg IV/IO (Maximum dose 500 mg) over 2 minutes
• Precaution
• Possible crystallization when mixed with Sodium Bicarbonate
• Hypovolemia- fluid challenge with 2L maximum
• Hypoxia- provide 100% O2 with use of BVM and appropriate airway adjunct
• Hydrogen Ion = acidosis
• Sodium Bicarbonate 1 mEq/kg IV/IO
• Contraindications
• None in Asystole/Pulseless Electrical Activity
• Precaution
• Do not mix with other drugs and flush line well after injecting
• Inactivates Epinephrine when mixed
• Inactivates Dopamine when mixed
• Hyperthermia/Hypothermia- cool or warm as needed
• Tension pneumothorax
• Needle decompression procedure (Appendix J)
• Toxins/Tablets
• Suspected narcotic overdose - Narcan 4mg IV/IO
• Calcium Channel blocker overdose
• Calcium Chloride 5 mg/kg IV/IO (Maximum dose 500 mg) over 2 minutes
• Precaution
• Possible crystallization when mixed with Sodium Bicarbonate
Post-Resuscitation Care
Patients may display a wide range of responses to resuscitation from being awake and alert with adequate spontaneous respirations and hemodynamic stability to
unconscious and NOT breathing with hemodynamic instability.
TREATMENT
• Reassess airway
• Provide 100% oxygen with appropriate airway adjunct
• Monitor ETCO2 and SpO2 values for all patients that have an advanced airway in
place
• Normal readings are 35 to 45 mmHg in a healthy patient
• Assure correct wave form
• Consider Midazolam 2 mg IV/IO for sedation, may repeat once in 5 minutes
• Contraindications
• Systolic BP <100mmHg
• Precaution
• Respiratory insufficiency and airway compromise
• Hypotension
• Establish IV/IO access if not already done
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Initiate cardiac monitoring
• Perform 12 lead ECG if time permits. The receiving hospital must receive a hard copy of
any 12 lead ECG that is performed
• Determine Blood Glucose Level
• Consider specific treatments:
• Hypotension without bradycardia
• If hypotension persists after fluid bolus, consider Dopamine 5-10 mcg/kg/min IV/IO
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
• Tachycardia
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If rhythm was converted with defibrillation prior to administering initial Amiodarone dose, 150 mg Amiodarone in small intravenous fluid bag (100-250cc) over 10 mins. Smaller bag is preferred.
• Bradycardia with hypotension (systolic BP <90 mmHg)
• Administer Atropine 0.5 mg IV/IO every 3 to 5 minutes (Maximum total dose 3 mg)
• Precaution
• Acute myocardial infarction
• Wide complex atrio-ventricular blocks
• Consider transcutaneous pacing (Appendix B) if refractory to Atropine or severe
symptoms
• If bradycardia persists after atropine, consider Dopamine 5-10 mcg/kg/min IV/IO
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
Patients may display a wide range of responses to resuscitation from being awake and alert with adequate spontaneous respirations and hemodynamic stability to
unconscious and NOT breathing with hemodynamic instability.
TREATMENT
• Reassess airway
• Provide 100% oxygen with appropriate airway adjunct
• Monitor ETCO2 and SpO2 values for all patients that have an advanced airway in
place
• Normal readings are 35 to 45 mmHg in a healthy patient
• Assure correct wave form
• Consider Midazolam 2 mg IV/IO for sedation, may repeat once in 5 minutes
• Contraindications
• Systolic BP <100mmHg
• Precaution
• Respiratory insufficiency and airway compromise
• Hypotension
• Establish IV/IO access if not already done
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Initiate cardiac monitoring
• Perform 12 lead ECG if time permits. The receiving hospital must receive a hard copy of
any 12 lead ECG that is performed
• Determine Blood Glucose Level
• Consider specific treatments:
• Hypotension without bradycardia
• If hypotension persists after fluid bolus, consider Dopamine 5-10 mcg/kg/min IV/IO
•Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
• Tachycardia
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If rhythm was converted with defibrillation prior to administering initial Amiodarone dose, 150 mg Amiodarone in small intravenous fluid bag (100-250cc) over 10 mins. Smaller bag is preferred.
• Bradycardia with hypotension (systolic BP <90 mmHg)
• Administer Atropine 0.5 mg IV/IO every 3 to 5 minutes (Maximum total dose 3 mg)
•Precaution
• Acute myocardial infarction
• Wide complex atrio-ventricular blocks
• Consider transcutaneous pacing (Appendix B) if refractory to Atropine or severe
symptoms
• If bradycardia persists after atropine, consider Dopamine 5-10 mcg/kg/min IV/IO
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
Tachycardia
When treating tachycardia, it is important to first consider a compensatory cause. It is not advantageous to eliminate a compensatory tachycardia in a patient who needs it to perfuse. Locating the cause of the decreased perfusion is optimal.
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Repeat as necessary if pain persists despite interventions, cases of clinical
deterioration, or ECG changes
• Do not delay treatment or transport
• Life-threatening ECGs should also be transmitted
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Determine Blood Glucose Level
• Consider specific treatment based on evaluation of patient and QRS
• Stable patient
• V-Tach or runs of V-Tach (>6 consecutive PVCs)
• Amiodarone 150 mg in 100 mL intravenous fluid bag over 10 mins
• Narrow regular QRS (SVT)
• Adenosine 6 mg rapid IV (may attempt vagal maneuvers before administration
of Adenosine). If Adenosine 6mg unsuccessful, administer Adenosine 12 mg rapid IV
• Contraindication
• Known WPW syndrome
• Precaution
• Patients taking Digoxin and/or Verapamil
• A Flutter & A Fib with sustained (>15 minutes under JFRD care) heart rates >140
• Amiodarone 150 mg in 100 mL intravenous fluid bag over 10 mins
• Contraindications
• Hypersensitivity to medication
• Patients taking Tikosyn
• Unstable patient. Symptoms include severe CP or SOB, hypotension, and altered mental status
• Synchronized Cardioversion. May consider brief trial of Adenosine or Amiodarone while preparing for cardioversion
• If patient requires sedation, Ketamine 1 mg/kg IV/IO, single dose only
• Narrow regular QRS (SVT) - Synchronized cardioversion at 50 J
• Repeat as needed with escalating doses up to 100 J
• Narrow irregular QRS – Synchronized cardioversion at 120 J
• Repeat as needed with escalating doses up to 200 J
• Wide regular QRS – Synchronized cardioversion at 100 J
• Repeat as needed with escalating doses up to 200 J
When treating tachycardia, it is important to first consider a compensatory cause. It is not advantageous to eliminate a compensatory tachycardia in a patient who needs it to perfuse. Locating the cause of the decreased perfusion is optimal.
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Repeat as necessary if pain persists despite interventions, cases of clinical
deterioration, or ECG changes
• Do not delay treatment or transport
• Life-threatening ECGs should also be transmitted
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Determine Blood Glucose Level
• Consider specific treatment based on evaluation of patient and QRS
• Stable patient
• V-Tach or runs of V-Tach (>6 consecutive PVCs)
• Amiodarone 150 mg in 100 mL intravenous fluid bag over 10 mins
• Narrow regular QRS (SVT)
• Adenosine 6 mg rapid IV (may attempt vagal maneuvers before administration
of Adenosine). If Adenosine 6mg unsuccessful, administer Adenosine 12 mg rapid IV
• Contraindication
• Known WPW syndrome
• Precaution
• Patients taking Digoxin and/or Verapamil
• A Flutter & A Fib with sustained (>15 minutes under JFRD care) heart rates >140
• Amiodarone 150 mg in 100 mL intravenous fluid bag over 10 mins
• Contraindications
• Hypersensitivity to medication
• Patients taking Tikosyn
• Unstable patient. Symptoms include severe CP or SOB, hypotension, and altered mental status
• Synchronized Cardioversion. May consider brief trial of Adenosine or Amiodarone while preparing for cardioversion
• If patient requires sedation, Ketamine 1 mg/kg IV/IO, single dose only
• Narrow regular QRS (SVT) - Synchronized cardioversion at 50 J
• Repeat as needed with escalating doses up to 100 J
• Narrow irregular QRS – Synchronized cardioversion at 120 J
• Repeat as needed with escalating doses up to 200 J
• Wide regular QRS – Synchronized cardioversion at 100 J
• Repeat as needed with escalating doses up to 200 J
Symptomatic Bradycardia
Symptomatic bradycardia is a combination of slow heart rate with symptoms such as altered mental status, ongoing chest discomfort, hypotension, or signs of shock.
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Do not delay treatment or transport
• Life-threatening ECGs may be transmitted
• Stable patient with bradycardia, first degree block or second-degree type I heart block without significant clinical symptoms. A normotensive patient typically does not require treatment
• Unstable patient with bradycardia. Presenting with poor perfusion evidenced by slow heart rate and hypotension (systolic <90 mmHg).
• Atropine 0.5 mg IV/IO, repeat once in 3 to 5 minutes
• Precaution
• Acute myocardial infarction
• Wide complex atrio-ventricular blocks
• Consider Transcutaneous Pacing (Appendix B). May be appropriate prior to Atropine if severity dictates (e.g., second degree type II, third degree heart block) or IV/IO delayed
• If patient requires sedation, Ketamine 1 mg/kg IV/IO, single dose only
• If Atropine or Transcutaneous Pacing does not improve blood pressure (systolic <90 mmHg), administer Dopamine 5-10 mcg/kg/min IV/IO and titrate to effect
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
Symptomatic bradycardia is a combination of slow heart rate with symptoms such as altered mental status, ongoing chest discomfort, hypotension, or signs of shock.
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Do not delay treatment or transport
• Life-threatening ECGs may be transmitted
• Stable patient with bradycardia, first degree block or second-degree type I heart block without significant clinical symptoms. A normotensive patient typically does not require treatment
• Unstable patient with bradycardia. Presenting with poor perfusion evidenced by slow heart rate and hypotension (systolic <90 mmHg).
• Atropine 0.5 mg IV/IO, repeat once in 3 to 5 minutes
• Precaution
• Acute myocardial infarction
• Wide complex atrio-ventricular blocks
• Consider Transcutaneous Pacing (Appendix B). May be appropriate prior to Atropine if severity dictates (e.g., second degree type II, third degree heart block) or IV/IO delayed
• If patient requires sedation, Ketamine 1 mg/kg IV/IO, single dose only
• If Atropine or Transcutaneous Pacing does not improve blood pressure (systolic <90 mmHg), administer Dopamine 5-10 mcg/kg/min IV/IO and titrate to effect
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
Respiratory Distress
In the patient with severe respiratory compromise, treatment should be aggressive in order to prevent respiratory arrest. Lung sounds and degree of distress should
guide treatment.
TREATMENT
• Airway/breathing management
• Monitor SpO2. However, SpO2 is not a reliable indicator of the patient’s level of distress
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine respiratory rate, depth, and quality
• Assess lung sounds
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, insert supraglottic airway (Appendix D)
• Consider possible treatment situations and refer to appropriate guideline
• Clear lung sounds with difficulty breathing
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Known or suspected pneumonia (fever, decreased lung sounds, and/or cough)
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May repeat as needed.
Subsequent nebulizer treatments will contain only Albuterol 5 mg
• If respiratory distress due to Asthma, COPD, Shock, or Acute Heart Failure, refer to
appropriate guideline
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Assess temperature
• Determine Blood Glucose Level
In the patient with severe respiratory compromise, treatment should be aggressive in order to prevent respiratory arrest. Lung sounds and degree of distress should
guide treatment.
TREATMENT
• Airway/breathing management
• Monitor SpO2. However, SpO2 is not a reliable indicator of the patient’s level of distress
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine respiratory rate, depth, and quality
• Assess lung sounds
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, insert supraglottic airway (Appendix D)
• Consider possible treatment situations and refer to appropriate guideline
• Clear lung sounds with difficulty breathing
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Known or suspected pneumonia (fever, decreased lung sounds, and/or cough)
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May repeat as needed.
Subsequent nebulizer treatments will contain only Albuterol 5 mg
• If respiratory distress due to Asthma, COPD, Shock, or Acute Heart Failure, refer to
appropriate guideline
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Assess temperature
• Determine Blood Glucose Level
Respiratory Arrest
TREATMENT
• Provide 100% oxygen via BVM with an airway adjunct(s) (oropharyngeal airway and/or nasopharyngeal airway)
• Provide suction as needed
• Airway/breathing management
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, insert supraglottic airway (Appendix D)
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Initiate cardiac monitoring
• Assess Blood Glucose Level
TREATMENT
• Provide 100% oxygen via BVM with an airway adjunct(s) (oropharyngeal airway and/or nasopharyngeal airway)
• Provide suction as needed
• Airway/breathing management
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, insert supraglottic airway (Appendix D)
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Initiate cardiac monitoring
• Assess Blood Glucose Level
Reactive Airway Disease
(Asthma, COPD)
TREATMENT
• Airway/breathing management
• Monitor SpO2. However, SpO2 is not a reliable indicator of the patient’s level of distress
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider early use of the CPAP (Appendix H)
• Determine respiratory rate, depth, and quality
• Assess lung sounds
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, insert supraglottic airway (Appendix D)
• Initiate cardiac monitoring
• Assess temperature
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Determine Blood Glucose Level
• Treatment should be based on lung sounds and level of distress
• Mild Distress - Wheezes only
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May repeat as needed. Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Moderate Distress - Wheezes/decreased breath sounds/accessory muscle use
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated as needed.
Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Magnesium Sulfate 2 grams IV in small intravenous fluid bag (100-250cc) over 10 mins.
Smaller bag is preferred
• Solu-Medrol 125 mg slow IV push
• Severe Distress - Wheezes/stridor/decreased breath sounds with little or no air movement/accessory muscle use/tripoding
• Epinephrine 1:1000 0.3 - 0.5 mg IM (0.3 mg appropriate for >50 years old)
• Only in the case of asthma exacerbation
• Continuous Positive Airway Pressure (CPAP) (Appendix H) in conjunction with
an in-line Albuterol/Atrovent nebulizer
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated. Subsequent
nebulizer treatments will contain only Albuterol 5 mg
• Magnesium Sulfate 2 grams IV in small intravenous fluid bag (100-250cc) over 10 mins.
Smaller bag is preferred.
• Solu-Medrol 125 mg slow IV/IO push
TREATMENT
• Airway/breathing management
• Monitor SpO2. However, SpO2 is not a reliable indicator of the patient’s level of distress
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider early use of the CPAP (Appendix H)
• Determine respiratory rate, depth, and quality
• Assess lung sounds
• Refer to Advanced Airway Guideline 9010 as indicated
• If unable to intubate patient after two attempts, insert supraglottic airway (Appendix D)
• Initiate cardiac monitoring
• Assess temperature
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Determine Blood Glucose Level
• Treatment should be based on lung sounds and level of distress
• Mild Distress - Wheezes only
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May repeat as needed. Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Moderate Distress - Wheezes/decreased breath sounds/accessory muscle use
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated as needed.
Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Magnesium Sulfate 2 grams IV in small intravenous fluid bag (100-250cc) over 10 mins.
Smaller bag is preferred
• Solu-Medrol 125 mg slow IV push
• Severe Distress - Wheezes/stridor/decreased breath sounds with little or no air movement/accessory muscle use/tripoding
• Epinephrine 1:1000 0.3 - 0.5 mg IM (0.3 mg appropriate for >50 years old)
• Only in the case of asthma exacerbation
• Continuous Positive Airway Pressure (CPAP) (Appendix H) in conjunction with
an in-line Albuterol/Atrovent nebulizer
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated. Subsequent
nebulizer treatments will contain only Albuterol 5 mg
• Magnesium Sulfate 2 grams IV in small intravenous fluid bag (100-250cc) over 10 mins.
Smaller bag is preferred.
• Solu-Medrol 125 mg slow IV/IO push
Foreign Body Airway Obstruction
TREATMENT
• Foreign Body Airway Obstruction (FBAO) maneuvers as indicated below:
• Conscious
• Mild Obstruction (with good air exchange)
• Encourage patient’s own spontaneous coughing and breathing efforts
• Severe Obstruction
• Abdominal Thrusts (Heimlich maneuver)
• If patient is pregnant or obese, perform chest thrusts instead of abdominal thrusts
• Unconscious
• Reposition airway and remove object by direct or video laryngoscopy with Magill
forceps
• Begin CPR as indicated
• Suction as indicated
• Assist ventilations with appropriate BVM with a nasopharyngeal airway
• If foreign body cannot be removed, attempt to bypass by pushing the obstruction into
one bronchus with the ET tube and then intubating the other bronchus
• Supraglottic airway is contraindicated in this situation
• If unable to bypass obstruction, consider cricothyrotomy (Appendix K)
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Assess lung sounds
• Determine respiratory rate, depth, and quality
• Initiate cardiac monitoring
• Establish IV/IO access
TREATMENT
• Foreign Body Airway Obstruction (FBAO) maneuvers as indicated below:
• Conscious
• Mild Obstruction (with good air exchange)
• Encourage patient’s own spontaneous coughing and breathing efforts
• Severe Obstruction
• Abdominal Thrusts (Heimlich maneuver)
• If patient is pregnant or obese, perform chest thrusts instead of abdominal thrusts
• Unconscious
• Reposition airway and remove object by direct or video laryngoscopy with Magill
forceps
• Begin CPR as indicated
• Suction as indicated
• Assist ventilations with appropriate BVM with a nasopharyngeal airway
• If foreign body cannot be removed, attempt to bypass by pushing the obstruction into
one bronchus with the ET tube and then intubating the other bronchus
• Supraglottic airway is contraindicated in this situation
• If unable to bypass obstruction, consider cricothyrotomy (Appendix K)
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Assess lung sounds
• Determine respiratory rate, depth, and quality
• Initiate cardiac monitoring
• Establish IV/IO access
Hyperventilation
Many serious medical problems can cause hyperventilation. Consider possible underlying causes.
TREATMENT
• Airway/breathing management
• Administer O2 via NRB until hyperventilation has resolved, then administer O2 via proper
adjunct to maintain oxygen saturation of 95% or greater
• Assess lung sounds
• Determine respiratory rate, depth, and quality
• Administer O2 via NRB until hyperventilation has resolved
• Do not administer CO2 re-breathing techniques
• Initiate cardiac monitoring
• Assess temperature
• Determine Blood Glucose Level
• Establish IV access if indicated
Many serious medical problems can cause hyperventilation. Consider possible underlying causes.
TREATMENT
• Airway/breathing management
• Administer O2 via NRB until hyperventilation has resolved, then administer O2 via proper
adjunct to maintain oxygen saturation of 95% or greater
• Assess lung sounds
• Determine respiratory rate, depth, and quality
• Administer O2 via NRB until hyperventilation has resolved
• Do not administer CO2 re-breathing techniques
• Initiate cardiac monitoring
• Assess temperature
• Determine Blood Glucose Level
• Establish IV access if indicated
Abdominal/Flank Pain
TREATMENT
• Place patient in position of comfort
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG for patients greater than 30 years old
• The receiving hospital must receive a hard copy of the 12 lead ECG
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Determine Blood Glucose Level
• Assess temperature
TREATMENT
• Place patient in position of comfort
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG for patients greater than 30 years old
• The receiving hospital must receive a hard copy of the 12 lead ECG
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Determine Blood Glucose Level
• Assess temperature
Alcohol Related Illness
TREATMENT
• Maintain aspiration prophylaxis by placing patient in the recovery position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation 95% or greater
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Look for underlying causes
• Determine Blood Glucose Level. If BGL is abnormal, refer to Diabetic Guideline 5050
• For all alcohol syndrome and malnourished patients prior to Dextrose administration
• Thiamine 100 mg IV/IM
• Contraindication
• Known hypersensitivity
• If suspected narcotic use
• If respiratory depression present or unable to protect airway
• Narcan 0.4 mg IV/IO/IM
• May repeat initial Narcan dose every 2 minutes to a maximum total dose of 2
mg
TREATMENT
• Maintain aspiration prophylaxis by placing patient in the recovery position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation 95% or greater
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Look for underlying causes
• Determine Blood Glucose Level. If BGL is abnormal, refer to Diabetic Guideline 5050
• For all alcohol syndrome and malnourished patients prior to Dextrose administration
• Thiamine 100 mg IV/IM
• Contraindication
• Known hypersensitivity
• If suspected narcotic use
• If respiratory depression present or unable to protect airway
• Narcan 0.4 mg IV/IO/IM
• May repeat initial Narcan dose every 2 minutes to a maximum total dose of 2
mg
Allergic Reaction/Anaphylaxis
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Anticipate rapid deterioration and the need for intubation
• Initiate cardiac monitoring
• Assist with administration of patient’s Auto-Injector Epinephrine if respiratory compromise
present
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Determine Blood Glucose Level
• Assess temperature
• Treatment based on assessment and patient’s level of distress:
• Mild/Moderate reaction without respiratory compromise
• Benadryl 25 mg IV/IM
• Solu-Medrol 125 mg IV
• Moderate reaction with respiratory compromise
• Benadryl 25 mg IV/IM
• Albuterol 5 mg and Atrovent 0.5 mg. Subsequent nebulizer treatments will contain
only Albuterol 5 mg
• Solu-Medrol 125 mg IV
• Severe reaction/Anaphylaxis (severe respiratory distress and/or cardiovascular compromise)
• Epinephrine 1:1,000 0.3 - 0.5 mg IM. (0.3 mg appropriate for >50 years old)
• May repeat once after 10 minutes if needed, at different site
• Albuterol 5 mg and Atrovent 0.5 mg. Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Benadryl 25 mg IV/IO/IM
• Solu-Medrol 125 mg IV/IO
• If hypotensive after fluid administration, administer:
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Anticipate rapid deterioration and the need for intubation
• Initiate cardiac monitoring
• Assist with administration of patient’s Auto-Injector Epinephrine if respiratory compromise
present
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Determine Blood Glucose Level
• Assess temperature
• Treatment based on assessment and patient’s level of distress:
• Mild/Moderate reaction without respiratory compromise
• Benadryl 25 mg IV/IM
• Solu-Medrol 125 mg IV
• Moderate reaction with respiratory compromise
• Benadryl 25 mg IV/IM
• Albuterol 5 mg and Atrovent 0.5 mg. Subsequent nebulizer treatments will contain
only Albuterol 5 mg
• Solu-Medrol 125 mg IV
• Severe reaction/Anaphylaxis (severe respiratory distress and/or cardiovascular compromise)
• Epinephrine 1:1,000 0.3 - 0.5 mg IM. (0.3 mg appropriate for >50 years old)
• May repeat once after 10 minutes if needed, at different site
• Albuterol 5 mg and Atrovent 0.5 mg. Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Benadryl 25 mg IV/IO/IM
• Solu-Medrol 125 mg IV/IO
• If hypotensive after fluid administration, administer:
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
Altered Consciousness
TREATMENT
• Maintain aspiration prophylaxis by placing patient in the recovery position
• Determine Blood Glucose Level. If BGL less than 60 mg/dL, refer to Diabetic Guideline
5050
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• If GCS <8 or inability to protect airway, refer to Advanced Airway Guideline 9010
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Treatment based on underlying cause:
• Narcotic use/exposure
• Refer to Overdose/Poisoning Guideline 6070
• Unknown etiology
• Consider other treatable neurological or metabolic disorders and if identified follow the appropriate guideline
• Assess for head trauma and consider use of a C-collar
TREATMENT
• Maintain aspiration prophylaxis by placing patient in the recovery position
• Determine Blood Glucose Level. If BGL less than 60 mg/dL, refer to Diabetic Guideline
5050
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• If GCS <8 or inability to protect airway, refer to Advanced Airway Guideline 9010
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Treatment based on underlying cause:
• Narcotic use/exposure
• Refer to Overdose/Poisoning Guideline 6070
• Unknown etiology
• Consider other treatable neurological or metabolic disorders and if identified follow the appropriate guideline
• Assess for head trauma and consider use of a C-collar
Diabetic
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Look for underlying causes
• Treatments based on blood glucose level and level of consciousness:
• Hypoglycemia
• Conscious and alert patient (GCS >=14) with BGL <60 mg/dL, administer oral Glucose paste 15 grams (1 tube)
• May repeat once in 10 minutes if BGL still <60 mg/dL
• Contraindications
• Altered level of consciousness
• Difficulty swallowing
• Decreased level of consciousness with BGL <60 mg/dL
• GCS <=8 and potential airway compromise
• Dextrose 25 grams IV/IO (D5W 12.5 grams is an acceptable alternative if D50W is not available)
• Repeat BGL by finger stick in 5 minutes
• If no improvement and BGL is still <60 mg/dL, administer an additional
Dextrose 12.5 grams
• GCS >8
• Dextrose 25 grams IV (D5W 12.5 grams is an acceptable alternative if D50W
is not available)
• Repeat BGL by finger stick in 5 minutes
• If no IV access, Glucagon 1mg IM
• Repeat BGL after 15 minutes
• Considerations
• Onset in 1 minute with a peak onset time of 30 minutes
• The hypoglycemic patient will usually awaken within 15 minutes
• Glucagon may not be effective in patients with liver disease
• Hyperglycemia
• BGL >300 mg/dL, administer 20ml/kg intravenous fluids; maximum 2L
• If no IV access and GCS <8, establish IO
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Look for underlying causes
• Treatments based on blood glucose level and level of consciousness:
• Hypoglycemia
• Conscious and alert patient (GCS >=14) with BGL <60 mg/dL, administer oral Glucose paste 15 grams (1 tube)
• May repeat once in 10 minutes if BGL still <60 mg/dL
• Contraindications
• Altered level of consciousness
• Difficulty swallowing
• Decreased level of consciousness with BGL <60 mg/dL
• GCS <=8 and potential airway compromise
• Dextrose 25 grams IV/IO (D5W 12.5 grams is an acceptable alternative if D50W is not available)
• Repeat BGL by finger stick in 5 minutes
• If no improvement and BGL is still <60 mg/dL, administer an additional
Dextrose 12.5 grams
• GCS >8
• Dextrose 25 grams IV (D5W 12.5 grams is an acceptable alternative if D50W
is not available)
• Repeat BGL by finger stick in 5 minutes
• If no IV access, Glucagon 1mg IM
• Repeat BGL after 15 minutes
• Considerations
• Onset in 1 minute with a peak onset time of 30 minutes
• The hypoglycemic patient will usually awaken within 15 minutes
• Glucagon may not be effective in patients with liver disease
• Hyperglycemia
• BGL >300 mg/dL, administer 20ml/kg intravenous fluids; maximum 2L
• If no IV access and GCS <8, establish IO
Nosebleed
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Look for underlying causes
• If other injuries do not exist, prevent aspiration of blood by placing the patient in a sitting position with their head leaning forward
• Suction the airway as required if unable to position the patient
• Control hemorrhage by pinching the nostrils
• To facilitate clotting instruct the patient to hold pressure for at least 20 minutes and not
to sniff, blow or manipulate the nasal passages in any way
• Uncontrollable Hemorrhage
• Neo-Synephrine 2 sprays in affected nostril • Contraindications
• Nosebleed secondary to hypertension (BP >180/110)
• Nosebleed secondary to head injury and CSF drainage
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Look for underlying causes
• If other injuries do not exist, prevent aspiration of blood by placing the patient in a sitting position with their head leaning forward
• Suction the airway as required if unable to position the patient
• Control hemorrhage by pinching the nostrils
• To facilitate clotting instruct the patient to hold pressure for at least 20 minutes and not
to sniff, blow or manipulate the nasal passages in any way
• Uncontrollable Hemorrhage
• Neo-Synephrine 2 sprays in affected nostril • Contraindications
• Nosebleed secondary to hypertension (BP >180/110)
• Nosebleed secondary to head injury and CSF drainage
Headache
TREATMENT
• If sudden severe headache (“Thunderclap Headache”) or sudden decrease in LOC, refer to Acute Stroke Guideline 3020
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Assess temperature
• Headaches with elevated temperature, nausea/vomiting and/or altered mental status
may indicate meningitis or neurological event
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Look for underlying causes
TREATMENT
• If sudden severe headache (“Thunderclap Headache”) or sudden decrease in LOC, refer to Acute Stroke Guideline 3020
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Assess temperature
• Headaches with elevated temperature, nausea/vomiting and/or altered mental status
may indicate meningitis or neurological event
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Look for underlying causes
Nausea/Vomiting
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Perform 12 lead ECG for patients >50 years old
• The receiving hospital must receive a hard copy of the 12 lead ECG
• The primary treatment for the patient with gastrointestinal related signs and symptoms is to
rehydrate them with IV fluids
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Gastrointestinal related nausea and vomiting
• Adult – Zofran 4 mg IV
• May repeat once after 15 minutes if vomiting persists
• Pediatric – Zofran 0.15 mg/kg IV (maximum total dose 4mg)
• No repeat dose
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Perform 12 lead ECG for patients >50 years old
• The receiving hospital must receive a hard copy of the 12 lead ECG
• The primary treatment for the patient with gastrointestinal related signs and symptoms is to
rehydrate them with IV fluids
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
• Gastrointestinal related nausea and vomiting
• Adult – Zofran 4 mg IV
• May repeat once after 15 minutes if vomiting persists
• Pediatric – Zofran 0.15 mg/kg IV (maximum total dose 4mg)
• No repeat dose
Seizures
TREATMENT
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• If trauma suspected, immobilize patient using proper technique
• If the patient is actively seizing, protect the patient from further injury
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Look for underlying causes
• Determine Blood Glucose Level. If BGL is abnormal, refer to Diabetic Guideline 5050
• Assess temperature
• Active seizures
• Midazolam 2-5 mg IV/IO/IM for active seizures. If active seizing persists or returns,
may repeat doses up to total Maximum of 10 mg
• Airway assistance may be necessary after Midazolam administration
TREATMENT
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• If trauma suspected, immobilize patient using proper technique
• If the patient is actively seizing, protect the patient from further injury
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Look for underlying causes
• Determine Blood Glucose Level. If BGL is abnormal, refer to Diabetic Guideline 5050
• Assess temperature
• Active seizures
• Midazolam 2-5 mg IV/IO/IM for active seizures. If active seizing persists or returns,
may repeat doses up to total Maximum of 10 mg
• Airway assistance may be necessary after Midazolam administration
Shock Medical
Shock patients may deteriorate rapidly. Signs of poor perfusion include cool mottled skin, diminished pulses, altered mental status, increased capillary refill time
(>2 seconds), tachycardia AND systolic BP less than 90 mm/hg.
TREATMENT
• Place patient in supine position with legs elevated
• Maintain body warmth
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is the preferred site
• If hypotensive after fluid administration, administer:
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
• For patients confirmed to have Acute Adrenal Insufficiency by either the presence of a medical alert bracelet, designation of medical records, patient, family, or medical confirmation
• Assist with administration of patient’s Solu-Cortef IM if present (adult dose is 100mg)
• If Solu-Cortef not available, Solu-Medrol 125 mg slow IV/IO push
• Assess temperature
• If patient is febrile, apply cooling measures
• Look for underlying causes
Shock patients may deteriorate rapidly. Signs of poor perfusion include cool mottled skin, diminished pulses, altered mental status, increased capillary refill time
(>2 seconds), tachycardia AND systolic BP less than 90 mm/hg.
TREATMENT
• Place patient in supine position with legs elevated
• Maintain body warmth
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is the preferred site
• If hypotensive after fluid administration, administer:
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• Contraindications
• Hypovolemic shock
• A-Fib/A-Flutter with RVR
• V-Tach
• For patients confirmed to have Acute Adrenal Insufficiency by either the presence of a medical alert bracelet, designation of medical records, patient, family, or medical confirmation
• Assist with administration of patient’s Solu-Cortef IM if present (adult dose is 100mg)
• If Solu-Cortef not available, Solu-Medrol 125 mg slow IV/IO push
• Assess temperature
• If patient is febrile, apply cooling measures
• Look for underlying causes
Syncope/Near Syncope
TREATMENT
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Look for underlying causes
• Determine Blood Glucose Level. If BGL is abnormal, refer to Diabetic Guideline 5050
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
TREATMENT
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• Look for underlying causes
• Determine Blood Glucose Level. If BGL is abnormal, refer to Diabetic Guideline 5050
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Assess temperature
Non-Fatal Drowning
TREATMENT
• If trauma suspected, immobilize patient using proper technique
• Determine submersion time
• Airway/breathing management
• Anticipate rapid deterioration and the need to intubate
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider CPAP (Appendix H) for patients with pulmonary edema
• Initiate cardiac monitoring
• Assess temperature
• Maintain body warmth and correct as necessary
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Determine Blood Glucose Level
TREATMENT
• If trauma suspected, immobilize patient using proper technique
• Determine submersion time
• Airway/breathing management
• Anticipate rapid deterioration and the need to intubate
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Consider CPAP (Appendix H) for patients with pulmonary edema
• Initiate cardiac monitoring
• Assess temperature
• Maintain body warmth and correct as necessary
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Determine Blood Glucose Level
Decompression Sickness
TREATMENT
• Place patient in recovery position (left side)
• Airway/breathing management
• Monitor SpO2 and provide 100% O2 via NRB
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Assess temperature
• Maintain body warmth and correct as necessary
• Retrieve dive computer (if appropriate) and ensure transport with patient or try to obtain
depth and length of dive from patient or bystanders
• Tension Pneumothorax
• Needle decompression procedure (Appendix J)
• Determine Blood Glucose Level
• Do not transport to a Stand-alone ER
• Transport to closest most appropriate emergency department
• There is currently no emergent hyperbaric treatment chamber in Duval County
TREATMENT
• Place patient in recovery position (left side)
• Airway/breathing management
• Monitor SpO2 and provide 100% O2 via NRB
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Assess temperature
• Maintain body warmth and correct as necessary
• Retrieve dive computer (if appropriate) and ensure transport with patient or try to obtain
depth and length of dive from patient or bystanders
• Tension Pneumothorax
• Needle decompression procedure (Appendix J)
• Determine Blood Glucose Level
• Do not transport to a Stand-alone ER
• Transport to closest most appropriate emergency department
• There is currently no emergent hyperbaric treatment chamber in Duval County
Combative Patient
Request law enforcement if they are not already on scene.
A wide variety of medical conditions can cause a patient to become combative.
Excited Delirium can mimic several medical conditions including hypoxia, hypoglycemia, stroke, or intracranial bleeding. All patients suspected of experiencing Excited Delirium must be transported.
• Physical signs of excited delirium include:
• Unfounded fear and panic
• Shouting/nonsensical speech
• Bizarre behavior (hallucinations/paranoia)
• Hyperactivity and thrashing about (especially after restraint)
• Unexplained strength/endurance
• Shedding clothes/nudity (due to increased body temperature)
• Profuse diaphoresis
• Decreased sensitivity to pain
A previously combative patient who becomes suddenly quiet should raise a red flag.
TREATMENT
• Attempt to calm patient
• Move patient to a calm, quiet environment
• Respond in a confident, supportive manner
• Inquire about resolving the cause of anger
• Express sympathy and concern
• Apply restraints if needed and not already in place by law enforcement (e.g., handcuffs, flex cuffs)
• Approved JFRD physical restraints include:
• Soft limb restraints
• Stretcher straps/harness
• Wide cloth restraints
• No patient will be restrained in the prone or “hogtied” position
• Restraints shall not prohibit evaluation of the patient’s medical status or injure the
patient in any way
• Frequently assess the patient to ensure that the airway is patent, distal limb circulation
is adequate and that restraints can be released quickly should the patient’s condition
deteriorate
• When restraints are in use, circulation to the extremities shall be evaluated at least
every 5 minutes
• JFRD personnel shall never leave the restrained patient unattended
• Document the following in the patient care report:
• The patient’s behavior necessitating placement of restraints
• The type of restraint used
• Status of circulation distal to restraints at least every 5 minutes
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Assess temperature
• Look for underlying causes
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If medication is required to calm the patient
• If IV unobtainable
• Administer Ketamine 4 mg/kg IM; maximum dose 400 mg
• After 15 minutes, if sedation still needed, administer Midazolam 2-5 mg IM
• If IV in place
• Midazolam 2-5 mg IV
• May repeat one dose in 10 minutes
• Precaution
• Hypotension
• Airway assistance will be required if both Ketamine and Midazolam are
administered
• Airway assistance may still be required if only one medication is used
Request law enforcement if they are not already on scene.
A wide variety of medical conditions can cause a patient to become combative.
Excited Delirium can mimic several medical conditions including hypoxia, hypoglycemia, stroke, or intracranial bleeding. All patients suspected of experiencing Excited Delirium must be transported.
• Physical signs of excited delirium include:
• Unfounded fear and panic
• Shouting/nonsensical speech
• Bizarre behavior (hallucinations/paranoia)
• Hyperactivity and thrashing about (especially after restraint)
• Unexplained strength/endurance
• Shedding clothes/nudity (due to increased body temperature)
• Profuse diaphoresis
• Decreased sensitivity to pain
A previously combative patient who becomes suddenly quiet should raise a red flag.
TREATMENT
• Attempt to calm patient
• Move patient to a calm, quiet environment
• Respond in a confident, supportive manner
• Inquire about resolving the cause of anger
• Express sympathy and concern
• Apply restraints if needed and not already in place by law enforcement (e.g., handcuffs, flex cuffs)
• Approved JFRD physical restraints include:
• Soft limb restraints
• Stretcher straps/harness
• Wide cloth restraints
• No patient will be restrained in the prone or “hogtied” position
• Restraints shall not prohibit evaluation of the patient’s medical status or injure the
patient in any way
• Frequently assess the patient to ensure that the airway is patent, distal limb circulation
is adequate and that restraints can be released quickly should the patient’s condition
deteriorate
• When restraints are in use, circulation to the extremities shall be evaluated at least
every 5 minutes
• JFRD personnel shall never leave the restrained patient unattended
• Document the following in the patient care report:
• The patient’s behavior necessitating placement of restraints
• The type of restraint used
• Status of circulation distal to restraints at least every 5 minutes
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Assess temperature
• Look for underlying causes
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If medication is required to calm the patient
• If IV unobtainable
• Administer Ketamine 4 mg/kg IM; maximum dose 400 mg
• After 15 minutes, if sedation still needed, administer Midazolam 2-5 mg IM
• If IV in place
• Midazolam 2-5 mg IV
• May repeat one dose in 10 minutes
• Precaution
• Hypotension
• Airway assistance will be required if both Ketamine and Midazolam are
administered
• Airway assistance may still be required if only one medication is used
Hyperthermia
TREATMENT
• Move patient to cooler environment and remove any clothing or gear
• Assess temperature
• Oral and/or tympanic readings are typically less accurate and lower than actual body
core temperature
• Reduce temperature in patient compartment
• Treat heat stroke aggressively
• Apply and practice cooling measures (application of ice packs/wet towels to neck,
axillae, groin, etc. and fanning the skin) to reduce body temperature to less than 104 degrees as quickly as possible
• If ice water immersion cooling has been initiated by health care professionals
or athletic trainers, consider allowing continued treatment for up to an
additional 10 minutes after arrival
• When removing patient from ice bath, place some of the ice on the stretcher around the patient. A drag blanket or tarp may prove beneficial in this scenario
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
TREATMENT
• Move patient to cooler environment and remove any clothing or gear
• Assess temperature
• Oral and/or tympanic readings are typically less accurate and lower than actual body
core temperature
• Reduce temperature in patient compartment
• Treat heat stroke aggressively
• Apply and practice cooling measures (application of ice packs/wet towels to neck,
axillae, groin, etc. and fanning the skin) to reduce body temperature to less than 104 degrees as quickly as possible
• If ice water immersion cooling has been initiated by health care professionals
or athletic trainers, consider allowing continued treatment for up to an
additional 10 minutes after arrival
• When removing patient from ice bath, place some of the ice on the stretcher around the patient. A drag blanket or tarp may prove beneficial in this scenario
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
Hypothermia
TREATMENT
• Place patient in supine position
• Move patient to warmer environment
• Handle patient gently
• The hypothermic heart is irritable; excessive movement may result in ventricular
arrhythmias
• Assess temperature
• Rewarming is the priority
• Remove any wet clothing
• Increase core temperature with blankets
• Increase temperature in patient compartment to at least 85o
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg warmed intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
TREATMENT
• Place patient in supine position
• Move patient to warmer environment
• Handle patient gently
• The hypothermic heart is irritable; excessive movement may result in ventricular
arrhythmias
• Assess temperature
• Rewarming is the priority
• Remove any wet clothing
• Increase core temperature with blankets
• Increase temperature in patient compartment to at least 85o
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg warmed intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
Bites and Stings
If signs of allergic reaction noted, follow Allergic Reaction/Anaphylaxis Guideline (Section 5030).
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Insects and Spiders
• Remove stinger if present and cleanse with peroxide
• Marine Stings
• Remove any clinging tentacles by saltwater rinse (if unavailable, intravenous fluids) or
by using a gloved hand
• Avoid rinsing with fresh water
• Irrigate affected eye with intravenous fluids
• Tetracaine 2 drops to each eye before and after irrigation
• May be repeated every 10 minutes
• Contraindications
• Open ocular trauma
• Snake Bites
• If constricting bands in place upon arrival, remove
• Mark initial edematous area with pen and note time
• Attempt to identify type of snake
• Have FRCC contact potential receiving facilities to determine if they have anti-venom on
hand
• Apply sterile dressing
If signs of allergic reaction noted, follow Allergic Reaction/Anaphylaxis Guideline (Section 5030).
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Insects and Spiders
• Remove stinger if present and cleanse with peroxide
• Marine Stings
• Remove any clinging tentacles by saltwater rinse (if unavailable, intravenous fluids) or
by using a gloved hand
• Avoid rinsing with fresh water
• Irrigate affected eye with intravenous fluids
• Tetracaine 2 drops to each eye before and after irrigation
• May be repeated every 10 minutes
• Contraindications
• Open ocular trauma
• Snake Bites
• If constricting bands in place upon arrival, remove
• Mark initial edematous area with pen and note time
• Attempt to identify type of snake
• Have FRCC contact potential receiving facilities to determine if they have anti-venom on
hand
• Apply sterile dressing
Overdose/Poisoning
TREATMENT
• If substance is known, contact Poison Control at 1-800-222-1222. Provide all information
requested by poison control representative
• Do not delay treatment or transport, but if possible, bring medication or substance ingested
• Airway/breathing management
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Initiate cardiac monitoring
• Determine blood glucose Level
• Seizures may develop in many overdose/poison/ingestion situations
• Midazolam 2-5 mg IV/IO/IM for active seizures. If active seizing persists or returns,
may repeat doses up to total Maximum of 10 mg
• Airway assistance may be necessary after Midazolam administration
• Wear appropriate personal protective equipment
• Narcotic use
• If respiratory depression present or unable to protect airway
• Narcan 0.4 mg IV/IO/IM
• May repeat initial Narcan dose every 2 minutes to a maximum total dose of 2
mg
• If nasal Narcan administered prior to JFRD arrival, transport shall be encouraged
• Organophosphate exposure
• For all suspected organophosphate exposures, notify Haz Mat Team
• Signs and symptoms include Diarrhea, Urination, Miosis, Bradycardia,
Bronchorrhea, Bronchospasm, Emesis, Lacrimation and Salivation
• Mild symptoms
• Administer one (1) Duodote Kit (injection). If symptoms worsen, administer two (2) additional doses
• Severe symptoms
• Administer three (3) Duodote Kits (injections). No more than three (3) doses should
be administered
• Atropine 2 - 4 mg IV/IO every 3 to 5 minutes until secretions dry. No
maximum dose
• Precaution
• Acute myocardial infarction
• Wide complex atrio-ventricular blocks
• Midazolam 2-5 mg IV/IO/IM for active seizures. If active seizing persists or returns, may repeat doses up to total Maximum of 10 mg
• Airway assistance may be necessary after Midazolam administration
• Acute Dystonic Reaction to anti-psychotics (e.g., Haldol)
• Signs and symptoms include painful muscle spasms of the face, neck and back
• Benadryl 25 mg IV/IM
• Beta-Blocker overdose
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12
lead ECG
• If indicated (e.g., tachycardia, hypotension), up to 20 mL/kg intravenous fluids;
maximum 2L
• If hypotensive after 500 mL fluid administration
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• First line medication for cardiogenic shock (pulmonary edema with
hypotension)
• Calcium Channel Blocker toxicity
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12
lead ECG
• Calcium Chloride 5 mg/kg IV/IO (Maximum dose 500 mg) over 2 minutes
• If indicated (e.g., tachycardia, hypotension), up to 20 mL/kg intravenous fluids;
maximum 2L
• If hypotensive after 500 mL fluid administration
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• First line medication for cardiogenic shock (pulmonary edema with
hypotension)
• Tricyclic Antidepressant overdose with hypotension, ALOC, tachycardia, seizures, ventricular arrhythmias or a wide QRS complex:
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12
lead ECG
• Sodium Bicarbonate 1 mEq/kg IV/IO
TREATMENT
• If substance is known, contact Poison Control at 1-800-222-1222. Provide all information
requested by poison control representative
• Do not delay treatment or transport, but if possible, bring medication or substance ingested
• Airway/breathing management
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Initiate cardiac monitoring
• Determine blood glucose Level
• Seizures may develop in many overdose/poison/ingestion situations
• Midazolam 2-5 mg IV/IO/IM for active seizures. If active seizing persists or returns,
may repeat doses up to total Maximum of 10 mg
• Airway assistance may be necessary after Midazolam administration
• Wear appropriate personal protective equipment
• Narcotic use
• If respiratory depression present or unable to protect airway
• Narcan 0.4 mg IV/IO/IM
• May repeat initial Narcan dose every 2 minutes to a maximum total dose of 2
mg
• If nasal Narcan administered prior to JFRD arrival, transport shall be encouraged
• Organophosphate exposure
• For all suspected organophosphate exposures, notify Haz Mat Team
• Signs and symptoms include Diarrhea, Urination, Miosis, Bradycardia,
Bronchorrhea, Bronchospasm, Emesis, Lacrimation and Salivation
• Mild symptoms
• Administer one (1) Duodote Kit (injection). If symptoms worsen, administer two (2) additional doses
• Severe symptoms
• Administer three (3) Duodote Kits (injections). No more than three (3) doses should
be administered
• Atropine 2 - 4 mg IV/IO every 3 to 5 minutes until secretions dry. No
maximum dose
• Precaution
• Acute myocardial infarction
• Wide complex atrio-ventricular blocks
• Midazolam 2-5 mg IV/IO/IM for active seizures. If active seizing persists or returns, may repeat doses up to total Maximum of 10 mg
• Airway assistance may be necessary after Midazolam administration
• Acute Dystonic Reaction to anti-psychotics (e.g., Haldol)
• Signs and symptoms include painful muscle spasms of the face, neck and back
• Benadryl 25 mg IV/IM
• Beta-Blocker overdose
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12
lead ECG
• If indicated (e.g., tachycardia, hypotension), up to 20 mL/kg intravenous fluids;
maximum 2L
• If hypotensive after 500 mL fluid administration
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• First line medication for cardiogenic shock (pulmonary edema with
hypotension)
• Calcium Channel Blocker toxicity
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12
lead ECG
• Calcium Chloride 5 mg/kg IV/IO (Maximum dose 500 mg) over 2 minutes
• If indicated (e.g., tachycardia, hypotension), up to 20 mL/kg intravenous fluids;
maximum 2L
• If hypotensive after 500 mL fluid administration
• Dopamine 5-10 mcg/kg/min IV/IO and titrate to systolic BP of 90 mmHg
• First line medication for cardiogenic shock (pulmonary edema with
hypotension)
• Tricyclic Antidepressant overdose with hypotension, ALOC, tachycardia, seizures, ventricular arrhythmias or a wide QRS complex:
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12
lead ECG
• Sodium Bicarbonate 1 mEq/kg IV/IO
Carbon Monoxide/Cyanide Exposure
TREATMENT
• Request the HAZMAT team when appropriate
• Wear appropriate personal protective barrier
• Remove the patient to an environment with fresh air
• Determine the carboxyhemoglobin saturation (SpCO) if possible
• Abnormal values
• Non-smoker
• Greater than 5%
• Smoker
• Greater than 10%
• Airway/breathing management
• Monitor SpO2, readings may be falsely high in the presence of Carbon Monoxide
• Administer 100% O2 via NRB
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead ECG
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Assess blood glucose level
• Do not transport to a Stand-alone ER
• There is currently no emergent hyperbaric treatment chamber in Duval County
TREATMENT
• Request the HAZMAT team when appropriate
• Wear appropriate personal protective barrier
• Remove the patient to an environment with fresh air
• Determine the carboxyhemoglobin saturation (SpCO) if possible
• Abnormal values
• Non-smoker
• Greater than 5%
• Smoker
• Greater than 10%
• Airway/breathing management
• Monitor SpO2, readings may be falsely high in the presence of Carbon Monoxide
• Administer 100% O2 via NRB
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead ECG
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present
• Assess blood glucose level
• Do not transport to a Stand-alone ER
• There is currently no emergent hyperbaric treatment chamber in Duval County
Left Ventricular Assist Device (LVAD)
An LVAD is a mechanical pump that is used to support heart function and blood flow in people who have weakened hearts. The device takes blood from the lower chamber of the heart and helps pump it to the body and vital organs just as a healthy heart would. A properly functioning device produces a continuous whirling sound which can be hard with auscultation of the chest.
This protocol applies to the management of all patients who have an LVAD implanted. Please
remember that these patients, along with their families, have been well trained in the care of
themselves and their devices. LISTEN TO THEM! Patients always carry a “backup bag” which
contains 2 extra fully charged batteries, and a second controller. Make sure to always bring this emergency backup equipment with them to the hospital.
Call the number listed on the device for the on-call LVAD coordinator and you must
transport to Mayo Clinic.
TREATMENT
• Auscultate for heart sounds to determine if LVAD is operating
• Airway/breathing management
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Obtain vital signs:
• In most of these patients, a pulse will not be palpable. This is because the LVAD
unloads the ventricle in a continuous fashion and therefore the aortic valve may not
open with each contraction
• A manual blood pressure may not be obtainable. An automated cuff should be used
and is likely to measure a narrow pulse pressure
• Your treatment of the patient will be based on the mean arterial pressure. In these
patients, the normal range for the MAP is greater than 60 and less than 90
• Pulse oximetry may not be accurate due to the continuous flow nature of the LVAD
• Initiate cardiac monitoring
• Perform 12 lead ECG if chest pain or ischemic equivalent symptoms present. The
receiving hospital must receive a hard copy of the 12 lead ECG
• If patient meets STEMI criteria on 12 lead ECG, follow STEMI procedures (Section
3010)
• All dysrhythmias should be treated in accordance with appropriate protocols
• If the patient is unconscious, unresponsive to stimuli, and pulseless:
• If LVAD is operating (able to auscultate whirling sound) with MAP >50mmHg, DO NOT PERFORM CPR
• The LVAD device has been surgically placed into the left ventricle and CPR could dislodge this device, causing death
• If LVAD is NOT operating or MAP <50mmHg, perform CPR per cardiac arrest protocol
• The Lucas CPR device is contraindicated
• Transport to Mayo Clinic
An LVAD is a mechanical pump that is used to support heart function and blood flow in people who have weakened hearts. The device takes blood from the lower chamber of the heart and helps pump it to the body and vital organs just as a healthy heart would. A properly functioning device produces a continuous whirling sound which can be hard with auscultation of the chest.
This protocol applies to the management of all patients who have an LVAD implanted. Please
remember that these patients, along with their families, have been well trained in the care of
themselves and their devices. LISTEN TO THEM! Patients always carry a “backup bag” which
contains 2 extra fully charged batteries, and a second controller. Make sure to always bring this emergency backup equipment with them to the hospital.
Call the number listed on the device for the on-call LVAD coordinator and you must
transport to Mayo Clinic.
TREATMENT
• Auscultate for heart sounds to determine if LVAD is operating
• Airway/breathing management
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9010 as indicated
• Obtain vital signs:
• In most of these patients, a pulse will not be palpable. This is because the LVAD
unloads the ventricle in a continuous fashion and therefore the aortic valve may not
open with each contraction
• A manual blood pressure may not be obtainable. An automated cuff should be used
and is likely to measure a narrow pulse pressure
• Your treatment of the patient will be based on the mean arterial pressure. In these
patients, the normal range for the MAP is greater than 60 and less than 90
• Pulse oximetry may not be accurate due to the continuous flow nature of the LVAD
• Initiate cardiac monitoring
• Perform 12 lead ECG if chest pain or ischemic equivalent symptoms present. The
receiving hospital must receive a hard copy of the 12 lead ECG
• If patient meets STEMI criteria on 12 lead ECG, follow STEMI procedures (Section
3010)
• All dysrhythmias should be treated in accordance with appropriate protocols
• If the patient is unconscious, unresponsive to stimuli, and pulseless:
• If LVAD is operating (able to auscultate whirling sound) with MAP >50mmHg, DO NOT PERFORM CPR
• The LVAD device has been surgically placed into the left ventricle and CPR could dislodge this device, causing death
• If LVAD is NOT operating or MAP <50mmHg, perform CPR per cardiac arrest protocol
• The Lucas CPR device is contraindicated
• Transport to Mayo Clinic
Vaginal Bleeding
TREATMENT
• Determine last menstrual period (LMP)
• Place patient in position of comfort
• If pregnant and greater than 20 weeks, place patient in recovery position (left side)
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Apply trauma pads to vaginal area for significant bleeding
TREATMENT
• Determine last menstrual period (LMP)
• Place patient in position of comfort
• If pregnant and greater than 20 weeks, place patient in recovery position (left side)
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Apply trauma pads to vaginal area for significant bleeding
Pre-Eclampsia/Eclampsia
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• Assess temperature
• If greater than 20 weeks, place patient in recovery position (left side)
• Pre-eclampsia
• Disorder of pregnancy after 20 weeks characterized by the onset of fluid retention and
high blood pressure
• Physical exam may reveal blood pressure greater than 140/90 mmHg, tachycardia,
tachypnea, pulmonary edema, confusion, and generalized edema
• Eclampsia/Severe Pre-eclampsia
• Further complication of the pre-eclampsia patient
• Physical exam may reveal seizure, altered LOC, and blood pressure greater than
160/110 mmHg
• Can occur postpartum (up to six weeks after delivery)
• This condition is life-threatening to the mother and baby if not treated promptly
• If presence of seizure activity or 2 consecutive blood pressure readings greater
than 160/110 mmHg within 5 minutes
• Magnesium Sulfate 4 grams IV/IO
• Considerations
• Watch for hypotension and respiratory depression
• Midazolam 2-5 mg IV/IO/IM for seizure activity unresolved by Magnesium Sulfate
• If active seizing persists or returns, may repeat dose once
• Precaution
• Airway assistance may be necessary after Midazolam administration
• Hypotension
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• Assess temperature
• If greater than 20 weeks, place patient in recovery position (left side)
• Pre-eclampsia
• Disorder of pregnancy after 20 weeks characterized by the onset of fluid retention and
high blood pressure
• Physical exam may reveal blood pressure greater than 140/90 mmHg, tachycardia,
tachypnea, pulmonary edema, confusion, and generalized edema
• Eclampsia/Severe Pre-eclampsia
• Further complication of the pre-eclampsia patient
• Physical exam may reveal seizure, altered LOC, and blood pressure greater than
160/110 mmHg
• Can occur postpartum (up to six weeks after delivery)
• This condition is life-threatening to the mother and baby if not treated promptly
• If presence of seizure activity or 2 consecutive blood pressure readings greater
than 160/110 mmHg within 5 minutes
• Magnesium Sulfate 4 grams IV/IO
• Considerations
• Watch for hypotension and respiratory depression
• Midazolam 2-5 mg IV/IO/IM for seizure activity unresolved by Magnesium Sulfate
• If active seizing persists or returns, may repeat dose once
• Precaution
• Airway assistance may be necessary after Midazolam administration
• Hypotension
Imminent Delivery
TREATMENT
• Provide rapid transport
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Delivery – without complications
• Apply gentle perineal pressure to allow a slow, controlled delivery of the head
• Observe for meconium staining, suctioning is imperative
• Gently guide the head downward to allow delivery of the upper shoulder. Do not pull on
the newborn to facilitate delivery
• Gently guide the head upward and allow delivery of the lower shoulder
• Once the shoulders are delivered, the newborn’s trunk and legs will follow rapidly. Be
prepared to grasp and support the newborn as it emerges
• Once the newborn is delivered, maintain body position at the same level as the vagina
to prevent blood drainage from the umbilical cord
• Wipe any blood or mucus from the newborn’s nose and mouth with a sterile gauze
• Use a bulb syringe to suction the mouth and nostrils only when the newborn is having
difficulty clearing the airway, if secretions are obstructing the airway, or if BVM
ventilation is necessary
• Dry the newborn and wrap in dry blanket
• Record the time of birth
• Apply 2 clamps (2 to 3 inches apart), 7 to 10 inches from abdomen of the neonate
• Cut cord between clamps
• Closely monitor the cut umbilical cord for bleeding
• Maintain body temperature of neonate post delivery
• Assess and record APGAR at one minute and five minutes post delivery
• Placenta must be brought to the hospital for evaluation
• Postpartum
• Assess for postpartum hemorrhage
• Gently massage uterus until firm
• Transport to the hospital where patient has received their prenatal care if possible
• For the complications listed below, transport to the nearest Emergency Department with
L&D capabilities (see Hospital Capabilities Chart for JFRD)
• Nuchal Cord
• Feel for the cord around the neck as soon as the head is delivered
• Gently remove the cord from around the neck
• If unable to remove, clamp and cut the cord
• Use extreme caution when cutting the cord
• Breech Delivery
• If delivery is not immediate:
• Place the mother in the knee-chest position
• If delivery is immediate:
• Allow the buttocks or feet to deliver on their own and support the trunk
• Check for the umbilical cord around the neonate’s neck and allow the head to
deliver
• If the head does not deliver within 3 minutes, use a gloved hand to make an
airway for the neonate, using the fingers to make airspace
• Limb or Brow Presentation
• Place the mother in the knee-chest position
• Prolapsed Cord
• Assessment should focus on the presence of pulses in the umbilical cord and relief
of the pressure obstructing the blood flow within the cord
• Place the mother in the knee-chest position or supine with hips elevated
• Relieve pressure from the prolapsed cord if no pulses are detected in the cord
• Use gloved hand to gently but firmly push the neonate’s head back into the vagina; avoid pushing on the fontanels
• Stop pushing upon the return of pulses in the cord
• Do not push the cord back into the vagina, but keep moist with soaked towels
• Abruptio Placenta or Placenta Previa
• Treat for shock if indicated. See Guideline 5100
TREATMENT
• Provide rapid transport
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Delivery – without complications
• Apply gentle perineal pressure to allow a slow, controlled delivery of the head
• Observe for meconium staining, suctioning is imperative
• Gently guide the head downward to allow delivery of the upper shoulder. Do not pull on
the newborn to facilitate delivery
• Gently guide the head upward and allow delivery of the lower shoulder
• Once the shoulders are delivered, the newborn’s trunk and legs will follow rapidly. Be
prepared to grasp and support the newborn as it emerges
• Once the newborn is delivered, maintain body position at the same level as the vagina
to prevent blood drainage from the umbilical cord
• Wipe any blood or mucus from the newborn’s nose and mouth with a sterile gauze
• Use a bulb syringe to suction the mouth and nostrils only when the newborn is having
difficulty clearing the airway, if secretions are obstructing the airway, or if BVM
ventilation is necessary
• Dry the newborn and wrap in dry blanket
• Record the time of birth
• Apply 2 clamps (2 to 3 inches apart), 7 to 10 inches from abdomen of the neonate
• Cut cord between clamps
• Closely monitor the cut umbilical cord for bleeding
• Maintain body temperature of neonate post delivery
• Assess and record APGAR at one minute and five minutes post delivery
• Placenta must be brought to the hospital for evaluation
• Postpartum
• Assess for postpartum hemorrhage
• Gently massage uterus until firm
• Transport to the hospital where patient has received their prenatal care if possible
• For the complications listed below, transport to the nearest Emergency Department with
L&D capabilities (see Hospital Capabilities Chart for JFRD)
• Nuchal Cord
• Feel for the cord around the neck as soon as the head is delivered
• Gently remove the cord from around the neck
• If unable to remove, clamp and cut the cord
• Use extreme caution when cutting the cord
• Breech Delivery
• If delivery is not immediate:
• Place the mother in the knee-chest position
• If delivery is immediate:
• Allow the buttocks or feet to deliver on their own and support the trunk
• Check for the umbilical cord around the neonate’s neck and allow the head to
deliver
• If the head does not deliver within 3 minutes, use a gloved hand to make an
airway for the neonate, using the fingers to make airspace
• Limb or Brow Presentation
• Place the mother in the knee-chest position
• Prolapsed Cord
• Assessment should focus on the presence of pulses in the umbilical cord and relief
of the pressure obstructing the blood flow within the cord
• Place the mother in the knee-chest position or supine with hips elevated
• Relieve pressure from the prolapsed cord if no pulses are detected in the cord
• Use gloved hand to gently but firmly push the neonate’s head back into the vagina; avoid pushing on the fontanels
• Stop pushing upon the return of pulses in the cord
• Do not push the cord back into the vagina, but keep moist with soaked towels
• Abruptio Placenta or Placenta Previa
• Treat for shock if indicated. See Guideline 5100
Newborn Stabilization/Resuscitation
The majority of newborns require no stabilization beyond drying, warming, positioning, suctioning, and tactile stimulation. More invasive procedures may be required for
multiple births, pre-mature birth, or there is meconium staining.
ASSESSMENT
APGAR SCORE
APPEARANCE
0-Blue all over
1-Acrocyanosis
2-Pink all over
PULSE
0-Absent
1-<100
2->=100
GRIMACE/IRRITABILITY
0-No response or none
1-Grimace, weak cry
2-Sneeze, cough, vigorous cry
ACTIVITY/MUSCLE TONE
0-Limp/flaccid
1-Some motion/flexion of extremities
2-Active motion
RESPIRATIONS
0-None
1-Slow/irregular
2-Vigorous cry or Normal respirations
The majority of newborns require no stabilization beyond drying, warming, positioning, suctioning, and tactile stimulation. More invasive procedures may be required for
multiple births, pre-mature birth, or there is meconium staining.
ASSESSMENT
APGAR SCORE
APPEARANCE
0-Blue all over
1-Acrocyanosis
2-Pink all over
PULSE
0-Absent
1-<100
2->=100
GRIMACE/IRRITABILITY
0-No response or none
1-Grimace, weak cry
2-Sneeze, cough, vigorous cry
ACTIVITY/MUSCLE TONE
0-Limp/flaccid
1-Some motion/flexion of extremities
2-Active motion
RESPIRATIONS
0-None
1-Slow/irregular
2-Vigorous cry or Normal respirations
Newborn Stabilization/Resuscitation
TREATMENT
• If complications are present with mother or child, request a second rescue if necessary
• Wipe any blood or mucus from the newborn’s nose and mouth with a sterile gauze
• Use a bulb syringe to suction the mouth and nostrils only when the newborn is having difficulty clearing the airway, if secretions are obstructing the airway, or if BVM ventilation is necessary
• Thoroughly dry the newborn with towels or blankets. Wrap newborn in a dry blanket
• Administer tactile stimulation, if required, by tapping soles of feet
• Assess and record APGAR at one minute and five minutes post delivery
• Position the infant in the supine position with the neck in a neutral position. A 1” blanket roll under the shoulders will help maintain head position, if aggressive airway management is needed
• Re-assess newborn every 30 seconds
• Determine BGL by heel stick
• Initiate cardiac monitoring
• Airway/breathing management
• Assess respiratory rate and effort
• Establish IV/IO access only if neonate is in distress, do not delay transport for vascular access
• If indicated (e.g., tachycardia, hypotension), 10 mL/kg intravenous fluids
• Consider specific treatment situations:
• Pre-viable delivery is defined as 24 weeks or less
• Resuscitation should not be initiated
• Any treatment should be comfort only
• Cyanosis isolated to the extremities (acrocyanosis)
• Saturation may remain less than normal for up to 10 minutes after birth
• Administer blow-by O2
• Heart rate less than 100 with labored breathing, apnea, persistent central cyanosis, and/or no muscle tone
• Provide 100% O2 at 40 to 60 ventilations/minute via infant BVM
• If symptoms persist, consider intubation of patient
• Heart rate less than 60
• Administer chest compressions/ventilations
• A 3:1 ratio of compressions to ventilation, with 90 compressions and 30 breaths to achieve approximately 120 events per minute to maximize ventilation at an achievable rate is recommended. Compressions and ventilations should be coordinated to avoid simultaneous delivery. The chest should be allowed to re- expand fully during relaxation (after each compression), but the rescuer’s thumbs should not leave the chest.
• Consider intubation
• Epinephrine 1:10,000 0.01 mg/kg every 3 to 5 min IV/IO
• Precaution
• Do not mix with any other drug
• Narcan 0.1 mg/kg IV/IO - Administer to improve respiratory depression in a newborn of a mother suspected of narcotic use within 4 hours of delivery
• Blood sugar <45 mg/dL
• D10W at 5mL/kg IV/IO
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Precaution
• Dextrose causes tissue necrosis and adequate vascular access must be ensured prior to administration
TREATMENT
• If complications are present with mother or child, request a second rescue if necessary
• Wipe any blood or mucus from the newborn’s nose and mouth with a sterile gauze
• Use a bulb syringe to suction the mouth and nostrils only when the newborn is having difficulty clearing the airway, if secretions are obstructing the airway, or if BVM ventilation is necessary
• Thoroughly dry the newborn with towels or blankets. Wrap newborn in a dry blanket
• Administer tactile stimulation, if required, by tapping soles of feet
• Assess and record APGAR at one minute and five minutes post delivery
• Position the infant in the supine position with the neck in a neutral position. A 1” blanket roll under the shoulders will help maintain head position, if aggressive airway management is needed
• Re-assess newborn every 30 seconds
• Determine BGL by heel stick
• Initiate cardiac monitoring
• Airway/breathing management
• Assess respiratory rate and effort
• Establish IV/IO access only if neonate is in distress, do not delay transport for vascular access
• If indicated (e.g., tachycardia, hypotension), 10 mL/kg intravenous fluids
• Consider specific treatment situations:
• Pre-viable delivery is defined as 24 weeks or less
• Resuscitation should not be initiated
• Any treatment should be comfort only
• Cyanosis isolated to the extremities (acrocyanosis)
• Saturation may remain less than normal for up to 10 minutes after birth
• Administer blow-by O2
• Heart rate less than 100 with labored breathing, apnea, persistent central cyanosis, and/or no muscle tone
• Provide 100% O2 at 40 to 60 ventilations/minute via infant BVM
• If symptoms persist, consider intubation of patient
• Heart rate less than 60
• Administer chest compressions/ventilations
• A 3:1 ratio of compressions to ventilation, with 90 compressions and 30 breaths to achieve approximately 120 events per minute to maximize ventilation at an achievable rate is recommended. Compressions and ventilations should be coordinated to avoid simultaneous delivery. The chest should be allowed to re- expand fully during relaxation (after each compression), but the rescuer’s thumbs should not leave the chest.
• Consider intubation
• Epinephrine 1:10,000 0.01 mg/kg every 3 to 5 min IV/IO
• Precaution
• Do not mix with any other drug
• Narcan 0.1 mg/kg IV/IO - Administer to improve respiratory depression in a newborn of a mother suspected of narcotic use within 4 hours of delivery
• Blood sugar <45 mg/dL
• D10W at 5mL/kg IV/IO
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Precaution
• Dextrose causes tissue necrosis and adequate vascular access must be ensured prior to administration
Pediatric Assessment
Pediatric assessment
• Identify parent, care giver or legal guardian
• Identify signs of abuse/neglect (observe patient’s surroundings)
• Ensure medications or accurate medication list is available for receiving facility
• Assessment of pediatric patient requires observation, auscultation and palpation
Abnormal findings:
• Appearance
• Decreased response to parents or environmental stimuli
• Rigid or poor muscle tone or not moving
• Breathing
• Abnormal or no cry or speech
• Increased/excessive nasal flaring
• Retractions or abdominal muscle use
• Decreased or no respiratory effort
• Noisy breathing (wheezing, grunting, gasping, or gurgling)
• Respiratory rate outside normal range
• Circulation
• Abnormal skin color (cyanosis, mottling, or paleness)
• Obvious significant bleeding
• Capillary refill >2 seconds with other abnormal findings
Normal vital signs:
Normal Respiratory Rate
Infant (<1yr): 30- 53
Toddler (1-3yr): 22 -37
Preschooler(4-5yr): 20-28
School-age(6-12yr): 18 -25
Adolescent(13-17yr): 12 -20
Normal Pulse Rate
Infant: 100-180
Toddler: 98-140
Preschooler: 80-120
School-age: 75-118
Adolescent: 60-100
Pulses slower in sleeping child/athlete
Lower Limit of Normal Systolic BP
Infant: >72 (or strong pulses)
Toddler: >86 (or strong pulses)
Preschooler: >89
School-age: >97
Adolescent: >110
Pediatric assessment
• Identify parent, care giver or legal guardian
• Identify signs of abuse/neglect (observe patient’s surroundings)
• Ensure medications or accurate medication list is available for receiving facility
• Assessment of pediatric patient requires observation, auscultation and palpation
Abnormal findings:
• Appearance
• Decreased response to parents or environmental stimuli
• Rigid or poor muscle tone or not moving
• Breathing
• Abnormal or no cry or speech
• Increased/excessive nasal flaring
• Retractions or abdominal muscle use
• Decreased or no respiratory effort
• Noisy breathing (wheezing, grunting, gasping, or gurgling)
• Respiratory rate outside normal range
• Circulation
• Abnormal skin color (cyanosis, mottling, or paleness)
• Obvious significant bleeding
• Capillary refill >2 seconds with other abnormal findings
Normal vital signs:
Normal Respiratory Rate
Infant (<1yr): 30- 53
Toddler (1-3yr): 22 -37
Preschooler(4-5yr): 20-28
School-age(6-12yr): 18 -25
Adolescent(13-17yr): 12 -20
Normal Pulse Rate
Infant: 100-180
Toddler: 98-140
Preschooler: 80-120
School-age: 75-118
Adolescent: 60-100
Pulses slower in sleeping child/athlete
Lower Limit of Normal Systolic BP
Infant: >72 (or strong pulses)
Toddler: >86 (or strong pulses)
Preschooler: >89
School-age: >97
Adolescent: >110
Pediatric Bradycardia
Symptomatic pediatric bradycardia: cool mottled skin, diminished pulses, altered mental status, increased capillary refill time (>2 seconds).
TREATMENT
• Airway/breathing management
• Monitor SpO2 and administer 100% O2 via NRB
• Refer to Advanced Airway Guideline 9030 as indicated
• If signs of severe cardiopulmonary compromise are present
• Ventilate with BVM
• If patient 8 years old or less and has signs of poor perfusion (as described above) with a
heart rate <60 despite 100% O2 and ventilation for 2 minutes, initiate chest compressions according to Pediatric Asystole/Pulseless Electrical Activity Guideline 8080
• Look for signs of airway obstruction:
• No breath sounds
• Tachypnea
• Intercostal and suprasternal retractions
• Stridor
• Choking
• Cyanosis
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• A 4 lead ECG is acceptable for an infant
• Establish IV/IO access
• If indicated (e.g., hypotension), up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• If heart rate remains <60 with signs of poor perfusion despite previous interventions
• Epinephrine 1:10,000 0.01 mg/kg every 3 to 5 min IV/IO; maximum dose 1 mg
• Precaution
• Do not mix with any other drug
• Refractory to Epinephrine or increased vagal tone, organophosphate exposure or high degree heart blocks:
• Atropine 0.02 mg/kg IV/IO
• Minimum dose 0.1 mg
• Maximum single dose 0.5 mg
• May repeat dose once in 5 minutes
• Determine Blood Glucose Level
• Assess temperature
• Hypothermia – Rewarm patient, ensure patient compartment is warm and administer
warm IV fluids
Symptomatic pediatric bradycardia: cool mottled skin, diminished pulses, altered mental status, increased capillary refill time (>2 seconds).
TREATMENT
• Airway/breathing management
• Monitor SpO2 and administer 100% O2 via NRB
• Refer to Advanced Airway Guideline 9030 as indicated
• If signs of severe cardiopulmonary compromise are present
• Ventilate with BVM
• If patient 8 years old or less and has signs of poor perfusion (as described above) with a
heart rate <60 despite 100% O2 and ventilation for 2 minutes, initiate chest compressions according to Pediatric Asystole/Pulseless Electrical Activity Guideline 8080
• Look for signs of airway obstruction:
• No breath sounds
• Tachypnea
• Intercostal and suprasternal retractions
• Stridor
• Choking
• Cyanosis
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• A 4 lead ECG is acceptable for an infant
• Establish IV/IO access
• If indicated (e.g., hypotension), up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• If heart rate remains <60 with signs of poor perfusion despite previous interventions
• Epinephrine 1:10,000 0.01 mg/kg every 3 to 5 min IV/IO; maximum dose 1 mg
• Precaution
• Do not mix with any other drug
• Refractory to Epinephrine or increased vagal tone, organophosphate exposure or high degree heart blocks:
• Atropine 0.02 mg/kg IV/IO
• Minimum dose 0.1 mg
• Maximum single dose 0.5 mg
• May repeat dose once in 5 minutes
• Determine Blood Glucose Level
• Assess temperature
• Hypothermia – Rewarm patient, ensure patient compartment is warm and administer
warm IV fluids
Pediatric Tachycardia
Symptomatic pediatric tachycardia: cool mottled skin, diminished pulses, altered mental status, increased capillary refill time (>2 seconds).
Sinus Tachycardia = Infant <220 or Child (1-17 years) <180 with narrow QRS
Symptomatic Tachycardia = Infant >220 or Child (1-17 years) >180 with signs of poor perfusion
TREATMENT
• If the patient is asymptomatic look for underlying causes (fever, dehydration, pain etc.)
• Airway/breathing management
• Monitor SpO2 and administer 100% O2 via NRB
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• A 4 lead ECG is acceptable for an infant
• Evaluate width of QRS
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Determine Blood Glucose Level
• Assess temperature
• Consider specific treatment based on evaluation of patient and QRS
• Stable
• Narrow QRS (<0.08) and infant rate >220/minute or child rate >180/minute (Supraventricular Tachycardia)
• Adenosine 0.1 mg/kg IV (Maximum 1st dose 6 mg) rapid bolus, followed by
intravenous fluids bolus, may repeat once at 0.2 mg/kg (Maximum 2nd dose 12 mg)
• Unstable
• Narrow QRS (<0.08) and infant rate >220/minute or child rate >180/minute
(Supraventricular Tachycardia)
• If vascular access is available, administer Adenosine 0.1 mg/kg IV/IO
(Maximum dose 6 mg) rapid bolus, followed by intravenous fluids bolus
• Synchronized cardioversion 0.5 - 1 J/kg; if not effective increase to 2 J/kg,
• If patient requires sedation, Ketamine 1 mg/kg IV/IO
• Wide QRS (>0.08) Ventricular tachycardia
• Synchronized cardioversion 0.5 - 1 J/kg; if not effective increase to 2 J/kg
• If patient requires sedation, Ketamine 1 mg/kg IV/IO
Symptomatic pediatric tachycardia: cool mottled skin, diminished pulses, altered mental status, increased capillary refill time (>2 seconds).
Sinus Tachycardia = Infant <220 or Child (1-17 years) <180 with narrow QRS
Symptomatic Tachycardia = Infant >220 or Child (1-17 years) >180 with signs of poor perfusion
TREATMENT
• If the patient is asymptomatic look for underlying causes (fever, dehydration, pain etc.)
• Airway/breathing management
• Monitor SpO2 and administer 100% O2 via NRB
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Perform 12 lead ECG. The receiving hospital must receive a hard copy of the 12 lead
ECG
• A 4 lead ECG is acceptable for an infant
• Evaluate width of QRS
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Determine Blood Glucose Level
• Assess temperature
• Consider specific treatment based on evaluation of patient and QRS
• Stable
• Narrow QRS (<0.08) and infant rate >220/minute or child rate >180/minute (Supraventricular Tachycardia)
• Adenosine 0.1 mg/kg IV (Maximum 1st dose 6 mg) rapid bolus, followed by
intravenous fluids bolus, may repeat once at 0.2 mg/kg (Maximum 2nd dose 12 mg)
• Unstable
• Narrow QRS (<0.08) and infant rate >220/minute or child rate >180/minute
(Supraventricular Tachycardia)
• If vascular access is available, administer Adenosine 0.1 mg/kg IV/IO
(Maximum dose 6 mg) rapid bolus, followed by intravenous fluids bolus
• Synchronized cardioversion 0.5 - 1 J/kg; if not effective increase to 2 J/kg,
• If patient requires sedation, Ketamine 1 mg/kg IV/IO
• Wide QRS (>0.08) Ventricular tachycardia
• Synchronized cardioversion 0.5 - 1 J/kg; if not effective increase to 2 J/kg
• If patient requires sedation, Ketamine 1 mg/kg IV/IO
Pediatric Shock
Shock patients may deteriorate rapidly. Signs of shock include hypotension, cool mottled skin, diminished pulses, altered mental status, increased capillary refill time (>2 seconds) and tachycardia.
TREATMENT
• Place patient in supine position
• Maintain body warmth
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9030 as indicated
• Assess temperature
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• For patients with Acute Adrenal Insufficiency, as confirmed by patient/family/medical professional or noted by the presence of a medical alert bracelet or record
• Assist with administration of patient’s Solu-Cortef IM if present
• <3 years: 25mg
• 4-12 years: 50mg
• 13 years and older: 100mg
• If Solu-Cortef not available, Solu-Medrol 2 mg/kg slow IV/IO push. Maximum dose 125 mg
Shock patients may deteriorate rapidly. Signs of shock include hypotension, cool mottled skin, diminished pulses, altered mental status, increased capillary refill time (>2 seconds) and tachycardia.
TREATMENT
• Place patient in supine position
• Maintain body warmth
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9030 as indicated
• Assess temperature
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• For patients with Acute Adrenal Insufficiency, as confirmed by patient/family/medical professional or noted by the presence of a medical alert bracelet or record
• Assist with administration of patient’s Solu-Cortef IM if present
• <3 years: 25mg
• 4-12 years: 50mg
• 13 years and older: 100mg
• If Solu-Cortef not available, Solu-Medrol 2 mg/kg slow IV/IO push. Maximum dose 125 mg
Pediatric Foreign Body Airway Obstruction
TREATMENT
• Airway/breathing management
• Foreign Body AIRWAY OBSTRUCTION MANEUVERS as indicated below:
• Infant (Less than 1 years)
• Conscious
• Mild Obstruction with good air exchange
• Do not interfere with patient’s own attempts to expel the obstruction
• Monitor closely for signs of worsening
• Attempt to keep patient calm
• Severe Obstruction
• If possible, bare the infant’s chest
• Support the infant in prone position, deliver up to 5 back blows in the
middle of the upper back
• Continuing to support the infant, rotate to a supine position with the head
lower than the trunk
• Deliver up to 5 quick downward chest thrusts in the same location as
chest compressions
• Repeat sequence until obstruction is cleared or the infant becomes
unconscious
• Unconscious
• Reposition airway and attempt to remove object by direct laryngoscopy with
Magill forceps
• Begin CPR as indicated
• Suction as indicated
• Refer to Advanced Airway Guideline 9030 as indicated
• If unable to clear airway and adequately oxygenate/ventilate, perform age appropriate cricothyrotomy (Appendix K)
• Child (1-17 years) • Conscious
• Mild Obstruction with good air exchange
• Encourage patient’s own spontaneous coughing and breathing efforts
• Attempt to keep patient calm
• Severe Obstruction:
• Abdominal thrusts (Heimlich maneuver)
• Unconscious
• Reposition airway and attempt to remove object by direct or video
laryngoscopy with Magill forceps Begin CPR as indicated
• Suction as indicated
• Refer to Advanced Airway Guideline 9030 as indicated
• If unable to clear airway and adequately oxygenate/ventilate, perform age
appropriate cricothyrotomy (Appendix K)
• Airway/breathing management
• Once obstruction is removed, administer O2 via proper adjunct to maintain oxygen
saturation of 95% or greater
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Establish IV/IO access only if obstruction cannot be relieved
• If IO used for access, the humerus is contraindicated in newborns and infants
TREATMENT
• Airway/breathing management
• Foreign Body AIRWAY OBSTRUCTION MANEUVERS as indicated below:
• Infant (Less than 1 years)
• Conscious
• Mild Obstruction with good air exchange
• Do not interfere with patient’s own attempts to expel the obstruction
• Monitor closely for signs of worsening
• Attempt to keep patient calm
• Severe Obstruction
• If possible, bare the infant’s chest
• Support the infant in prone position, deliver up to 5 back blows in the
middle of the upper back
• Continuing to support the infant, rotate to a supine position with the head
lower than the trunk
• Deliver up to 5 quick downward chest thrusts in the same location as
chest compressions
• Repeat sequence until obstruction is cleared or the infant becomes
unconscious
• Unconscious
• Reposition airway and attempt to remove object by direct laryngoscopy with
Magill forceps
• Begin CPR as indicated
• Suction as indicated
• Refer to Advanced Airway Guideline 9030 as indicated
• If unable to clear airway and adequately oxygenate/ventilate, perform age appropriate cricothyrotomy (Appendix K)
• Child (1-17 years) • Conscious
• Mild Obstruction with good air exchange
• Encourage patient’s own spontaneous coughing and breathing efforts
• Attempt to keep patient calm
• Severe Obstruction:
• Abdominal thrusts (Heimlich maneuver)
• Unconscious
• Reposition airway and attempt to remove object by direct or video
laryngoscopy with Magill forceps Begin CPR as indicated
• Suction as indicated
• Refer to Advanced Airway Guideline 9030 as indicated
• If unable to clear airway and adequately oxygenate/ventilate, perform age
appropriate cricothyrotomy (Appendix K)
• Airway/breathing management
• Once obstruction is removed, administer O2 via proper adjunct to maintain oxygen
saturation of 95% or greater
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Establish IV/IO access only if obstruction cannot be relieved
• If IO used for access, the humerus is contraindicated in newborns and infants
Pediatric Respiratory Distress
The following signs and symptoms will be treated as Respiratory Distress: increased respiratory rate, increased work of breathing, retractions, nasal flaring, SpO2 <95%.
• Normal Respiratory Rates
• Infant (<1yr): 30-53
• Toddler (1-3yr): 22-37
• Preschooler (4-5yr): 20-28
• School-age (6-12yr): 18 -25
• Adolescent (13-17yr): 12 -20
TREATMENT
• Airway/breathing management
• Assess breath sounds
• Administer O2 via NRB
• If unable to maintain an oxygen saturation of >=92% with NRB, provide 100% O2 with
BVM and positive pressure ventilations
• Refer to Advanced Airway Guideline 9030 as indicated
• If wheezing present, refer to Pediatric Asthma Guideline 8060
• Initiate cardiac monitoring
• Assess temperature
• Establish IV/IO access only if medication administration is required
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Determine Blood Glucose Level
• Mild croup (barking cough)
• Intravenous fluid 5 mL nebulized
• Moderate to severe croup (Inspiratory or expiratory stridor at rest)
• Mix 0.5 mg of Epinephrine 1:1000 in 5 mL of intravenous fluid in nebulizer
• Single dose only
• Possible Side Effects
• Tachycardia
• Tremors
• Vomiting
The following signs and symptoms will be treated as Respiratory Distress: increased respiratory rate, increased work of breathing, retractions, nasal flaring, SpO2 <95%.
• Normal Respiratory Rates
• Infant (<1yr): 30-53
• Toddler (1-3yr): 22-37
• Preschooler (4-5yr): 20-28
• School-age (6-12yr): 18 -25
• Adolescent (13-17yr): 12 -20
TREATMENT
• Airway/breathing management
• Assess breath sounds
• Administer O2 via NRB
• If unable to maintain an oxygen saturation of >=92% with NRB, provide 100% O2 with
BVM and positive pressure ventilations
• Refer to Advanced Airway Guideline 9030 as indicated
• If wheezing present, refer to Pediatric Asthma Guideline 8060
• Initiate cardiac monitoring
• Assess temperature
• Establish IV/IO access only if medication administration is required
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Determine Blood Glucose Level
• Mild croup (barking cough)
• Intravenous fluid 5 mL nebulized
• Moderate to severe croup (Inspiratory or expiratory stridor at rest)
• Mix 0.5 mg of Epinephrine 1:1000 in 5 mL of intravenous fluid in nebulizer
• Single dose only
• Possible Side Effects
• Tachycardia
• Tremors
• Vomiting
Pediatric Asthma
TREATMENT
• Airway/breathing management
• Assess breath sounds
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Establish IV/IO access only if medication administration is required
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Treatment should be based on lung sounds and level of distress
• Mild distress - Wheezes only
• Albuterol 5 mg and Atrovent 0.5 mg. May be repeated as needed. Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Moderate distress - Wheezes/decreased breath sounds/accessory muscle use
• Albuterol 5 mg and Atrovent 0.5 mg. May be repeated as needed. Subsequent
nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Magnesium Sulfate 50 mg/kg IV in 100-250 mL of intravenous fluid, infused over
10 minutes. Smaller bag is preferred
• Maximum dose 2 grams
• If patient weighs >25kg, dilution into 500 mL is acceptable if a smaller bag is not
available
• Solu-Medrol 2 mg/kg IV
• Maximum dose 125 mg
• Severe distress - Wheezes/stridor/decreased breath sounds with little or no air
movement/accessory muscle use/tripoding
• Epinephrine 1:1000 0.01 mg/kg IM only, Maximum dose 0.5 mg
• Continuous Positive Airway Pressure (CPAP) (Appendix H) in conjunction with
an in-line Albuterol/Atrovent nebulizer
• Albuterol 5 mg and Atrovent 0.5 mg. May be repeated as needed. Subsequent
nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Magnesium Sulfate 50 mg/kg IV/IO in 100-250 mL of intravenous fluid, infused
over 10 minutes. Smaller bag is preferred
• Maximum dose 2 grams
• If patient weighs >25kg, dilution into 500 mL is acceptable if a smaller bag is not
available
• Solu-Medrol 2 mg/kg IV/IO
• Maximum dose 125 mg
• Assess temperature
• Determine Blood Glucose Level
TREATMENT
• Airway/breathing management
• Assess breath sounds
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Establish IV/IO access only if medication administration is required
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Treatment should be based on lung sounds and level of distress
• Mild distress - Wheezes only
• Albuterol 5 mg and Atrovent 0.5 mg. May be repeated as needed. Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Moderate distress - Wheezes/decreased breath sounds/accessory muscle use
• Albuterol 5 mg and Atrovent 0.5 mg. May be repeated as needed. Subsequent
nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Magnesium Sulfate 50 mg/kg IV in 100-250 mL of intravenous fluid, infused over
10 minutes. Smaller bag is preferred
• Maximum dose 2 grams
• If patient weighs >25kg, dilution into 500 mL is acceptable if a smaller bag is not
available
• Solu-Medrol 2 mg/kg IV
• Maximum dose 125 mg
• Severe distress - Wheezes/stridor/decreased breath sounds with little or no air
movement/accessory muscle use/tripoding
• Epinephrine 1:1000 0.01 mg/kg IM only, Maximum dose 0.5 mg
• Continuous Positive Airway Pressure (CPAP) (Appendix H) in conjunction with
an in-line Albuterol/Atrovent nebulizer
• Albuterol 5 mg and Atrovent 0.5 mg. May be repeated as needed. Subsequent
nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Magnesium Sulfate 50 mg/kg IV/IO in 100-250 mL of intravenous fluid, infused
over 10 minutes. Smaller bag is preferred
• Maximum dose 2 grams
• If patient weighs >25kg, dilution into 500 mL is acceptable if a smaller bag is not
available
• Solu-Medrol 2 mg/kg IV/IO
• Maximum dose 125 mg
• Assess temperature
• Determine Blood Glucose Level
Pediatric V-Fib/Pulseless V-Tach
Children usually experience cardiopulmonary failure secondary to respiratory failure or shock and rarely due to primary cardiac disease or primary cardiac arrest. The emphasis should be placed on early identification of cardiac arrest with continuous well-performed compressions and defibrillation.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (should not take more than 10 seconds)
• If NO pulse present, proceed with chest compressions. Depress the chest at least one third the anterior-posterior diameter of the chest (approx. 11⁄2 inches in infants and 2 inches in children)
• Start cycles of 15 compressions to 2 breaths (with 100% O2 and BVM)
• The Lucas CPR Device (Appendix A) may be used when the patient is large enough. If the patient is too small, the Lucas device will alert with 3 fast signals when lowering the Suction Cup and you cannot enter the PAUSE mode or ACTIVE mode
• Continue this compression to ventilation ratio until placement of an advanced airway
• Use of basic airway adjuncts (OPA and/or NPAs) should be utilized when ventilating the
patient without an advanced airway in place
• Once an advanced airway is placed, provide continuous chest compressions and
provide 1 breath every 6 seconds
• If the provider is alone (brush truck or tanker), the use of a BVM in single rescuer
CPR is no longer recommended. Continuous, uninterrupted chest compressions with pauses for AED application/use only until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible. Perform 5 cycles of CPR in the unwitnessed arrest
• Check for shockable rhythm
• If shockable, give 1 shock at 2 J/KG and IMMEDIATELY continue CPR, starting with
compressions, for 2 minutes then reassess
• The time from the last compression to defibrillation should be minimized, within 5
seconds
• Continue to provide defibrillation every two minutes (the second shock and
subsequent shocks should be at 4 J/kg) if shockable rhythm is noted upon
reassessment
• If no shock advised, IMMEDIATELY continue CPR, starting with compressions, for 2
minutes then reassess
• Airway/breathing management
• Refer to Advanced Airway Guideline 9030 as indicated
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Administer Epinephrine 0.01 mg/kg (1:10,000) IV/IO; maximum dose 1mg
• Continue CPR
• Reassess for rhythm after 2 minutes
• If shockable rhythm, repeat shock sequence
• If not a shockable rhythm, continue CPR and change to appropriate treatment guideline
• Repeat Epinephrine every 3 to 5 minutes (consistently)
• Precaution
• Do not mix with any other drug
• After administration of Epinephrine, circulate for two minutes before giving anti-arrhythmic
• Administer antiarrhythmic, Amiodarone 5 mg/kg IV/IO (maximum single dose 300 mg), for recurrent VF/VT
• Continue CPR
• Reassess rhythm after 2 minutes
• If shockable rhythm, repeat shock sequence
• If not shockable rhythm, continue CPR and change to appropriate treatment guideline
• Repeat dose of Amiodarone 5 mg/kg IV/IO once (maximum repeat dose 150 mg)
• If rhythm was converted with defibrillation prior to administering initial Amiodarone dose, 5 mg/kg Amiodarone (maximum dose 150 mg) in small intravenous fluid bag (100-250cc) over 10 mins. Smaller bag is preferred
• This includes AED shocks by bystanders
• For Torsades de Pointes, Polymorphic VT, and refractory VF/VT:
• Administer Magnesium Sulfate 50 mg/kg IV/IO
• Maximum single dose 2 grams
• Magnesium Sulfate is to be used as the FIRST antiarrhythmic of choice in Torsades
(polymorphic VT)
• Continue CPR
• Reassess rhythm after two minutes
• If shockable rhythm, repeat shock sequence
• If not shockable rhythm, continue CPR and change to appropriate treatment
guideline
• Determine Blood Glucose Level
• Consider the following less common causes of cardiac arrest, H’s and T’s and their appropriate treatments:
• Hypovolemia
• Give bolus of intravenous fluid 20 mL/kg, repeat once if needed
• Hypoxia – provide 100% O2 with use of BVM and appropriate airway adjunct
• Hydrogen ion = acidosis
• Sodium Bicarbonate 1 mEq/kg IV/IO, Maximum single dose 50 mEq
• Contraindications
• None in Asystole/Pulseless Electrical Activity
• Precaution
• Do not mix with other drugs and flush line well after injecting
• Inactivates Epinephrine when mixed
• Inactivates Dopamine when mixed
• Hyperthermia/Hypothermia – cool or warm as needed
• Hypoglycemia – Appropriate dextrose concentration for the pediatric patient
• Neonate (<1 month) D10W at 5 mL/kg IV/IO for BGL less than 45 mg/dL
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of
intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Infant/child (1 month – 12 years) D25W at 2 mL/kg IV/IO for BGL less than 60 mg/dL
• To make D25W, discard 25ml out of one amp of D50 then draw 25ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Adolescent (13-18 years) D50W at 1 mL/kg IV/IO for BGL less than 60 mg/dL
• Maximum dose 25 grams
• If no improvement and BGL is below 60 mg/dL
• Repeat appropriate Dextrose concentration and dose
• Toxins/Tablets
• Narcan 0.1 mg/kg IV/IO (maximum 2 mg)
• Tension pneumothorax
• Needle decompression procedure (Appendix J)
Children usually experience cardiopulmonary failure secondary to respiratory failure or shock and rarely due to primary cardiac disease or primary cardiac arrest. The emphasis should be placed on early identification of cardiac arrest with continuous well-performed compressions and defibrillation.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (should not take more than 10 seconds)
• If NO pulse present, proceed with chest compressions. Depress the chest at least one third the anterior-posterior diameter of the chest (approx. 11⁄2 inches in infants and 2 inches in children)
• Start cycles of 15 compressions to 2 breaths (with 100% O2 and BVM)
• The Lucas CPR Device (Appendix A) may be used when the patient is large enough. If the patient is too small, the Lucas device will alert with 3 fast signals when lowering the Suction Cup and you cannot enter the PAUSE mode or ACTIVE mode
• Continue this compression to ventilation ratio until placement of an advanced airway
• Use of basic airway adjuncts (OPA and/or NPAs) should be utilized when ventilating the
patient without an advanced airway in place
• Once an advanced airway is placed, provide continuous chest compressions and
provide 1 breath every 6 seconds
• If the provider is alone (brush truck or tanker), the use of a BVM in single rescuer
CPR is no longer recommended. Continuous, uninterrupted chest compressions with pauses for AED application/use only until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible. Perform 5 cycles of CPR in the unwitnessed arrest
• Check for shockable rhythm
• If shockable, give 1 shock at 2 J/KG and IMMEDIATELY continue CPR, starting with
compressions, for 2 minutes then reassess
• The time from the last compression to defibrillation should be minimized, within 5
seconds
• Continue to provide defibrillation every two minutes (the second shock and
subsequent shocks should be at 4 J/kg) if shockable rhythm is noted upon
reassessment
• If no shock advised, IMMEDIATELY continue CPR, starting with compressions, for 2
minutes then reassess
• Airway/breathing management
• Refer to Advanced Airway Guideline 9030 as indicated
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Administer Epinephrine 0.01 mg/kg (1:10,000) IV/IO; maximum dose 1mg
• Continue CPR
• Reassess for rhythm after 2 minutes
• If shockable rhythm, repeat shock sequence
• If not a shockable rhythm, continue CPR and change to appropriate treatment guideline
• Repeat Epinephrine every 3 to 5 minutes (consistently)
• Precaution
• Do not mix with any other drug
• After administration of Epinephrine, circulate for two minutes before giving anti-arrhythmic
• Administer antiarrhythmic, Amiodarone 5 mg/kg IV/IO (maximum single dose 300 mg), for recurrent VF/VT
• Continue CPR
• Reassess rhythm after 2 minutes
• If shockable rhythm, repeat shock sequence
• If not shockable rhythm, continue CPR and change to appropriate treatment guideline
• Repeat dose of Amiodarone 5 mg/kg IV/IO once (maximum repeat dose 150 mg)
• If rhythm was converted with defibrillation prior to administering initial Amiodarone dose, 5 mg/kg Amiodarone (maximum dose 150 mg) in small intravenous fluid bag (100-250cc) over 10 mins. Smaller bag is preferred
• This includes AED shocks by bystanders
• For Torsades de Pointes, Polymorphic VT, and refractory VF/VT:
• Administer Magnesium Sulfate 50 mg/kg IV/IO
• Maximum single dose 2 grams
• Magnesium Sulfate is to be used as the FIRST antiarrhythmic of choice in Torsades
(polymorphic VT)
• Continue CPR
• Reassess rhythm after two minutes
• If shockable rhythm, repeat shock sequence
• If not shockable rhythm, continue CPR and change to appropriate treatment
guideline
• Determine Blood Glucose Level
• Consider the following less common causes of cardiac arrest, H’s and T’s and their appropriate treatments:
• Hypovolemia
• Give bolus of intravenous fluid 20 mL/kg, repeat once if needed
• Hypoxia – provide 100% O2 with use of BVM and appropriate airway adjunct
• Hydrogen ion = acidosis
• Sodium Bicarbonate 1 mEq/kg IV/IO, Maximum single dose 50 mEq
• Contraindications
• None in Asystole/Pulseless Electrical Activity
• Precaution
• Do not mix with other drugs and flush line well after injecting
• Inactivates Epinephrine when mixed
• Inactivates Dopamine when mixed
• Hyperthermia/Hypothermia – cool or warm as needed
• Hypoglycemia – Appropriate dextrose concentration for the pediatric patient
• Neonate (<1 month) D10W at 5 mL/kg IV/IO for BGL less than 45 mg/dL
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of
intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Infant/child (1 month – 12 years) D25W at 2 mL/kg IV/IO for BGL less than 60 mg/dL
• To make D25W, discard 25ml out of one amp of D50 then draw 25ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Adolescent (13-18 years) D50W at 1 mL/kg IV/IO for BGL less than 60 mg/dL
• Maximum dose 25 grams
• If no improvement and BGL is below 60 mg/dL
• Repeat appropriate Dextrose concentration and dose
• Toxins/Tablets
• Narcan 0.1 mg/kg IV/IO (maximum 2 mg)
• Tension pneumothorax
• Needle decompression procedure (Appendix J)
Pediatric Asystole/PEA or Symptomatic Bradycardia
Children usually experience cardiopulmonary failure secondary to respiratory failure or shock and rarely due to primary cardiac disease or primary cardiac arrest. The emphasis should be placed on early identification of cardiac arrest with continuous well-performed compressions.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (should not take more than 10 seconds)
• If NO pulse present, OR
• Patient is 8 years or less and has a heart rate less than 60 with signs of poor perfusion
(e.g., cool mottled skin, altered mental status) despite oxygenation and ventilation
• Proceed with chest compressions
• Depress the chest at least one third the anterior-posterior diameter of the chest (approx.
11⁄2 inches in infants and 2 inches in children)
• Start cycles of 15 compressions to 2 breaths (with 100% O2 and BVM)
• The Lucas CPR Device (Appendix A) may be used when the patient is large enough. If the patient is too small, the Lucas device will alert with 3 fast signals when lowering the Suction Cup and you cannot enter the PAUSE mode or ACTIVE mode
• Continue this compression to ventilation ratio until placement of advanced airway
• Use of basic airway adjuncts (OPA and/or NPAs) should be utilized when ventilating the
patient without an advanced airway in place
• Once an advanced airway is in place, provide continuous chest compressions and
1 breath every 6 seconds
• If the provider is alone (brush truck or tanker) the use of a BVM in single rescuer
CPR is no longer recommended. Continuous, uninterrupted chest compressions are
to be provided until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible. Perform 5 cycles of CPR in the
unwitnessed arrest
• Check for shockable rhythm
• If no shock advised; IMMEDIATELY continue CPR, starting with compressions, for 2
minutes then reassess
• Airway/breathing management
• Refer to Advanced Airway Guideline 9030 as indicated
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Administer Epinephrine 0.01 mg/kg (1:10,000) IV/IO; Maximum dose 1 mg
• Continue CPR
• Reassess rhythm after 2 minutes
• If shockable rhythm, refer to V-Fib/Pulseless V-Tach Treatment Guideline 8070
• If not a shockable rhythm, continue CPR and change to appropriate treatment guideline
• Repeat Epinephrine every 3 to 5 minutes
• Precaution
• Do not mix with any other drug
• Determine Blood Glucose Level
• Consider the following less common causes of cardiac arrest, H’s and T’s and their appropriate treatments:
• Hypovolemia
• Give bolus of intravenous fluid 20 mL/kg, repeat once if needed
• Hypoxia – provide 100% O2 with use of BVM and appropriate airway adjunct
• Hydrogen ion = acidosis
• Sodium Bicarbonate 1 mEq/kg IV/IO, Maximum single dose 50 mEq
• Contraindications
• None in Asystole/Pulseless Electrical Activity
• Precaution
• Do not mix with other drugs and flush line well after injecting
• Inactivates Epinephrine when mixed
• Inactivates Dopamine when mixed
• Hyperthermia/Hypothermia – cool or warm as needed
• Hypoglycemia – Appropriate dextrose concentration for the pediatric patient
• Neonate (<1 month) D10W at 5 mL/kg IV/IO for BGL less than 45 mg/dL
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of
intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Infant/child (1 month – 12 years) D25W at 2 mL/kg IV/IO for BGL less than 60 mg/dL
• To make D25W, discard 25ml out of one amp of D50 then draw 25ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Adolescent (13-18 years) D50W at 1 mL/kg IV/IO for BGL less than 60 mg/dL
• Maximum dose 25 grams
• Precaution
• Dextrose causes tissue necrosis and adequate vascular access must be
ensured prior to administration
• If no improvement and BGL is below 50 mg/dL
• Repeat appropriate Dextrose concentration and dose
• Toxins/Tablets
• Narcan 0.1 mg/kg IV/IO (maximum 2 mg)
• Tension pneumothorax
• Needle decompression procedure (Appendix J)
Children usually experience cardiopulmonary failure secondary to respiratory failure or shock and rarely due to primary cardiac disease or primary cardiac arrest. The emphasis should be placed on early identification of cardiac arrest with continuous well-performed compressions.
TREATMENT
• Check responsiveness, check for breathing (no breathing or only gasping), check for carotid pulse (should not take more than 10 seconds)
• If NO pulse present, OR
• Patient is 8 years or less and has a heart rate less than 60 with signs of poor perfusion
(e.g., cool mottled skin, altered mental status) despite oxygenation and ventilation
• Proceed with chest compressions
• Depress the chest at least one third the anterior-posterior diameter of the chest (approx.
11⁄2 inches in infants and 2 inches in children)
• Start cycles of 15 compressions to 2 breaths (with 100% O2 and BVM)
• The Lucas CPR Device (Appendix A) may be used when the patient is large enough. If the patient is too small, the Lucas device will alert with 3 fast signals when lowering the Suction Cup and you cannot enter the PAUSE mode or ACTIVE mode
• Continue this compression to ventilation ratio until placement of advanced airway
• Use of basic airway adjuncts (OPA and/or NPAs) should be utilized when ventilating the
patient without an advanced airway in place
• Once an advanced airway is in place, provide continuous chest compressions and
1 breath every 6 seconds
• If the provider is alone (brush truck or tanker) the use of a BVM in single rescuer
CPR is no longer recommended. Continuous, uninterrupted chest compressions are
to be provided until assisting units arrive
• Apply monitor/defibrillator pads as soon as possible. Perform 5 cycles of CPR in the
unwitnessed arrest
• Check for shockable rhythm
• If no shock advised; IMMEDIATELY continue CPR, starting with compressions, for 2
minutes then reassess
• Airway/breathing management
• Refer to Advanced Airway Guideline 9030 as indicated
• Establish IV/IO access
• 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Administer Epinephrine 0.01 mg/kg (1:10,000) IV/IO; Maximum dose 1 mg
• Continue CPR
• Reassess rhythm after 2 minutes
• If shockable rhythm, refer to V-Fib/Pulseless V-Tach Treatment Guideline 8070
• If not a shockable rhythm, continue CPR and change to appropriate treatment guideline
• Repeat Epinephrine every 3 to 5 minutes
• Precaution
• Do not mix with any other drug
• Determine Blood Glucose Level
• Consider the following less common causes of cardiac arrest, H’s and T’s and their appropriate treatments:
• Hypovolemia
• Give bolus of intravenous fluid 20 mL/kg, repeat once if needed
• Hypoxia – provide 100% O2 with use of BVM and appropriate airway adjunct
• Hydrogen ion = acidosis
• Sodium Bicarbonate 1 mEq/kg IV/IO, Maximum single dose 50 mEq
• Contraindications
• None in Asystole/Pulseless Electrical Activity
• Precaution
• Do not mix with other drugs and flush line well after injecting
• Inactivates Epinephrine when mixed
• Inactivates Dopamine when mixed
• Hyperthermia/Hypothermia – cool or warm as needed
• Hypoglycemia – Appropriate dextrose concentration for the pediatric patient
• Neonate (<1 month) D10W at 5 mL/kg IV/IO for BGL less than 45 mg/dL
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of
intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Infant/child (1 month – 12 years) D25W at 2 mL/kg IV/IO for BGL less than 60 mg/dL
• To make D25W, discard 25ml out of one amp of D50 then draw 25ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution
• Adolescent (13-18 years) D50W at 1 mL/kg IV/IO for BGL less than 60 mg/dL
• Maximum dose 25 grams
• Precaution
• Dextrose causes tissue necrosis and adequate vascular access must be
ensured prior to administration
• If no improvement and BGL is below 50 mg/dL
• Repeat appropriate Dextrose concentration and dose
• Toxins/Tablets
• Narcan 0.1 mg/kg IV/IO (maximum 2 mg)
• Tension pneumothorax
• Needle decompression procedure (Appendix J)
Pediatric Allergic Reaction/Anaphylaxis
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Anticipate rapid deterioration and the need to intubate
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Assist with administration of patient’s Auto-Injector Epinephrine if present
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Determine Blood Glucose Level
• Assess temperature
• Treatment based on assessment and patient’s level of distress:
• Mild/moderate reaction without respiratory compromise
• Benadryl 1 mg/kg IV or IM. Maximum dose 25 mg
• Solu-Medrol 2 mg/kg IV. Maximum dose 125 mg
• Moderate reaction with respiratory compromise
• Benadryl 1 mg/kg IV or IM. Maximum dose 25 mg
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated as needed
Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Solu-Medrol 2 mg/kg IV. Maximum dose 125 mg
• Severe reaction/ Anaphylaxis (severe respiratory distress and/or cardiovascular compromise)
• Epinephrine 1:1,000 0.01 mg/kg IM only; maximum single dose 0.5 mg
• May repeat once after 10 minutes if needed, at different site
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated as needed Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Benadryl 1 mg/kg IV/IO or IM. Maximum dose 25 mg
• Solu-Medrol 2 mg/kg IV/IO. Maximum dose 125 mg
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Anticipate rapid deterioration and the need to intubate
• Refer to Advanced Airway Guideline 9030 as indicated
• Initiate cardiac monitoring
• Assist with administration of patient’s Auto-Injector Epinephrine if present
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Determine Blood Glucose Level
• Assess temperature
• Treatment based on assessment and patient’s level of distress:
• Mild/moderate reaction without respiratory compromise
• Benadryl 1 mg/kg IV or IM. Maximum dose 25 mg
• Solu-Medrol 2 mg/kg IV. Maximum dose 125 mg
• Moderate reaction with respiratory compromise
• Benadryl 1 mg/kg IV or IM. Maximum dose 25 mg
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated as needed
Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Solu-Medrol 2 mg/kg IV. Maximum dose 125 mg
• Severe reaction/ Anaphylaxis (severe respiratory distress and/or cardiovascular compromise)
• Epinephrine 1:1,000 0.01 mg/kg IM only; maximum single dose 0.5 mg
• May repeat once after 10 minutes if needed, at different site
• Albuterol 5 mg and Atrovent 0.5 mg nebulized. May be repeated as needed Subsequent nebulizer treatments will contain only Albuterol 5 mg
• Albuterol dose 2.5mg for patient less than 10kg, may be repeated
• Benadryl 1 mg/kg IV/IO or IM. Maximum dose 25 mg
• Solu-Medrol 2 mg/kg IV/IO. Maximum dose 125 mg
Pediatric Altered Consciousness
TREATMENT
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Determine blood glucose level. If BGL is abnormal, refer to Pediatric Diabetic Guideline
8110
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• If GCS <=8 or inability to protect airway, refer to Advanced Airway Guideline 9030
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Assess temperature
• Treatment based on underlying cause:
• Narcotic use/exposure
• Refer to Pediatric Overdose/Poisoning Guideline 8120
• Unknown etiology
• Consider other treatable neurological or metabolic disorders and if identified follow the appropriate guideline
TREATMENT
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Determine blood glucose level. If BGL is abnormal, refer to Pediatric Diabetic Guideline
8110
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• If GCS <=8 or inability to protect airway, refer to Advanced Airway Guideline 9030
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Assess temperature
• Treatment based on underlying cause:
• Narcotic use/exposure
• Refer to Pediatric Overdose/Poisoning Guideline 8120
• Unknown etiology
• Consider other treatable neurological or metabolic disorders and if identified follow the appropriate guideline
Pediatric Diabetic
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If the patient experiences a seizure due to hypoglycemia and IV access is unobtainable,
establish IO
• If IO used for access, the humerus is contraindicated in newborns and infants
• Assess temperature
• Look for underlying causes
• Treatments based on blood glucose level and level of consciousness:
• Hypoglycemia with vascular access
• <1 month: D10W at 5 mL/kg IV for BGL less than 45 mg/dL
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of
intravenous fluid into the D50 amp. Agitate syringe to mix solution.
• 1 month-12 years: D25W at 2 mL/kg IV for BGL less than 60 mg/dL
• To make D25W, discard 25mL out of one amp of D50 then draw 25ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution.
• 13-17 years: D50W at 1 mL/kg IV for BGL less than 60 mg/dL
• Maximum dose 25 grams
• If no improvement and BGL is below 60 mg/dL
• Repeat appropriate Dextrose concentration and dose for the pediatric patient
• Hypoglycemia (BGL <60 mg/dL) without vascular access and unresponsive
• Establish IO and administer dextrose as listed above
• Hypoglycemia (BGL <60 mg/dL or altered mental status) without vascular access
• Conscious and alert patient (GCS >=14) with BGL <60 mg/dL, administer oral
Glucose paste 15 grams (1 tube)
• May repeat once in 10 minutes if BGL still <60 mg/dL
• Contraindications
• Patient less than 2 years old
• Altered level of consciousness
• Difficulty swallowing
• Altered level of consciousness or difficulty swallowing
• Less than 20 kg, Glucagon 0.5 mg IM
• 20 kg or greater, Glucagon 1 mg IM
• Repeat BGL after 15 minutes
• Considerations
• Onset in 1 minute with a peak onset time of 30 minutes
• The hypoglycemic patient will usually awaken within 15 minutes
• Hyperglycemia
• If BGL is greater than 300 mg/dL, administer intravenous fluids 20 mL/kg
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Establish IV access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If the patient experiences a seizure due to hypoglycemia and IV access is unobtainable,
establish IO
• If IO used for access, the humerus is contraindicated in newborns and infants
• Assess temperature
• Look for underlying causes
• Treatments based on blood glucose level and level of consciousness:
• Hypoglycemia with vascular access
• <1 month: D10W at 5 mL/kg IV for BGL less than 45 mg/dL
• To make D10W, discard 40ml out of one amp of D50 then draw 40ml of
intravenous fluid into the D50 amp. Agitate syringe to mix solution.
• 1 month-12 years: D25W at 2 mL/kg IV for BGL less than 60 mg/dL
• To make D25W, discard 25mL out of one amp of D50 then draw 25ml of intravenous fluid into the D50 amp. Agitate syringe to mix solution.
• 13-17 years: D50W at 1 mL/kg IV for BGL less than 60 mg/dL
• Maximum dose 25 grams
• If no improvement and BGL is below 60 mg/dL
• Repeat appropriate Dextrose concentration and dose for the pediatric patient
• Hypoglycemia (BGL <60 mg/dL) without vascular access and unresponsive
• Establish IO and administer dextrose as listed above
• Hypoglycemia (BGL <60 mg/dL or altered mental status) without vascular access
• Conscious and alert patient (GCS >=14) with BGL <60 mg/dL, administer oral
Glucose paste 15 grams (1 tube)
• May repeat once in 10 minutes if BGL still <60 mg/dL
• Contraindications
• Patient less than 2 years old
• Altered level of consciousness
• Difficulty swallowing
• Altered level of consciousness or difficulty swallowing
• Less than 20 kg, Glucagon 0.5 mg IM
• 20 kg or greater, Glucagon 1 mg IM
• Repeat BGL after 15 minutes
• Considerations
• Onset in 1 minute with a peak onset time of 30 minutes
• The hypoglycemic patient will usually awaken within 15 minutes
• Hyperglycemia
• If BGL is greater than 300 mg/dL, administer intravenous fluids 20 mL/kg
Pediatric Overdose/Poisoning
TREATMENT
• If substance is known, contact Poison Control at 1-800-222-1222. Provide all information
requested by poison control representative
• Airway/breathing management
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present • If IO used for access, the humerus is contraindicated in newborns and infants
• Initiate cardiac monitoring
• Determine Blood Glucose Level
• Wear appropriate personal protective equipment
• Seizures may develop in many overdose/poison/ingestion situations
• Refer to Pediatric Seizure Guideline 8130
• Consider specific treatment situations:
• Narcotic use/exposure
• Narcan 0.1 mg/kg IV/IO/IM (maximum single dose 0.4 mg)
• If no change in 5 minutes, may repeat Narcan 0.1 mg/kg IV/IO/IM
• Maximum total dose 2 mg
• Use in respiratory depression, unable to protect airway
• The goal is to increase respirations, not LOC
• Organophosphate exposure
• For all suspected organophosphate exposures, notify HAZMAT Team
• Signs and symptoms include Diarrhea, Urination, Miosis, Bradycardia,
Bronchorrhea, Bronchospasm, Emesis, Lacrimation and Salivation
• Atropine 0.02 mg/kg is indicated in the unstable patient
• Minimum initial dose 0.1 mg, maximum initial dose 2 mg IV/IO
• Repeat every 3 to 5 min as needed until secretions dry
• No maximum total dose
• Acute Dystonic Reaction to anti-psychotics (Haldol)
• Signs and symptoms include painful muscle spasms of the face, neck and back
• Benadryl 1 mg/kg IV/IO/IM (maximum dose 25 mg)
• Do not delay treatment or transport but if possible, bring medication or substance ingested
TREATMENT
• If substance is known, contact Poison Control at 1-800-222-1222. Provide all information
requested by poison control representative
• Airway/breathing management
• Maintain aspiration prophylaxis by placing the patient in the recovery position
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Discontinue fluid administration if evidence of pulmonary edema is present • If IO used for access, the humerus is contraindicated in newborns and infants
• Initiate cardiac monitoring
• Determine Blood Glucose Level
• Wear appropriate personal protective equipment
• Seizures may develop in many overdose/poison/ingestion situations
• Refer to Pediatric Seizure Guideline 8130
• Consider specific treatment situations:
• Narcotic use/exposure
• Narcan 0.1 mg/kg IV/IO/IM (maximum single dose 0.4 mg)
• If no change in 5 minutes, may repeat Narcan 0.1 mg/kg IV/IO/IM
• Maximum total dose 2 mg
• Use in respiratory depression, unable to protect airway
• The goal is to increase respirations, not LOC
• Organophosphate exposure
• For all suspected organophosphate exposures, notify HAZMAT Team
• Signs and symptoms include Diarrhea, Urination, Miosis, Bradycardia,
Bronchorrhea, Bronchospasm, Emesis, Lacrimation and Salivation
• Atropine 0.02 mg/kg is indicated in the unstable patient
• Minimum initial dose 0.1 mg, maximum initial dose 2 mg IV/IO
• Repeat every 3 to 5 min as needed until secretions dry
• No maximum total dose
• Acute Dystonic Reaction to anti-psychotics (Haldol)
• Signs and symptoms include painful muscle spasms of the face, neck and back
• Benadryl 1 mg/kg IV/IO/IM (maximum dose 25 mg)
• Do not delay treatment or transport but if possible, bring medication or substance ingested
Pediatric Seizures
TREATMENT
• Maintain aspiration precaution by placing the patient in the recovery position
• If trauma suspected, immobilize patient using proper technique
• If the patient is actively seizing, protect the patient from further injury
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Look for underlying causes
• Determine blood glucose level. If BGL is abnormal, refer to Pediatric Diabetic Guideline
8110
• Assess temperature
• Apply cooling measures (ice packs or wet towels to neck, axillae, groin, etc.) when the patient has a temperature >102 degrees
• Active seizures
• Treat status epilepticus aggressively. For active seizures, administer Midazolam 0.1
mg/kg IV/IO/IM. Maximum single dose 5 mg
• If active seizing persists or returns, may repeat initial dose in 5 minutes
• Airway assistance may be necessary after Midazolam administration
TREATMENT
• Maintain aspiration precaution by placing the patient in the recovery position
• If trauma suspected, immobilize patient using proper technique
• If the patient is actively seizing, protect the patient from further injury
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Initiate cardiac monitoring
• Establish IV/IO access
• Up to 20 mL/kg intravenous fluids; maximum 2L
• If IO used for access, the humerus is contraindicated in newborns and infants
• Look for underlying causes
• Determine blood glucose level. If BGL is abnormal, refer to Pediatric Diabetic Guideline
8110
• Assess temperature
• Apply cooling measures (ice packs or wet towels to neck, axillae, groin, etc.) when the patient has a temperature >102 degrees
• Active seizures
• Treat status epilepticus aggressively. For active seizures, administer Midazolam 0.1
mg/kg IV/IO/IM. Maximum single dose 5 mg
• If active seizing persists or returns, may repeat initial dose in 5 minutes
• Airway assistance may be necessary after Midazolam administration
Pediatric Fever
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Assess temperature
• Apply cooling measures (ice packs or wet towels to neck, axillae, groin, etc.) when the
patient has a temperature >102 degrees
• Establish IV access only if medication administration is required
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Each Celsius degree of fever results in a heart rate increase of approximately 10 beats
per minute
• If the pediatric patient has a temperature >102 degrees and the parent has Ibuprofen or Acetaminophen:
• Administer Ibuprofen 10 mg/kg (not for children under 6 months) PO or
Acetaminophen 15 mg/kg PO
TREATMENT
• Airway/breathing management
• Administer O2 via proper adjunct to maintain oxygen saturation of 95% or greater
• Assess temperature
• Apply cooling measures (ice packs or wet towels to neck, axillae, groin, etc.) when the
patient has a temperature >102 degrees
• Establish IV access only if medication administration is required
• Up to 20 mL/kg intravenous fluids; maximum 2L
• Determine Blood Glucose Level
• Initiate cardiac monitoring
• Each Celsius degree of fever results in a heart rate increase of approximately 10 beats
per minute
• If the pediatric patient has a temperature >102 degrees and the parent has Ibuprofen or Acetaminophen:
• Administer Ibuprofen 10 mg/kg (not for children under 6 months) PO or
Acetaminophen 15 mg/kg PO
Advanced Airway-Adult Medical
Intubation of the patient should only occur if the patient is in severe respiratory failure that is refractory to medical management, respirations less than 10/min or greater than 40/min, or a decreased LOC (GCS <8).
• Continuous Positive Airway Pressure (CPAP) (Appendix H) should be considered prior to intubation for those without a decreased LOC
• Give 10 cm/H2O and titrate to the patient’s work of breathing
• If airway obstruction present and unable to oxygenate/ventilate, consider cricothyrotomy (Appendix K)
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, JVD, and hypoxia)
• In the non-trauma setting, only spontaneous pneumothorax is normally present.
However, positive pressure ventilation can lead to tension pneumothorax
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• Suction as necessary
• If sedation required:
• ASTHMA, ANAPHYLAXIS, SHOCK:
• Administer Ketamine 2 mg/kg IV/IO (maximum dose 200mg)
• ALL OTHER INTUBATION INDICATIONS:
• Administer Etomidate 0.3 mg/kg IV/IO (maximum dose 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Cardiac/Trauma arrest
• If Ketamine or Etomidate is not successful at completing sedation (e.g., trismus,
combative) and systolic BP is greater than 100 mm/Hg, administer Midazolam 2-5
mg IV/IO
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D).
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document ETCO2 and SpO2 values (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Expect higher values and use controlled hyperventilation to reduce
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Consider Midazolam 2 - 5 mg IV/IO to maintain sedation in the intubated patient, may repeat once in 10 minutes
• Avoid use in hypotensive patients and beware that administration may cause a drop
in the patient’s blood pressure
• Greater than 64 years old, administer in 2 mg increments
• If wheezing present, consider in-line nebulizer (Appendix G or H)
• DO NOT HYPERVENTILATE patients with suspected Ischemic Brain Injury
• Secure tube with commercial tube holder (may use other means if necessary)
Intubation of the patient should only occur if the patient is in severe respiratory failure that is refractory to medical management, respirations less than 10/min or greater than 40/min, or a decreased LOC (GCS <8).
• Continuous Positive Airway Pressure (CPAP) (Appendix H) should be considered prior to intubation for those without a decreased LOC
• Give 10 cm/H2O and titrate to the patient’s work of breathing
• If airway obstruction present and unable to oxygenate/ventilate, consider cricothyrotomy (Appendix K)
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, JVD, and hypoxia)
• In the non-trauma setting, only spontaneous pneumothorax is normally present.
However, positive pressure ventilation can lead to tension pneumothorax
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• Suction as necessary
• If sedation required:
• ASTHMA, ANAPHYLAXIS, SHOCK:
• Administer Ketamine 2 mg/kg IV/IO (maximum dose 200mg)
• ALL OTHER INTUBATION INDICATIONS:
• Administer Etomidate 0.3 mg/kg IV/IO (maximum dose 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Cardiac/Trauma arrest
• If Ketamine or Etomidate is not successful at completing sedation (e.g., trismus,
combative) and systolic BP is greater than 100 mm/Hg, administer Midazolam 2-5
mg IV/IO
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D).
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document ETCO2 and SpO2 values (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Expect higher values and use controlled hyperventilation to reduce
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Consider Midazolam 2 - 5 mg IV/IO to maintain sedation in the intubated patient, may repeat once in 10 minutes
• Avoid use in hypotensive patients and beware that administration may cause a drop
in the patient’s blood pressure
• Greater than 64 years old, administer in 2 mg increments
• If wheezing present, consider in-line nebulizer (Appendix G or H)
• DO NOT HYPERVENTILATE patients with suspected Ischemic Brain Injury
• Secure tube with commercial tube holder (may use other means if necessary)
Advanced Airway-Adult Trauma
Intubation of the patient should only occur if the patient is in severe respiratory failure) that is refractory to medical management, respirations less than 10/min or greater than 40/min, or a decreased LOC (GCS <8).
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• Suction as necessary
• Sedation required:
• NON-SHOCK TRAUMA:
• Administer Etomidate 0.3 mg/kg IV/IO (maximum dose 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Known sensitivity
• Cardiac/Trauma arrest
• If Etomidate is not successful at completing sedation (e.g., trismus, combative)
and post Etomidate systolic BP is greater than 100 mm/Hg, administer
Midazolam 2-5 mg IV/IO
• SHOCK TRAUMA or AIRWAY PROTECTION IN A BURN PT:
• Administer Ketamine 2mg/kg IV/IO (maximum 200mg)
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D)
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document both capnography waveform and ETCO2 value (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Consider Midazolam 2 - 5 mg IV/IO to maintain sedation, may repeat once in 10
minutes
• Avoid use in hypotensive patients and beware administration may cause a drop in the
patient’s blood pressure
• Greater than 64 years old, administer in 2 mg increments
• DO NOT HYPERVENTILATE patients with suspected TBI
• Secure tube with commercial tube holder (may use other means if necessary)
Intubation of the patient should only occur if the patient is in severe respiratory failure) that is refractory to medical management, respirations less than 10/min or greater than 40/min, or a decreased LOC (GCS <8).
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• Suction as necessary
• Sedation required:
• NON-SHOCK TRAUMA:
• Administer Etomidate 0.3 mg/kg IV/IO (maximum dose 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Known sensitivity
• Cardiac/Trauma arrest
• If Etomidate is not successful at completing sedation (e.g., trismus, combative)
and post Etomidate systolic BP is greater than 100 mm/Hg, administer
Midazolam 2-5 mg IV/IO
• SHOCK TRAUMA or AIRWAY PROTECTION IN A BURN PT:
• Administer Ketamine 2mg/kg IV/IO (maximum 200mg)
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D)
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document both capnography waveform and ETCO2 value (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Consider Midazolam 2 - 5 mg IV/IO to maintain sedation, may repeat once in 10
minutes
• Avoid use in hypotensive patients and beware administration may cause a drop in the
patient’s blood pressure
• Greater than 64 years old, administer in 2 mg increments
• DO NOT HYPERVENTILATE patients with suspected TBI
• Secure tube with commercial tube holder (may use other means if necessary)
Advanced Airway-Pediatric Medical
Intubation of the patient should only occur if the patient is in severe respiratory failure that is refractory to medical management or has a decreased LOC (GCS <8).
• Continuous Positive Airway Pressure (CPAP) (Appendix H) should be considered prior to intubation for those without a decreased LOC
• If patient less than 12 years old, give 4 cm/H2O and titrate to the patient’s work of
breathing
• If 12 years or older, give 10 cm/H2O and titrate to the patient’s work of breathing
• If airway obstruction present and unable to oxygenate/ventilate, consider cricothyrotomy (Appendix K)
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
• In the non-trauma setting, only spontaneous pneumothorax is normally present.
However, positive pressure ventilation can lead to tension pneumothorax
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• BVM ventilation rates
• Premature Neonate and Neonate: 40 to 60 per minute
• Infants and Children: 12 to 20 per minute
• Suction as necessary
• Supraglottic airway (King Tube) may be first option for patients 5 years or less
• If sedation required:
• ASTHMA, ANAPHYLAXIS, or SHOCK:
• Administer Ketamine 2 mg/kg IV/IO (maximum 200mg)
• ALL OTHER INTUBATION INDICATIONS:
• Administer Etomidate 0.3 mg/kg slow IVP (maximum 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Cardiac/Trauma arrest
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized in patients 10 years and older
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D)
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document both capnography waveform and ETCO2 value (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Expect higher values and use controlled hyperventilation to reduce
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Consider Midazolam 0.1 mg/kg IV/IO, maximum dose 5 mg to maintain sedation
• Avoid use in hypotensive patients and beware administration may cause a drop in the
patient’s blood pressure
• If wheezing present, consider in-line nebulizer (Appendix G or H)
• DO NOT HYPERVENTILATE patients with suspected Ischemic Brain Injury
• Secure tube with commercial tube holder (may use other means if necessary)
Intubation of the patient should only occur if the patient is in severe respiratory failure that is refractory to medical management or has a decreased LOC (GCS <8).
• Continuous Positive Airway Pressure (CPAP) (Appendix H) should be considered prior to intubation for those without a decreased LOC
• If patient less than 12 years old, give 4 cm/H2O and titrate to the patient’s work of
breathing
• If 12 years or older, give 10 cm/H2O and titrate to the patient’s work of breathing
• If airway obstruction present and unable to oxygenate/ventilate, consider cricothyrotomy (Appendix K)
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
• In the non-trauma setting, only spontaneous pneumothorax is normally present.
However, positive pressure ventilation can lead to tension pneumothorax
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• BVM ventilation rates
• Premature Neonate and Neonate: 40 to 60 per minute
• Infants and Children: 12 to 20 per minute
• Suction as necessary
• Supraglottic airway (King Tube) may be first option for patients 5 years or less
• If sedation required:
• ASTHMA, ANAPHYLAXIS, or SHOCK:
• Administer Ketamine 2 mg/kg IV/IO (maximum 200mg)
• ALL OTHER INTUBATION INDICATIONS:
• Administer Etomidate 0.3 mg/kg slow IVP (maximum 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Cardiac/Trauma arrest
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized in patients 10 years and older
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D)
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document both capnography waveform and ETCO2 value (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Expect higher values and use controlled hyperventilation to reduce
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Consider Midazolam 0.1 mg/kg IV/IO, maximum dose 5 mg to maintain sedation
• Avoid use in hypotensive patients and beware administration may cause a drop in the
patient’s blood pressure
• If wheezing present, consider in-line nebulizer (Appendix G or H)
• DO NOT HYPERVENTILATE patients with suspected Ischemic Brain Injury
• Secure tube with commercial tube holder (may use other means if necessary)
Advanced Airway-Pediatric Trauma
Intubation of the patient should only occur if the patient is in severe respiratory failure that is refractory to medical management or has a decreased LOC (GCS <8).
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• BVM ventilation rates
• Premature Neonate and Neonate: 40 to 60 per minute
• Infants and Children: 12 to 20 per minute
• Suction as necessary
• Supraglottic airway (King Tube) may be first option for patients 5 years or less
• Sedation required:
• NON-SHOCK TRAUMA:
• Administer Etomidate 0.3 mg/kg slow IVP (maximum 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Cardiac/Trauma arrest
• SHOCK TRAUMA or AIRWAY PROTECTION IN A BURN PT:
• Administer Ketamine 2mg/kg IV/IO (maximum 200mg)
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized in patients 10 years and older
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D)
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document both capnography waveform and ETCO2 value (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Administer Midazolam 0.1 mg/kg IV/IO, maximum dose 5 mg to maintain sedation
• Avoid use in hypotensive patients and beware administration may cause B/P drop
• DO NOT HYPERVENTILATE patients with suspected TBI
• Secure tube with commercial tube holder (may use other means if necessary)
Intubation of the patient should only occur if the patient is in severe respiratory failure that is refractory to medical management or has a decreased LOC (GCS <8).
• Assess for tension pneumothorax (unilateral absent or decreased breath sounds with severe respiratory distress or signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
• Needle decompression procedure (Appendix J)
PRIOR TO INTUBATION :
• Pre-oxygenate with adjunct(s) for 1 minute with NRBM for spontaneous breathing or BVM for apnea/agonal respirations
• BVM ventilation rates
• Premature Neonate and Neonate: 40 to 60 per minute
• Infants and Children: 12 to 20 per minute
• Suction as necessary
• Supraglottic airway (King Tube) may be first option for patients 5 years or less
• Sedation required:
• NON-SHOCK TRAUMA:
• Administer Etomidate 0.3 mg/kg slow IVP (maximum 40mg)
• Peak effect: 1 minute, do not try to intubate for one minute
• Duration: 3-5 minutes
• Contraindications
• Cardiac/Trauma arrest
• SHOCK TRAUMA or AIRWAY PROTECTION IN A BURN PT:
• Administer Ketamine 2mg/kg IV/IO (maximum 200mg)
• Consider use of the bougie (Appendix I) when the laryngeal inlet cannot be completely
visualized in patients 10 years and older
• Each intubation attempt should be limited to a maximum of 10 seconds
UNABLE TO INTUBATE :
• After two unsuccessful intubation attempts, insert supraglottic airway (Appendix D)
• If supraglottic airway unsuccessful, use a BVM with airway adjunct(s)
• If unable to oxygenate/ventilate, proceed to cricothyrotomy (Appendix K)
AFTER INTUBATION or INSERTION OF SUPRAGLOTTIC AIRWAY :
• Confirm tube placement and constantly monitor adequacy of ventilations:
• Assess and document both capnography waveform and ETCO2 value (Appendix F)
• Normal readings are 35-45 mmHg in a healthy patient
• Absence of gastric sounds with auscultation
• Auscultating for the presence of bilateral breath sounds
• Look for equal chest rise
• Administer Midazolam 0.1 mg/kg IV/IO, maximum dose 5 mg to maintain sedation
• Avoid use in hypotensive patients and beware administration may cause B/P drop
• DO NOT HYPERVENTILATE patients with suspected TBI
• Secure tube with commercial tube holder (may use other means if necessary)
Lucas Device
Indication
• Cardiac Arrest
• Should be used in every cardiac arrest except those contraindicated as listed below.
Device should be applied as early as possible (i.e., while still inside a residence) and prior to moving the patient
Contraindications
• Patient is too large. Recognized when the Upper Part of the device will not lock to the Back Plate without compressing the patient’s chest
• Patient is too small. Recognized when the Lucas device alerts with 3 fast signals when lowering the Suction Cup, and you cannot enter the PAUSE mode or ACTIVE mode.
• Pregnancy >20 weeks
• Known or suspected aortic rupture
• Mechanical heart pump (e.g., LVAD)
Cautions
• If there is gel on the patient’s chest, the Suction Cup position can change
• If the position of the Suction Cup changes during operation, immediately push the #1
button, and then adjust the position
• Do not block the vent holes
Daily Inspection
• Ensure device is plugged in so that the inserted battery is fully charged
• Ensure Suction Cup is mounted
• Ensure that there is a spare Suction Cup and fully charged spare battery inside the case
• Inspect for physical damage to the unit/case
Batteries/Charging
• The device should remain plugged in inside the unit when not in use so that the inserted battery remains fully charged
• The inserted battery should be swapped with the spare battery once a week on Apparatus Day
Cleaning
• Clean all surfaces and straps with a mild cleaning agent or disinfectant
• Allow device to dry before placing into the carrying case
• Dispose of Suction Cup after each patient use
Procedure
• Start manual CPR
• Unpack the device
• Push ON/OFF for 1 second to power up and start the self-test. The green LED adjacent to the
key illuminates when the device is ready for use
• Place the Lucas Back Plate under the patient, immediately below the arm pits
• Hold the handles on the support legs to remove the Lucas Upper Part from the carrying case
• Pull the release rings once to make sure that the claw locks are open
• Let go of the release rings
• Attach the support leg that is nearest to you to the Back Plate. Listen for a click
• Attach the other support leg to the Back Plate, so that the two support legs lock against the Back Plate. Listen for a click
• Ensure that the Lucas device is in the Adjust mode (#1)
• Push the Suction Cup down until it touches the patient’s chest without compressing the chest
• The lower edge of the Suction Cup should be immediately above the end of the sternum, which is the same spot for manual CPR
• Push the #1 button on the control panel to lock the Start Position
• Push the #3 button to start either CONTINUOUS or 30:2 chest compressions
• Continuous mode if advanced airway in place
• 30:2 mode if airway not secured (e.g., BVM only)
• If device needs to be paused, push #2 (PAUSE)
• If Suction Cup position needs adjustment, push #1, then pull up the Suction Cup to
readjust
• You can secure the patient’s arms with the straps attached to the Lucas device
• Defibrillation can be performed while the Lucas device is operating
• To remove the device from the patient, push ON/OFF for 1 second or press the #2
(PAUSE) button
• Pull the release rings to remove the Upper Part from the Back Plate
• If the situation and patient’s condition permits, remove the Back Plate
Indication
• Cardiac Arrest
• Should be used in every cardiac arrest except those contraindicated as listed below.
Device should be applied as early as possible (i.e., while still inside a residence) and prior to moving the patient
Contraindications
• Patient is too large. Recognized when the Upper Part of the device will not lock to the Back Plate without compressing the patient’s chest
• Patient is too small. Recognized when the Lucas device alerts with 3 fast signals when lowering the Suction Cup, and you cannot enter the PAUSE mode or ACTIVE mode.
• Pregnancy >20 weeks
• Known or suspected aortic rupture
• Mechanical heart pump (e.g., LVAD)
Cautions
• If there is gel on the patient’s chest, the Suction Cup position can change
• If the position of the Suction Cup changes during operation, immediately push the #1
button, and then adjust the position
• Do not block the vent holes
Daily Inspection
• Ensure device is plugged in so that the inserted battery is fully charged
• Ensure Suction Cup is mounted
• Ensure that there is a spare Suction Cup and fully charged spare battery inside the case
• Inspect for physical damage to the unit/case
Batteries/Charging
• The device should remain plugged in inside the unit when not in use so that the inserted battery remains fully charged
• The inserted battery should be swapped with the spare battery once a week on Apparatus Day
Cleaning
• Clean all surfaces and straps with a mild cleaning agent or disinfectant
• Allow device to dry before placing into the carrying case
• Dispose of Suction Cup after each patient use
Procedure
• Start manual CPR
• Unpack the device
• Push ON/OFF for 1 second to power up and start the self-test. The green LED adjacent to the
key illuminates when the device is ready for use
• Place the Lucas Back Plate under the patient, immediately below the arm pits
• Hold the handles on the support legs to remove the Lucas Upper Part from the carrying case
• Pull the release rings once to make sure that the claw locks are open
• Let go of the release rings
• Attach the support leg that is nearest to you to the Back Plate. Listen for a click
• Attach the other support leg to the Back Plate, so that the two support legs lock against the Back Plate. Listen for a click
• Ensure that the Lucas device is in the Adjust mode (#1)
• Push the Suction Cup down until it touches the patient’s chest without compressing the chest
• The lower edge of the Suction Cup should be immediately above the end of the sternum, which is the same spot for manual CPR
• Push the #1 button on the control panel to lock the Start Position
• Push the #3 button to start either CONTINUOUS or 30:2 chest compressions
• Continuous mode if advanced airway in place
• 30:2 mode if airway not secured (e.g., BVM only)
• If device needs to be paused, push #2 (PAUSE)
• If Suction Cup position needs adjustment, push #1, then pull up the Suction Cup to
readjust
• You can secure the patient’s arms with the straps attached to the Lucas device
• Defibrillation can be performed while the Lucas device is operating
• To remove the device from the patient, push ON/OFF for 1 second or press the #2
(PAUSE) button
• Pull the release rings to remove the Upper Part from the Back Plate
• If the situation and patient’s condition permits, remove the Back Plate
External Pacer
Transcutaneous pacing offers a noninvasive, rapid, and effective way to institute ventricular pacing, support the patient’s hemodynamics and reestablish perfusion. The most common reason for using pacing is to maintain an optimal cardiac output when the patient has bradycardia with inadequate perfusion.
Indications
• Symptomatic bradycardia unresponsive to Atropine
Contraindications
• Asystole
• Severe hypothermia
Procedure
• Prepare the Patient - Remove all clothing covering the patient’s chest. Dry chest if necessary. If the patient has excessive chest hair, shave it to ensure proper adhesion of the electrodes
• Turn on unit - Press the green power switch located on the top of the unit. The green, yellow, and red lights at the top of the unit flash on and off, and the unit displays the message SELF TEST PASSED
• Apply ECG Electrodes and Fast Patches
• Poor adherence and/or air under the therapy electrodes can lead to the possibility of
arcing and skin burns
• Press the Lead quick access key and select I, II, or III to provide the largest
amplitude QRS complex
• When the Pacer is on, the lead selection is restricted to Leads I, II, or III
• Verify that R-waves are being properly detected by confirming that a QRS tone
occurs with each displayed R wave or by verifying that the X Series unit’s heart rate
display accurately reflects the patient’s pulse rate
• Press Pacer button - Press the Pacer button on the front panel of the unit. The Pacer
Settings window displays
• Set Mode - Use the arrow keys to navigate to Mode, press the Select button, and then
use the arrow keys and the Select button to set the Pacer Mode to Demand
• Set Pacer Rate - Use the arrow keys to navigate to Rate, press the Select button, and
then use the arrow keys and the Select button to set the Pacer Rate to a value 10-20 ppm higher than the patient’s intrinsic heart rate. If no intrinsic rate exists, use 100 ppm. You can increase or decrease the pacer rate by a value of 5 ppm for rates below 100, and by 10 ppm for rates above 100
• Turn On Pacer - Use the arrow keys to navigate to Start Pacer and then press the Select button to select it. The Pacing window displays behind the Pacer Settings window
• Set Pacer Output - In the Pacer Settings window, use the arrow keys and the Select button to adjust the pacer output. The pacer output is adjustable in 10 mA increments
when increasing the output, and in 5 mA increments when decreasing the output. Observe the ECG for evidence of electrical capture. Select the lowest output current that achieves both electrical and mechanical capture
• If the Pacer Settings window disappears before you have set the output current,
press the Pacer button again to display the settings window
• Determine Capture - It is important to recognize when pacing stimulation has produced
a ventricular response (capture). Determination of capture must be assessed both electrically and mechanically to ensure appropriate circulatory support of the patient. Electrical capture is determined by the presence of a widened QRS complex, the loss of any underlying intrinsic rhythm, and the appearance of an extended, and sometimes enlarged, T-wave. Ventricular response is normally characterized by suppression of the intrinsic QRS complex
• Confirm mechanical capture by palpation of the peripheral pulse. To avoid mistaking muscular response to pacing stimuli for arterial pulsations, use ONLY the following locations for palpating pulse during pacing:
• Femoral artery
• Right brachial or right radial artery
• Determine Optimum Threshold - The ideal pacer current is the lowest value that
maintains capture — it is usually about 10% above threshold. Typical threshold currents range from 40 to 80 mA. Location of the fast patches affect the current required to obtain ventricular capture. Typically, the lowest threshold is obtained when the position of the electrodes provides the most direct current pathway through the heart while avoiding large chest muscles. Lower stimulation currents produce less skeletal muscle contraction and are better tolerated
Transcutaneous pacing offers a noninvasive, rapid, and effective way to institute ventricular pacing, support the patient’s hemodynamics and reestablish perfusion. The most common reason for using pacing is to maintain an optimal cardiac output when the patient has bradycardia with inadequate perfusion.
Indications
• Symptomatic bradycardia unresponsive to Atropine
Contraindications
• Asystole
• Severe hypothermia
Procedure
• Prepare the Patient - Remove all clothing covering the patient’s chest. Dry chest if necessary. If the patient has excessive chest hair, shave it to ensure proper adhesion of the electrodes
• Turn on unit - Press the green power switch located on the top of the unit. The green, yellow, and red lights at the top of the unit flash on and off, and the unit displays the message SELF TEST PASSED
• Apply ECG Electrodes and Fast Patches
• Poor adherence and/or air under the therapy electrodes can lead to the possibility of
arcing and skin burns
• Press the Lead quick access key and select I, II, or III to provide the largest
amplitude QRS complex
• When the Pacer is on, the lead selection is restricted to Leads I, II, or III
• Verify that R-waves are being properly detected by confirming that a QRS tone
occurs with each displayed R wave or by verifying that the X Series unit’s heart rate
display accurately reflects the patient’s pulse rate
• Press Pacer button - Press the Pacer button on the front panel of the unit. The Pacer
Settings window displays
• Set Mode - Use the arrow keys to navigate to Mode, press the Select button, and then
use the arrow keys and the Select button to set the Pacer Mode to Demand
• Set Pacer Rate - Use the arrow keys to navigate to Rate, press the Select button, and
then use the arrow keys and the Select button to set the Pacer Rate to a value 10-20 ppm higher than the patient’s intrinsic heart rate. If no intrinsic rate exists, use 100 ppm. You can increase or decrease the pacer rate by a value of 5 ppm for rates below 100, and by 10 ppm for rates above 100
• Turn On Pacer - Use the arrow keys to navigate to Start Pacer and then press the Select button to select it. The Pacing window displays behind the Pacer Settings window
• Set Pacer Output - In the Pacer Settings window, use the arrow keys and the Select button to adjust the pacer output. The pacer output is adjustable in 10 mA increments
when increasing the output, and in 5 mA increments when decreasing the output. Observe the ECG for evidence of electrical capture. Select the lowest output current that achieves both electrical and mechanical capture
• If the Pacer Settings window disappears before you have set the output current,
press the Pacer button again to display the settings window
• Determine Capture - It is important to recognize when pacing stimulation has produced
a ventricular response (capture). Determination of capture must be assessed both electrically and mechanically to ensure appropriate circulatory support of the patient. Electrical capture is determined by the presence of a widened QRS complex, the loss of any underlying intrinsic rhythm, and the appearance of an extended, and sometimes enlarged, T-wave. Ventricular response is normally characterized by suppression of the intrinsic QRS complex
• Confirm mechanical capture by palpation of the peripheral pulse. To avoid mistaking muscular response to pacing stimuli for arterial pulsations, use ONLY the following locations for palpating pulse during pacing:
• Femoral artery
• Right brachial or right radial artery
• Determine Optimum Threshold - The ideal pacer current is the lowest value that
maintains capture — it is usually about 10% above threshold. Typical threshold currents range from 40 to 80 mA. Location of the fast patches affect the current required to obtain ventricular capture. Typically, the lowest threshold is obtained when the position of the electrodes provides the most direct current pathway through the heart while avoiding large chest muscles. Lower stimulation currents produce less skeletal muscle contraction and are better tolerated
V4R
Indication
• Inferior MI indicated by ST segment elevation in two of the following leads: II, III, aVF
Purpose
• Identifies Right Ventricular (RV) infarction. Patients with RV infarction are very preload sensitive and can develop severe hypotension in response to NTG
Procedure
• Leave the 12 lead ECG electrodes and leads (wires) in place
• Remove the V4 lead from the left side of the patient’s chest
• Attach the lead to a new electrode
• Place the V4 lead on the patient’s right side (5th intercostal space, mid-clavicular)
• Acquire a new 12 lead ECG
• A 1 mm ST-segment elevation in V4(R) indicates RV infarct • Write “V4R” on the printed 12 lead ECG and deliver to ER
Indication
• Inferior MI indicated by ST segment elevation in two of the following leads: II, III, aVF
Purpose
• Identifies Right Ventricular (RV) infarction. Patients with RV infarction are very preload sensitive and can develop severe hypotension in response to NTG
Procedure
• Leave the 12 lead ECG electrodes and leads (wires) in place
• Remove the V4 lead from the left side of the patient’s chest
• Attach the lead to a new electrode
• Place the V4 lead on the patient’s right side (5th intercostal space, mid-clavicular)
• Acquire a new 12 lead ECG
• A 1 mm ST-segment elevation in V4(R) indicates RV infarct • Write “V4R” on the printed 12 lead ECG and deliver to ER
King Tube
Indications
• Intended to be used as a rescue airway device after one or two failed intubation attempts
• May be used as primary airway if intubation anticipated to be difficult and rapid
airway control is necessary
• Designated advanced airway for EMTs
Contraindication
• Foreign body airway obstruction
• Intact gag reflex
• Caustic ingestion
Procedure for EMT and Paramedic
• Initiate BLS airway sequence
• Select proper size King Tube based on patient height (includes pediatrics):
• 5-12kg=#1
• 12- 25 kg= #2
• 4’ to 5’ tall = #3
• 5’-6’ tall = #4
• Greater than 6’ tall = #5
• Assemble equipment, inflate cuff to proper volume, test balloon for leaks and then deflate, lubricate posterior aspect distal tip with water-soluble lubricant
• Suction airway and pre-oxygenate with BVM ventilations, if possible
• If possible spinal injury, maintain cervical immobilization
• If no spinal injury, place head into sniffing position or with slight cervical hyperextension
• Hold King Tube in dominant hand at connector. With other hand, open mouth and lift chin
• Rotate King Tube so blue index line is facing corner of mouth
• Introduce tip into mouth and advance airway behind tongue into the hypopharynx
• As tube passes tongue, rotate King Tube so that blue index line is again facing the chin
• Without excessive force, advance King Tube so that base is aligned with teeth or gums
• Using supplied syringe, inflate cuff with correct volume of air (marked on King Tube)
• Size 1 = 20 mL
• Size 2 = 35 mL
• Size 3 = 50 mL
• Size 4 = 70 mL
• Size 5 = 80 mL
• Attach bag to King Tube and begin ventilating patient. While ventilating, slowly and slightly withdraw King Tube until ventilations are easy and chest rise is adequate
• Confirm tube placement by auscultation, chest movement, and ETCO2
• Secure tube with commercial tube holder (may use other means if necessary)
• Insert properly sized NG/OG tube into gastric lumen for suctioning and/or passive
venting. This can decrease gastric pressure and reduce the risk of aspiration
• Monitor patient for vomiting and aspiration
• Continuously monitor ETCO2 and SpO2 values
• Do not remove a properly functioning King Tube to attempt intubation
Indications
• Intended to be used as a rescue airway device after one or two failed intubation attempts
• May be used as primary airway if intubation anticipated to be difficult and rapid
airway control is necessary
• Designated advanced airway for EMTs
Contraindication
• Foreign body airway obstruction
• Intact gag reflex
• Caustic ingestion
Procedure for EMT and Paramedic
• Initiate BLS airway sequence
• Select proper size King Tube based on patient height (includes pediatrics):
• 5-12kg=#1
• 12- 25 kg= #2
• 4’ to 5’ tall = #3
• 5’-6’ tall = #4
• Greater than 6’ tall = #5
• Assemble equipment, inflate cuff to proper volume, test balloon for leaks and then deflate, lubricate posterior aspect distal tip with water-soluble lubricant
• Suction airway and pre-oxygenate with BVM ventilations, if possible
• If possible spinal injury, maintain cervical immobilization
• If no spinal injury, place head into sniffing position or with slight cervical hyperextension
• Hold King Tube in dominant hand at connector. With other hand, open mouth and lift chin
• Rotate King Tube so blue index line is facing corner of mouth
• Introduce tip into mouth and advance airway behind tongue into the hypopharynx
• As tube passes tongue, rotate King Tube so that blue index line is again facing the chin
• Without excessive force, advance King Tube so that base is aligned with teeth or gums
• Using supplied syringe, inflate cuff with correct volume of air (marked on King Tube)
• Size 1 = 20 mL
• Size 2 = 35 mL
• Size 3 = 50 mL
• Size 4 = 70 mL
• Size 5 = 80 mL
• Attach bag to King Tube and begin ventilating patient. While ventilating, slowly and slightly withdraw King Tube until ventilations are easy and chest rise is adequate
• Confirm tube placement by auscultation, chest movement, and ETCO2
• Secure tube with commercial tube holder (may use other means if necessary)
• Insert properly sized NG/OG tube into gastric lumen for suctioning and/or passive
venting. This can decrease gastric pressure and reduce the risk of aspiration
• Monitor patient for vomiting and aspiration
• Continuously monitor ETCO2 and SpO2 values
• Do not remove a properly functioning King Tube to attempt intubation
Airtraq
Indications
• Acceptable for use as the initial means of intubation in the routine airway
• To be used in place of standard laryngoscope in difficult or anticipated to be difficult
adult intubations
Contraindications
• Small pediatrics when blade is too large
Procedure
• Select appropriate blade color based on ETT size:
• Purple: 4.0 – 5.5
• Green: 6.0 – 7.5
• Blue: 7.0 – 8.5
• Connect blade and press orange power button on underside of display to turn on the light
• Lubricate guiding channel
• Preload guiding channel with the endotracheal tube
• Distal end of endotracheal tube should align with end of channel
• Suction prior to inserting the blade to avoid secretions which could cover the
camera lens and cloud the image
• Use your left hand to facilitate insertion into patient’s mouth. Hold it gently using your
fingers rather than the full palm. Do not hold like a direct laryngoscope
• Insert blade midline around the tongue. Visualize airway structures while inserting blade
• Place blade tip in the vallecula and elevate the epiglottis
• The view of the vocal cords should be centered on the screen but not a close-up. A
panoramic view is optimal and allows for plenty of room to pass the tube
• Twist device if needed to better center vocal cords
• Advance the endotracheal tube slowly and watch for the cuff to pass through the vocal
cords
• Grasp end of endotracheal tube and move to side of mouth while removing Airtraq midline. The endotracheal tube should easily separate from the channel
Precaution
• If the lens becomes obstructed with bodily fluids, remove the blade from the patient’s mouth and clear the lens
Indications
• Acceptable for use as the initial means of intubation in the routine airway
• To be used in place of standard laryngoscope in difficult or anticipated to be difficult
adult intubations
Contraindications
• Small pediatrics when blade is too large
Procedure
• Select appropriate blade color based on ETT size:
• Purple: 4.0 – 5.5
• Green: 6.0 – 7.5
• Blue: 7.0 – 8.5
• Connect blade and press orange power button on underside of display to turn on the light
• Lubricate guiding channel
• Preload guiding channel with the endotracheal tube
• Distal end of endotracheal tube should align with end of channel
• Suction prior to inserting the blade to avoid secretions which could cover the
camera lens and cloud the image
• Use your left hand to facilitate insertion into patient’s mouth. Hold it gently using your
fingers rather than the full palm. Do not hold like a direct laryngoscope
• Insert blade midline around the tongue. Visualize airway structures while inserting blade
• Place blade tip in the vallecula and elevate the epiglottis
• The view of the vocal cords should be centered on the screen but not a close-up. A
panoramic view is optimal and allows for plenty of room to pass the tube
• Twist device if needed to better center vocal cords
• Advance the endotracheal tube slowly and watch for the cuff to pass through the vocal
cords
• Grasp end of endotracheal tube and move to side of mouth while removing Airtraq midline. The endotracheal tube should easily separate from the channel
Precaution
• If the lens becomes obstructed with bodily fluids, remove the blade from the patient’s mouth and clear the lens
Capnography
Indications
• To confirm proper placement of ALL intubations and supraglottic airways (e.g., King
Tube)
• To rule out esophageal intubation
• To identify late endotracheal tube dislodgement
Procedure
• Attach the sampling line to the unit’s CO2 inlet port
• In patient with ETT or advanced airway: place the ETCO2 detector in-line between
airway adaptor and BVM after airway positioned and secured
• Place the airway adapter at the proximal end of the airway circuit between the elbow
and the ventilator circuit wye. Do NOT place the airway adapter between the ET
tube and the elbow as this may allow patient secretions to accumulate in the adapter
• Select the correct patient type - Adult, Pediatric, or Neonate
• Press the CO2 quick access key ( ) to initiate CO2 monitoring
• The numeric CO2 display appears on the screen and displays the message,
INITIALIZING. The CO2 display gives the current EtCO2 value, and after a delay of approximately 1 minute, the patient’s Respiration Rate (in Breaths/Minute), identified as BR:
• Check that connections have been made correctly by verifying the display a proper capnogram (the waveform is inserted automatically on the waveform display window)
Readings
• Normal readings are 35-45 mmHg in a healthy patient
• High ETCO2 (>45)
• Hypoventilation/CO2 retention
• Low ETCO2 (<35)
• Hyperventilation
• Low perfusion: shock, PE, sepsis
• Cardiac Arrest:
• In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant of ETCO2 is blood flow, so ETCO2 is a good indicator of quality of CPR
• If ETCO2 is dropping, change out person doing chest compression
• In cardiac arrest, if ETCO2 not >10 mmHg after 20 minutes of good CPR, this likely
reflects very low CO2 production and an extended down time
Precaution
• Sudden loss of ETCO2:
• Tube dislodged
• Tube obstruction (e.g., secretions)
• Circuit disconnected
• Cardiac arrest
Indications
• To confirm proper placement of ALL intubations and supraglottic airways (e.g., King
Tube)
• To rule out esophageal intubation
• To identify late endotracheal tube dislodgement
Procedure
• Attach the sampling line to the unit’s CO2 inlet port
• In patient with ETT or advanced airway: place the ETCO2 detector in-line between
airway adaptor and BVM after airway positioned and secured
• Place the airway adapter at the proximal end of the airway circuit between the elbow
and the ventilator circuit wye. Do NOT place the airway adapter between the ET
tube and the elbow as this may allow patient secretions to accumulate in the adapter
• Select the correct patient type - Adult, Pediatric, or Neonate
• Press the CO2 quick access key ( ) to initiate CO2 monitoring
• The numeric CO2 display appears on the screen and displays the message,
INITIALIZING. The CO2 display gives the current EtCO2 value, and after a delay of approximately 1 minute, the patient’s Respiration Rate (in Breaths/Minute), identified as BR:
• Check that connections have been made correctly by verifying the display a proper capnogram (the waveform is inserted automatically on the waveform display window)
Readings
• Normal readings are 35-45 mmHg in a healthy patient
• High ETCO2 (>45)
• Hypoventilation/CO2 retention
• Low ETCO2 (<35)
• Hyperventilation
• Low perfusion: shock, PE, sepsis
• Cardiac Arrest:
• In low-pulmonary blood flow states, such as cardiac arrest, the primary determinant of ETCO2 is blood flow, so ETCO2 is a good indicator of quality of CPR
• If ETCO2 is dropping, change out person doing chest compression
• In cardiac arrest, if ETCO2 not >10 mmHg after 20 minutes of good CPR, this likely
reflects very low CO2 production and an extended down time
Precaution
• Sudden loss of ETCO2:
• Tube dislodged
• Tube obstruction (e.g., secretions)
• Circuit disconnected
• Cardiac arrest
CPAP & CPAP with Inline Nebulizer
Pulmodyne O2-Max is a high-pressure disposable CPAP that filters inspiratory and expiratory air.
Indication
• Symptomatic patients with moderate-to-severe respiratory distress (wheezes, rales, decreased breath sounds, etc.)
Contraindications
• Respiratory or cardiac arrest
• Systolic BP less than 90mmHg
• Lack of airway protective reflexes
• Decreased LOC or unable to follow verbal instructions
• Vomiting or active upper GI bleed
• Suspected pneumothorax
• Trauma
• Patient size or anatomy prevents adequate mask seal
Procedure
• Place patient in a seated position and explain the procedure to him or her
• Select appropriate size mask
• Connect O2 tubing to the high-pressure oxygen source
• Hand mask to the patient and allow them to feel the air flow on their face
• Apply the CPAP mask and secure with provided straps, progressively tightening as
tolerated to minimize air leak
• Adjust the PEEP valve so that the desired pressure is obtained. The valve comes preset
at 5 cm H2O, but can be adjusted to 7.5 or 10 cm H2O
• <12 y/o – maintain the 5 cm H2O
• Adult and pediatric >12 y/o – adjust valve to 10 cm H2O
• Advanced airway indicated if signs of deterioration or failure of response to CPAP present:
• Decrease in level of consciousness
• Substantially increased heart rate or respiratory rate
• Substantially decreased blood pressure
• Visible signs of fatigue
• Sustained low or decreasing SpO2 readings
• Diminished or no improvement in tidal volume
Utilize Ohmeda style connector for high-pressure wall outlet
CPAP with inline nebulized medications
• Continue with normal CPAP
• Insert nebulizer into the designated integrated port
• Connect nebulizer to a standard low-pressure oxygen port
Pulmodyne O2-Max is a high-pressure disposable CPAP that filters inspiratory and expiratory air.
Indication
• Symptomatic patients with moderate-to-severe respiratory distress (wheezes, rales, decreased breath sounds, etc.)
Contraindications
• Respiratory or cardiac arrest
• Systolic BP less than 90mmHg
• Lack of airway protective reflexes
• Decreased LOC or unable to follow verbal instructions
• Vomiting or active upper GI bleed
• Suspected pneumothorax
• Trauma
• Patient size or anatomy prevents adequate mask seal
Procedure
• Place patient in a seated position and explain the procedure to him or her
• Select appropriate size mask
• Connect O2 tubing to the high-pressure oxygen source
• Hand mask to the patient and allow them to feel the air flow on their face
• Apply the CPAP mask and secure with provided straps, progressively tightening as
tolerated to minimize air leak
• Adjust the PEEP valve so that the desired pressure is obtained. The valve comes preset
at 5 cm H2O, but can be adjusted to 7.5 or 10 cm H2O
• <12 y/o – maintain the 5 cm H2O
• Adult and pediatric >12 y/o – adjust valve to 10 cm H2O
• Advanced airway indicated if signs of deterioration or failure of response to CPAP present:
• Decrease in level of consciousness
• Substantially increased heart rate or respiratory rate
• Substantially decreased blood pressure
• Visible signs of fatigue
• Sustained low or decreasing SpO2 readings
• Diminished or no improvement in tidal volume
Utilize Ohmeda style connector for high-pressure wall outlet
CPAP with inline nebulized medications
• Continue with normal CPAP
• Insert nebulizer into the designated integrated port
• Connect nebulizer to a standard low-pressure oxygen port
Bougie
Indication
• To be used as an endotracheal tube inducer (ETI) when the tube cannot be passed despite a good view of the vocal cords or an incomplete view of the glottis opening
• Can be used with standard laryngoscope or Airtraq
• Can be used as a tube exchanger should the need arise for a replacement ET tube
• To be used when performing a cricothyrotomy (Appendix K)
Precaution
• Not to be used in a completely blind fashion
• Excessive force, passage beyond the carina, or blind introduction may result in damage
to oropharynx or trachea/bronchi
Procedure
• Size 15 Fr appropriate for >6.0 mm ET tubes (10 years and older)
• Place bougie (with curved tip) into the mouth and direct into glottis with the firm end of
the ETI pointing anterior
• You should feel the tip of the bougie ‘click’ as it passes along the tracheal rings
• Advance the ETI to approximately 20 cm at the teeth (look for black mark)
• If possible, continue laryngoscopy to elevate the pharyngeal soft tissue while an
assistant threads an endotracheal tube over the introducer into the trachea. If the endotracheal tube meets resistance at the laryngeal inlet and will not pass, stop advancement efforts, withdraw the endotracheal tube 1-2 cm with rotation of the tube 90° in either or both directions while reattempting to advance the tube may help negotiate passage of the tube
• While the assistant holds the ETI, advance the endotracheal tube to the desired depth and hold the tube firmly in place while the ETI is gently withdrawn
• Remove laryngoscope, secure the endotracheal tube, and confirm tube placement as usual
Indication
• To be used as an endotracheal tube inducer (ETI) when the tube cannot be passed despite a good view of the vocal cords or an incomplete view of the glottis opening
• Can be used with standard laryngoscope or Airtraq
• Can be used as a tube exchanger should the need arise for a replacement ET tube
• To be used when performing a cricothyrotomy (Appendix K)
Precaution
• Not to be used in a completely blind fashion
• Excessive force, passage beyond the carina, or blind introduction may result in damage
to oropharynx or trachea/bronchi
Procedure
• Size 15 Fr appropriate for >6.0 mm ET tubes (10 years and older)
• Place bougie (with curved tip) into the mouth and direct into glottis with the firm end of
the ETI pointing anterior
• You should feel the tip of the bougie ‘click’ as it passes along the tracheal rings
• Advance the ETI to approximately 20 cm at the teeth (look for black mark)
• If possible, continue laryngoscopy to elevate the pharyngeal soft tissue while an
assistant threads an endotracheal tube over the introducer into the trachea. If the endotracheal tube meets resistance at the laryngeal inlet and will not pass, stop advancement efforts, withdraw the endotracheal tube 1-2 cm with rotation of the tube 90° in either or both directions while reattempting to advance the tube may help negotiate passage of the tube
• While the assistant holds the ETI, advance the endotracheal tube to the desired depth and hold the tube firmly in place while the ETI is gently withdrawn
• Remove laryngoscope, secure the endotracheal tube, and confirm tube placement as usual
Needle Decompression
Indications
• Trauma Arrest from penetrating chest injury
• Unilateral absent or decreased breath sounds with severe respiratory distress or
signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
Procedure for Paramedics
• Expose entire chest
• Clean skin overlying site with available skin prep
• Insert largest, longest available angiocath (typically 14g 3.25” for adults and 14g
1.25” for pediatrics) over top of inferior rib at the 2nd intercostal space at mid-
clavicular line on the affected side(s)
• Remove needle while leaving catheter in place
• Consider placement of second angiocath if initial placement was successful but
patient deteriorates. First angiocath may have become occluded with blood or soft tissue
Notify receiving hospital of needle decompression attempt.
A simple pneumothorax is NOT an indication for needle decompression.
Indications
• Trauma Arrest from penetrating chest injury
• Unilateral absent or decreased breath sounds with severe respiratory distress or
signs/symptoms of tension pneumothorax such as hypotension, tachycardia, and hypoxia
Procedure for Paramedics
• Expose entire chest
• Clean skin overlying site with available skin prep
• Insert largest, longest available angiocath (typically 14g 3.25” for adults and 14g
1.25” for pediatrics) over top of inferior rib at the 2nd intercostal space at mid-
clavicular line on the affected side(s)
• Remove needle while leaving catheter in place
• Consider placement of second angiocath if initial placement was successful but
patient deteriorates. First angiocath may have become occluded with blood or soft tissue
Notify receiving hospital of needle decompression attempt.
A simple pneumothorax is NOT an indication for needle decompression.
Cricothyrotomy
Indications
• “Failed Airway” (unable to ventilate and/or intubate)
• Facial trauma that prohibits orotracheal intubation
• Unrelieved Foreign Body Airway Obstruction (FBAO)
• Upper airway obstruction not from a foreign body
Contraindications
• Ability to secure the airway by other means
• Unable to locate anatomical landmarks
• Laryngeal injury
Procedure for Paramedic Surgical (>8 years old):
• Assemble all equipment
• Place the head/neck in the neutral position
• Locate and stabilize the larynx with your non-dominate hand
• Locate the cricothyroid membrane
• Clean the area with alcohol prep
• Pull the skin taught over the cricothyroid membrane
• Make a vertical incision to the skin over the membrane
• Identify the cricothyroid membrane
• With the scalpel vertical to the cricothyroid membrane, puncture the membrane
• Insert the bougie (curved tip first) through the incision and angled towards the
patient’s feet
• You should feel the tip of the bougie ‘click’ as it passes along the tracheal rings
• Secure the scalpel
• Advance a 6.0 ET tube over the bougie and into the opening in the trachea
• Remove bougie while stabilizing ET tube
• Inflate the pilot balloon
• Ventilate with 100% O2
• Confirm ET tube placement
• Monitor adequacy of ventilations
• Document ETCO2 value (Appendix F)
• Secure the ET tube with tape
Needle (<= 8 years old):
• Assemble all equipment
• Place the head/neck in the neutral position
• Locate and stabilize the larynx with your non-dominant hand
• Locate the cricothyroid membrane
• Clean the area with alcohol prep
• Direct an 18g angiocath 45-60 degrees caudally
• Puncture the cricothyroid membrane with the needle
• Advance the catheter over the needle
• Attach a 10cc syringe and aspirate air to confirm placement in the trachea
• If the catheter is in the trachea, attach the adapter from a 3.0 mm ET tube onto
the hub of the catheter
• Ventilate via BVM
• Secure with 4x4’s and tape and dedicate one member to maintain control of the
catheter throughout transport to prevent dislodgement or kinking
• Needle cricothyrotomy may provide adequate oxygenation for a limited time,
rapid transport is necessary
Indications
• “Failed Airway” (unable to ventilate and/or intubate)
• Facial trauma that prohibits orotracheal intubation
• Unrelieved Foreign Body Airway Obstruction (FBAO)
• Upper airway obstruction not from a foreign body
Contraindications
• Ability to secure the airway by other means
• Unable to locate anatomical landmarks
• Laryngeal injury
Procedure for Paramedic Surgical (>8 years old):
• Assemble all equipment
• Place the head/neck in the neutral position
• Locate and stabilize the larynx with your non-dominate hand
• Locate the cricothyroid membrane
• Clean the area with alcohol prep
• Pull the skin taught over the cricothyroid membrane
• Make a vertical incision to the skin over the membrane
• Identify the cricothyroid membrane
• With the scalpel vertical to the cricothyroid membrane, puncture the membrane
• Insert the bougie (curved tip first) through the incision and angled towards the
patient’s feet
• You should feel the tip of the bougie ‘click’ as it passes along the tracheal rings
• Secure the scalpel
• Advance a 6.0 ET tube over the bougie and into the opening in the trachea
• Remove bougie while stabilizing ET tube
• Inflate the pilot balloon
• Ventilate with 100% O2
• Confirm ET tube placement
• Monitor adequacy of ventilations
• Document ETCO2 value (Appendix F)
• Secure the ET tube with tape
Needle (<= 8 years old):
• Assemble all equipment
• Place the head/neck in the neutral position
• Locate and stabilize the larynx with your non-dominant hand
• Locate the cricothyroid membrane
• Clean the area with alcohol prep
• Direct an 18g angiocath 45-60 degrees caudally
• Puncture the cricothyroid membrane with the needle
• Advance the catheter over the needle
• Attach a 10cc syringe and aspirate air to confirm placement in the trachea
• If the catheter is in the trachea, attach the adapter from a 3.0 mm ET tube onto
the hub of the catheter
• Ventilate via BVM
• Secure with 4x4’s and tape and dedicate one member to maintain control of the
catheter throughout transport to prevent dislodgement or kinking
• Needle cricothyrotomy may provide adequate oxygenation for a limited time,
rapid transport is necessary
Pediatric Restraint Device
Indications
• Transporting a non-immobilized pediatric patient
• Use of this device should be the standard. Exceptions may be made based on
the child’s level of distress
• A car seat is a viable option to the Pediatric Restraint Device. Both methods
are better alternatives than a parent’s lap
Procedure for EMT or Paramedic
• Place Pediatric Stretcher Restraint Device (PSRD) on the stretcher pad
• Release the buckles from the long strap and the 2 smaller straps
• Open it and lay it flat on the stretcher pad
• Wrap the large strap from the PSRD around the head portion of the stretcher, close
the buckle and tighten the strap
• Wrap the short straps from the PSRD around the stretcher rail, close the buckle and
tighten the strap
• Pick a point closest to the strap
• Open the buckle on the “V” strap of the PSRD
• Open the buckle on the lateral chest strap
• Place the child on the stretcher and on top of the PSRD
• Secure the patient in the PSRD by bringing the “V” strap over the patient’s head
• Connect the “V” strap to the groin strap, close the buckle and tighten the strap
• Pad around the child if there are any gaps between the patient and the PSRD
• Close the lateral chest strap buckle and tighten
• Always document every use of the PSRD in the PCR
Caution
• Do not cut any portion of the device
Indications
• Transporting a non-immobilized pediatric patient
• Use of this device should be the standard. Exceptions may be made based on
the child’s level of distress
• A car seat is a viable option to the Pediatric Restraint Device. Both methods
are better alternatives than a parent’s lap
Procedure for EMT or Paramedic
• Place Pediatric Stretcher Restraint Device (PSRD) on the stretcher pad
• Release the buckles from the long strap and the 2 smaller straps
• Open it and lay it flat on the stretcher pad
• Wrap the large strap from the PSRD around the head portion of the stretcher, close
the buckle and tighten the strap
• Wrap the short straps from the PSRD around the stretcher rail, close the buckle and
tighten the strap
• Pick a point closest to the strap
• Open the buckle on the “V” strap of the PSRD
• Open the buckle on the lateral chest strap
• Place the child on the stretcher and on top of the PSRD
• Secure the patient in the PSRD by bringing the “V” strap over the patient’s head
• Connect the “V” strap to the groin strap, close the buckle and tighten the strap
• Pad around the child if there are any gaps between the patient and the PSRD
• Close the lateral chest strap buckle and tighten
• Always document every use of the PSRD in the PCR
Caution
• Do not cut any portion of the device
Tourniquet
Indications
• To control potentially fatal extremity hemorrhage only after other means of hemorrhage control has failed. Examples may include an amputation, profuse pulsating bleeding, blood soaking through pressure bandage and signs of shock with continued bleeding
Procedure for EMT or Paramedic
• First attempt to control hemorrhage by using direct pressure over bleeding area
• If a bleeding vessel can be identified, point pressure over bleeding vessel is more
effective than a large bandage applying diffuse pressure
If unable to control hemorrhage using direct pressure, apply SOF© Tactical Tourniquet:
- Cut away any clothing so that the tourniquet will be clearly visible. NEVER obscure a tourniquet with clothing or bandages
- Select location proximal to the wound and not across any joints
- Place tourniquet 2-3” proximal to the wound
• Slide tourniquet over extremity if possible. Otherwise, unbuckle tourniquet, go
around the limb and then re-buckle - Pull tail tight
- Twist handle until bleeding stops. Applying tourniquet too loosely will only increase blood loss by inhibiting venous return
- Lock handle into triangle
- Mark the time and date of application on the patients skin next to the tourniquet
- Keep tourniquet on throughout hospital transport – a correctly applied tourniquet should only be removed by the receiving hospital
Precaution
• Injury due to a properly applied tourniquet is unlikely if the tourniquet is removed within 1-2 hours. In cases of life-threatening bleeding, benefit outweighs theoretical risk
• A commercially made tourniquet is the preferred tourniquet. If none is available, a blood pressure cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative. Other improvised tourniquets are not allowed
Indications
• To control potentially fatal extremity hemorrhage only after other means of hemorrhage control has failed. Examples may include an amputation, profuse pulsating bleeding, blood soaking through pressure bandage and signs of shock with continued bleeding
Procedure for EMT or Paramedic
• First attempt to control hemorrhage by using direct pressure over bleeding area
• If a bleeding vessel can be identified, point pressure over bleeding vessel is more
effective than a large bandage applying diffuse pressure
If unable to control hemorrhage using direct pressure, apply SOF© Tactical Tourniquet:
- Cut away any clothing so that the tourniquet will be clearly visible. NEVER obscure a tourniquet with clothing or bandages
- Select location proximal to the wound and not across any joints
- Place tourniquet 2-3” proximal to the wound
• Slide tourniquet over extremity if possible. Otherwise, unbuckle tourniquet, go
around the limb and then re-buckle - Pull tail tight
- Twist handle until bleeding stops. Applying tourniquet too loosely will only increase blood loss by inhibiting venous return
- Lock handle into triangle
- Mark the time and date of application on the patients skin next to the tourniquet
- Keep tourniquet on throughout hospital transport – a correctly applied tourniquet should only be removed by the receiving hospital
Precaution
• Injury due to a properly applied tourniquet is unlikely if the tourniquet is removed within 1-2 hours. In cases of life-threatening bleeding, benefit outweighs theoretical risk
• A commercially made tourniquet is the preferred tourniquet. If none is available, a blood pressure cuff inflated to a pressure sufficient to stop bleeding is an acceptable alternative. Other improvised tourniquets are not allowed
SAM Pelvic Splint
Indications
• Unstable pelvis
Procedure for EMT and Paramedic
• Remove all objects from the patient’s pockets
• Lay the splint out next to the patient’s pelvis (printed side down)
• Slide the splint under the pelvis at the level of the bottom of the buttock (figure 1)
• Wrap the black strap completely through the buckle (figure 2)
• Hold the orange strap and PULL the black strap in the opposite direction (figure 3)
• Pull until you hear the “Click”
• Maintain the tension and press the black strap onto the Velcro® portion of the splint
Cautions
• Do not use on pediatric patients
• Do not cut any portion of the splint
Indications
• Unstable pelvis
Procedure for EMT and Paramedic
• Remove all objects from the patient’s pockets
• Lay the splint out next to the patient’s pelvis (printed side down)
• Slide the splint under the pelvis at the level of the bottom of the buttock (figure 1)
• Wrap the black strap completely through the buckle (figure 2)
• Hold the orange strap and PULL the black strap in the opposite direction (figure 3)
• Pull until you hear the “Click”
• Maintain the tension and press the black strap onto the Velcro® portion of the splint
Cautions
• Do not use on pediatric patients
• Do not cut any portion of the splint
Spinal Immobilization
The goal of spinal immobilization is to prevent neurologic damage or limit the extent of a spinal cord injury.
Purpose
• To provide guidelines and recommendations for determining full or partial spinal immobilization
Indications for full spinal immobilization
• Numbness, tingling, or motor weakness in any extremity
• Point tenderness over the spinal process
• Neck pain during movement
• Head injury with GCS <15
• Significant mechanism of injury such as ejection, high falls, and abrupt deceleration crashes
• An intoxicated patient who suffers a significant mechanism of injury must receive spinal immobilization regardless of whether they are alert and oriented
• Any patient <5 or >65 who has experienced a mechanism of injury which could result in spinal injury
Indication for partial immobilization (cervical collar only)
• Isolated neck pain with none of the indications above
• Patient who refuses or can’t tolerate full spinal immobilization
• Deviation must be documented in the PCR
Precaution
• Range of motion should NOT be assessed if patient has midline spinal tenderness
• Range of motion should not be assisted
• Consider spinal immobilization in any patient with arthritis, cancer, or other
underlying spinal or bone disease
• If there is any doubt during the evaluation of the spine, it is better to immobilize
• Patients with spinal curvature or rounding of the back may require improvised
(towels, blanket, pillow, etc.) immobilization
Infants and children less than 60 lbs, use Pedi-ImmobilizerTM when appropriate.
The goal of spinal immobilization is to prevent neurologic damage or limit the extent of a spinal cord injury.
Purpose
• To provide guidelines and recommendations for determining full or partial spinal immobilization
Indications for full spinal immobilization
• Numbness, tingling, or motor weakness in any extremity
• Point tenderness over the spinal process
• Neck pain during movement
• Head injury with GCS <15
• Significant mechanism of injury such as ejection, high falls, and abrupt deceleration crashes
• An intoxicated patient who suffers a significant mechanism of injury must receive spinal immobilization regardless of whether they are alert and oriented
• Any patient <5 or >65 who has experienced a mechanism of injury which could result in spinal injury
Indication for partial immobilization (cervical collar only)
• Isolated neck pain with none of the indications above
• Patient who refuses or can’t tolerate full spinal immobilization
• Deviation must be documented in the PCR
Precaution
• Range of motion should NOT be assessed if patient has midline spinal tenderness
• Range of motion should not be assisted
• Consider spinal immobilization in any patient with arthritis, cancer, or other
underlying spinal or bone disease
• If there is any doubt during the evaluation of the spine, it is better to immobilize
• Patients with spinal curvature or rounding of the back may require improvised
(towels, blanket, pillow, etc.) immobilization
Infants and children less than 60 lbs, use Pedi-ImmobilizerTM when appropriate.
Intraosseous Access
Intraosseous Access (IO)
• May be used in adult or pediatric patients
• IO may be considered earlier in the arrest setting
• Proximal Humerus is preferred site for volume resuscitation (except
newborn/infants)
• Proximal Tibia is preferred site in cardiac arrests and medication
administration only
• IO insertion site selection is not affected by paralysis
Criteria for IO access
• Must meet all the following in the non-arrest patient:
• Urgent need for fluid/medication administration
• Two failed IV attempts or more than 90 seconds
• Severe cardiovascular compromise or unconscious/unresponsive
Contraindications
• The humerus is contraindicated in newborns and infants
• The ability to readily obtain peripheral or external jugular IV access
• Fracture of the tibia (consider alternative site)
• Fracture of the humerus (consider alternative site)
• Excessive tissue at the selected insertion site (consider alternative site)
• Inability to identify appropriate anatomical landmarks
• Infection at the selected site
• Previous significant orthopedic procedures (e.g., IO within 24 hours, joint
replacement)
• Compromising pre-existing medical condition (e.g., bone cancer, peripheral vascular
disease)
Procedure
• Don appropriate PPE
• Identify appropriate indication(s) and absence of contraindications
• Select the site and identify the appropriate landmarks
• Humerus
• Proximal tibia (medial aspect)
• Cleanse insertion site with alcohol swab
• Utilize EZ-IO® driver and appropriate needle set
• Needle selection will be based on the amount of soft tissue at the insertion site.
Gauge the amount of soft tissue by pressing the site with your thumb and correlate the finding with the appropriate needle length. Better too long than too short
• Pink – 15mm long (3-39kg)
• Blue – 25mm long (40kg and above)
• Yellow – 45mm long (excessive tissue)
• Stabilize site and manually insert the needle set through the skin until it contacts the
surface of the bone; DO NOT power (operate or squeeze trigger) the driver
• Ensure black mark is visible on the needle. If not, remove needle, it is too short
• Power the driver with firm and steady pressure until a sudden lack of resistance is
felt indicating entrance into the bone marrow canal
• Unnecessary excessive pressure will slow the drill (simulates a dying battery)
• Remove the EZ-IO® driver from the needle set while stabilizing the catheter hub
• Remove the stylet and secure it in a sharp’s container
• Confirm placement:
• IO catheter stands firmly seated at a 90-degree angle to the insertion site
• Able to aspirate blood
• Fluids flow without evidence of extravasation
• Connect flushed EZ-Connect® or standard luer lock extension set
• Conscious or semi-conscious patient administer Lidocaine for suppression of
intramedullary pressure receptors; allow 1 minute for anesthetic effect
• Flush the EZ-Connect® or extension set with Lidocaine
• Adult patient: 20 - 40mg IO slow push
• Flush with 10mL intravenous fluid
• Pediatric patient: 0.5mg/kg IO (Maximum dose 40mg) slow push
• Flush with 10mL intravenous fluid
• Unconscious patient:
• Flush site with 10mL intravenous fluid
• Utilize a pressure infusion bag for intravenous fluid administration
• Medication infusion - follow all medication infusions with 10mL intravenous fluid flush
• Dress site and secure tubing
• Manual Pediatric IO (only for use when EZ-IO® is unavailable)
• Restricted for use in the proximal tibia only
• Procedures are the same as with the EZ-IO® as listed above with the following
adjustments
• Stabilize child’s leg and begin insertion from a 90-degree angle to the plane of
the tibial plateau
• Gently advance the needle set into position–do not force. Stop when you feel the
“pop” on smaller patients
Removal
• Monitor the EZ-IO site for evidence of leakage (extravasation) underneath the skin
• If it is determined that the EZ-IO needle is not properly placed (extravasation
noted), it will be removed prior to delivering the patient to the receiving facility
• Attached a 10mL syringe to the catheter hub
• Support the insertion site while rotating the syringe clockwise and gently pull
the catheter out without rocking
• If a catheter hub separation occurs grasp the catheter with a hemostat, rotate
clockwise and gently pull the catheter out without rocking
• Secure the catheter in an appropriate sharp’s container
• A properly placed EZ-IO is NOT to be removed in the field; the patient MUST be transported to the appropriate receiving facility
Intraosseous Access (IO)
• May be used in adult or pediatric patients
• IO may be considered earlier in the arrest setting
• Proximal Humerus is preferred site for volume resuscitation (except
newborn/infants)
• Proximal Tibia is preferred site in cardiac arrests and medication
administration only
• IO insertion site selection is not affected by paralysis
Criteria for IO access
• Must meet all the following in the non-arrest patient:
• Urgent need for fluid/medication administration
• Two failed IV attempts or more than 90 seconds
• Severe cardiovascular compromise or unconscious/unresponsive
Contraindications
• The humerus is contraindicated in newborns and infants
• The ability to readily obtain peripheral or external jugular IV access
• Fracture of the tibia (consider alternative site)
• Fracture of the humerus (consider alternative site)
• Excessive tissue at the selected insertion site (consider alternative site)
• Inability to identify appropriate anatomical landmarks
• Infection at the selected site
• Previous significant orthopedic procedures (e.g., IO within 24 hours, joint
replacement)
• Compromising pre-existing medical condition (e.g., bone cancer, peripheral vascular
disease)
Procedure
• Don appropriate PPE
• Identify appropriate indication(s) and absence of contraindications
• Select the site and identify the appropriate landmarks
• Humerus
• Proximal tibia (medial aspect)
• Cleanse insertion site with alcohol swab
• Utilize EZ-IO® driver and appropriate needle set
• Needle selection will be based on the amount of soft tissue at the insertion site.
Gauge the amount of soft tissue by pressing the site with your thumb and correlate the finding with the appropriate needle length. Better too long than too short
• Pink – 15mm long (3-39kg)
• Blue – 25mm long (40kg and above)
• Yellow – 45mm long (excessive tissue)
• Stabilize site and manually insert the needle set through the skin until it contacts the
surface of the bone; DO NOT power (operate or squeeze trigger) the driver
• Ensure black mark is visible on the needle. If not, remove needle, it is too short
• Power the driver with firm and steady pressure until a sudden lack of resistance is
felt indicating entrance into the bone marrow canal
• Unnecessary excessive pressure will slow the drill (simulates a dying battery)
• Remove the EZ-IO® driver from the needle set while stabilizing the catheter hub
• Remove the stylet and secure it in a sharp’s container
• Confirm placement:
• IO catheter stands firmly seated at a 90-degree angle to the insertion site
• Able to aspirate blood
• Fluids flow without evidence of extravasation
• Connect flushed EZ-Connect® or standard luer lock extension set
• Conscious or semi-conscious patient administer Lidocaine for suppression of
intramedullary pressure receptors; allow 1 minute for anesthetic effect
• Flush the EZ-Connect® or extension set with Lidocaine
• Adult patient: 20 - 40mg IO slow push
• Flush with 10mL intravenous fluid
• Pediatric patient: 0.5mg/kg IO (Maximum dose 40mg) slow push
• Flush with 10mL intravenous fluid
• Unconscious patient:
• Flush site with 10mL intravenous fluid
• Utilize a pressure infusion bag for intravenous fluid administration
• Medication infusion - follow all medication infusions with 10mL intravenous fluid flush
• Dress site and secure tubing
• Manual Pediatric IO (only for use when EZ-IO® is unavailable)
• Restricted for use in the proximal tibia only
• Procedures are the same as with the EZ-IO® as listed above with the following
adjustments
• Stabilize child’s leg and begin insertion from a 90-degree angle to the plane of
the tibial plateau
• Gently advance the needle set into position–do not force. Stop when you feel the
“pop” on smaller patients
Removal
• Monitor the EZ-IO site for evidence of leakage (extravasation) underneath the skin
• If it is determined that the EZ-IO needle is not properly placed (extravasation
noted), it will be removed prior to delivering the patient to the receiving facility
• Attached a 10mL syringe to the catheter hub
• Support the insertion site while rotating the syringe clockwise and gently pull
the catheter out without rocking
• If a catheter hub separation occurs grasp the catheter with a hemostat, rotate
clockwise and gently pull the catheter out without rocking
• Secure the catheter in an appropriate sharp’s container
• A properly placed EZ-IO is NOT to be removed in the field; the patient MUST be transported to the appropriate receiving facility
Sports Helmet Removal
In all circumstances, the face mask should be removed first for airway access. Also, cutting of the ties of the shoulder pads can be performed (both anteriorly and under the arms) to allow for access to the chest if needed for cardiopulmonary resuscitation (CPR).
Equipment (helmet and shoulder pads) should be left in place until arrival to the ED, unless the circumstance dictates removal. When equipment removal is necessary, it needs to follow the “all or nothing” principle, meaning removed together. As the helmet and shoulder pads work together to help maintain a neutral spine when they are properly fitted, removing the helmet without the shoulder pads will lead to cervical spine hyperextension, potentially worsening an injury.
Team athletic trainers or health care professionals may be present and able to provide assistance.
Procedure
• Stabilize helmet in a neutral in-line position
• Second individual removes the chin strap
• The individual that removes the chin strap will support the occipital and mandible of the
patient
• The individual that stabilized the helmet then gently removes the helmet
• Once helmet is removed, apply C-collar and immobilize on a long back board, KED, or
pediatric immobilization device
• If unable to remove helmet:
• Assure the face shield/mask has been removed for airway access
• Assure spinal immobilization with tape and towels
In all circumstances, the face mask should be removed first for airway access. Also, cutting of the ties of the shoulder pads can be performed (both anteriorly and under the arms) to allow for access to the chest if needed for cardiopulmonary resuscitation (CPR).
Equipment (helmet and shoulder pads) should be left in place until arrival to the ED, unless the circumstance dictates removal. When equipment removal is necessary, it needs to follow the “all or nothing” principle, meaning removed together. As the helmet and shoulder pads work together to help maintain a neutral spine when they are properly fitted, removing the helmet without the shoulder pads will lead to cervical spine hyperextension, potentially worsening an injury.
Team athletic trainers or health care professionals may be present and able to provide assistance.
Procedure
• Stabilize helmet in a neutral in-line position
• Second individual removes the chin strap
• The individual that removes the chin strap will support the occipital and mandible of the
patient
• The individual that stabilized the helmet then gently removes the helmet
• Once helmet is removed, apply C-collar and immobilize on a long back board, KED, or
pediatric immobilization device
• If unable to remove helmet:
• Assure the face shield/mask has been removed for airway access
• Assure spinal immobilization with tape and towels
Advanced Trauma Care Bag
Every field chief vehicle contains an Advanced Trauma Care Bag as pictured below.
Purpose
• With an assortment of advanced trauma care contents, these trauma kits are designed primarily for deployment at mass casualty incidents.
Contents
• HALO VENT - Adhesive, vented seal for treating penetrating chest injuries. Each
package contains one vented and one non-vented seal. The vented seal should be
applied to entrance wounds and the non-vented seal should be applied to exit wounds.
•Z-PACK DRESSING - Highly absorbent cotton gauze that is “Z-Folded” for ease in
packing wounds.
• HEMORRHAGE CONTROL BANDAGE - The Emergency Bandage (or Israeli bandage) is an elasticized bandage with a built-in pressure bar that can be twisted to apply more pressure to a wound. Designed to be applied on top of existing gauze/packing
•CHITO GAUZE-Hemostatic (promotes coagulation) dressing for the external,
temporary control of severely bleeding wounds.
• DRAG BLANKETS
• TOURNIQUETS
• DECOMPRESSIONS NEEDLES
• SHEARS
• ACE BANDAGES
• TRAUMA DRESSING
• 4X4GAUZE
Every field chief vehicle contains an Advanced Trauma Care Bag as pictured below.
Purpose
• With an assortment of advanced trauma care contents, these trauma kits are designed primarily for deployment at mass casualty incidents.
Contents
• HALO VENT - Adhesive, vented seal for treating penetrating chest injuries. Each
package contains one vented and one non-vented seal. The vented seal should be
applied to entrance wounds and the non-vented seal should be applied to exit wounds.
•Z-PACK DRESSING - Highly absorbent cotton gauze that is “Z-Folded” for ease in
packing wounds.
• HEMORRHAGE CONTROL BANDAGE - The Emergency Bandage (or Israeli bandage) is an elasticized bandage with a built-in pressure bar that can be twisted to apply more pressure to a wound. Designed to be applied on top of existing gauze/packing
•CHITO GAUZE-Hemostatic (promotes coagulation) dressing for the external,
temporary control of severely bleeding wounds.
• DRAG BLANKETS
• TOURNIQUETS
• DECOMPRESSIONS NEEDLES
• SHEARS
• ACE BANDAGES
• TRAUMA DRESSING
• 4X4GAUZE
