General Information Flashcards
Criteria for Deviation from the Protocol
It is recognized that the EMS protocols cannot address every possible scenario. Therefore, two concurring paramedics are given the authority to deviate from the ALS protocols as required. Good judgment and the patient’s best interest must be considered at all times. When deviating from the protocols always document the reason clearly. When possible the EMS Captain should be contacted and will provide input to this decision.
- Two concurring paramedics
- When possible EMS 17 should be consulted
MEDICATION ADMINISTRATION
- Allergies and Adverse reactions: Prior to administering any medication, inquire about medication allergies or adverse reactions to medications.
- Medication Integrity: Check the medication’s name, date of expiration, color and clarity before administration.
- Timing of medication administration during cardiac arrest: Medications administered during cardiac arrest should be administered during compressions and followed by a 10mL Normal Saline flush.
- Allergy: A true allergy to a medication causes a rash, SOB, swelling of the tongue, face and/or throat.
- Fluid resuscitation: shall be limited to 1L of Normal Saline and administered as follows: 500mL bolus, may repeat 1x. Check lung sounds before and after each 500mL bolus. Monitor these patients carefully as they are at risk for fluid overload (pulmonary edema).
Medication Administration
INTRAOSSEOUS
• An IO should be placed for patients with emergency medical conditions that require urgent vascular access in whom an IV is not immediately obtainable or is deemed to have insufficient access.
* IO is the preferred method of vascular access during cardiac arrest.
• All medications administered to patients with a pulse should be given slow IV/IO (over 2 minutes), unless otherwise stated.
Medication Administration
IM INJECTIONS
• Infants and Children
use a 23 gauge 1 inch needle. The injection site is the lateral thigh 1.25mL maximum. If greater than 1.25 mL needs to be administered, split the dose between both thighs.
Medication Administration
IM INJECTIONS
Adults and large Children
use a 21 gauge 1.5 inch needle. The injection site is the lateral thigh (4mL maximum) or deltoid. If greater than 4mL needs to be administered, split the dose between both thighs.
Medication Administration
MUCOSAL ATOMIZATION DEVICE (MAD)
- Versed, Narcan, and Fentanyl can all be administered via the MAD.
- Ideal dose is 0.5mL per nostril. Maximum of 1mL per nostril
Medication Administration INTRAOSSEOUS SITES (EZ-IO) ADULTS ( In order of Preference)
- Proximal Humerus, 2. Proximal Tibia
Medication Administration INTRAOSSEOUS SITES (EZ-IO) PEDIATRIC ( In order of Preference)
- Distal Femur, 2. Proximal Tibia 3. Proximal Humerus (only if the surgical neck can be palpated) approximately age 10
Medication Administration
PUSH DOSE EPINEPHRINE
(Adult and Pediatric)
(Pt’s with a pulse and in shock)
(10mcg/ml)
Mix 9 mL of Normal Saline with 1 ml of Epi 1:10,000 = Epi (1:100,000) 10 ml solution
Adult: EPINEPHRINE: titrate slowly 1 ml every 30 seconds IV/IO (titrate to SBP over 100). May repeat 2x Max total dose 0.3mg
Peds: EPINEPHRINE: titrate slowly 1 ml every 30 seconds IV/IO (titrate to age appropriate SBP). May repeat 2x Max total dose 0.3mg
- Titrate to age appropriate blood pressure
Medication Administration
BENADRYL for Pediatrics
BENADRYL ADMINISTRATION IV/IO: Dilute with 9 mL of Normal Saline to make a 5mg/ml solution
Medication Administration
Ketamine: IV
All IV Ketamine must be diluted 500mg in 50ml NS to make a 10mg/ml solution
OR
Pain Management IV Ketamine: Remove 1ml Saline from a 10ml saline syringe and then, pull 1ml of 100mg/ml of Ketamine. This creates a concentration of 10mg/ml.
Medication Administration
Fentanyl: dilution for pediatrics
Diluted for pediatrics patients when given IV/IO, 2ml (or 100mcg) in 8ml NS to make a 10mcg/ml solution
Medication Administration
Sodium Bicarbonate: Pediatric dilution
Diluted for infants and neonates- 8.4% - 25ml and mix with 25ml NS to make a 4.2% sodium bicarbonate solution
Medication Administration
Adult Drug Infusions
Amiodarone (for stable VT-Pt with pulse)
150mg in 50ml NS over 10 min
60 gtts/min with a 10gtt set, 1 gtt every sec = 6ml/min = 10min
Medication Administration
Adult Drug Infusions
Magnesium Sulfate (Eclampsia, Asthma, and Torsades)
4 ml or 2g in 50ml over 10 min
60 gtts/min with a 10gtt set, 1 gtt every sec = 6ml/min = 10min
Medication Administration
Pediatric Drug Infusions
Amiodarone (Stable SVT)
5mg/kg #ml (as per Per Med tool) in 50ml NS max of 3ml (150mg) for infusion
20gtts/min with a 10gtt set, 1 gtt every 3 secs =2ml/min =25 min
Pediatric Medication Administration Magnesium Sulfate (Severe Asthma, Stable Torsades)
40mg/kg #ml (as per Per Med tool) in 50ml NS max of 4ml (2g)
60gtts/min with a 10gtt set, 1gtt/sec =6ml/min =10 min.
Legal
FLORIDA INCAPACITATED PERSONS ACT : 401.445
Patient who have a medical emergency and lack capacity to refuse transport shall be transported to the appropriate Emergency Department for evaluation.
Emergency examination and treatment of incapacitated persons.—
(1) No recovery shall be allowed in any court in this state against any emergency medical technician, paramedic, or physician as defined in this chapter, any advanced registered nurse practitioner certified under s. 464.012, or any physician assistant licensed under s. 458.347 or s. 459.022, or any person acting under the direct medical supervision of a physician, in an action brought for examining or treating a patient without his or her informed consent if:
(a) The patient at the time of examination or treatment is intoxicated, under the influence of drugs, or otherwise incapable of providing informed consent as provided in s. 766.103;
(b) The patient at the time of examination or treatment is experiencing an emergency medical condition; and
(c) The patient would reasonably, under all the surrounding circumstances, undergo such examination, treatment, or procedure if he or she were advised by the emergency medical technician, paramedic, physician, advanced registered nurse practitioner, or physician assistant in accordance with s. 766.103(3).
(d) Examination and treatment provided under this subsection shall be limited to reasonable examination of the patient to determine the medical condition of the patient and treatment reasonably necessary to alleviate the emergency medical condition or to stabilize the patient.
(2) In examining and treating a person who is apparently intoxicated, under the influence of drugs, or otherwise incapable of providing informed consent, the emergency medical technician, paramedic, physician, advanced registered nurse practitioner, or physician assistant, or any person acting under the direct medical supervision of a physician, shall proceed wherever possible with the consent of the person. If the person reasonably appears to be incapacitated and refuses his or her consent, the person may be examined, treated, or taken to a hospital or other appropriate treatment resource if he or she is in need of emergency attention, without his or her consent, but unreasonable force shall not be used
Patient Assessment/Treatment
Airway Positioning
Head-tilt/chin-lift or modified jaw thrust for suspected spinal cord injury.
Patient Assessment/Treatment
Airway Semi-conscious patient
with an intact gag reflex shall have a nasopharyngeal airway inserted, unless contraindicated.
Patient Assessment/Treatment
Airway Unresponsive patient
without a gag reflex shall have an oropharyngeal airway inserted, unless contraindicated. If ventilation is required for more than two minutes, an IGELor ETTshould be inserted (Adults).
Patient Assessment/Treatment
Airway Pediatric:
The preferred method for ventilating pediatric patient is with a BVM in conjunction with an oral or nasal airway. Pediatric patients who can not protect their airway, are unable to maintain oxygen saturation despite BVM ventilation, and/or can not be effectively ventilated with a BVM, should be upgraded to an advanced airway. Infants and children who have an advanced airway placed during CPR should be ventilated at a rate of 1 breath every 6 seconds.
Patient Assessment/Treatment Airway
* Pediatric Patients in respiratory distress, who have had a recent illness accompanied by fever, drooling, or stridor:
should not have an NPA or OPA inserted. DO NOT STRESS Patient.
Patient Assessment/Treatment
Airway Recovery position
for spontaneously breathing patients: Altered mental status, postictal, suspected drug overdose, etc., if no suspected spinal cord injury.
Patient Assessment/Treatment
Oxygenation
• Oxygen should ONLY be administered in order to maintain SpO2of 95% or 90% for COPD & asthma patients.
* Do not withhold oxygen if the patient is dyspneic, tachypneic or hypoxic.
• Traumatic Brain Injury (TBI) patients shall receive 15 Lpm via NRB.
• Pregnancy 3rd trimester trauma patients shall receive 15 Lpm via NRB.
• Pulse oximetry should be documented (pre and post oxygen administration) and applied for continuous monitoring on all ALS patients.
• If oxygen saturation cannot be maintained, ventilatory support should be provided.
Patient Assessment/Treatment
Ventilation
- Ventilatory support shall be accomplished via BVM (with either an NPA/OPA), IGEL, or ETT intubation.
- Oxygenation Goal is to maintain an SpO2of 95% and 90% for chronic COPD patients and EtCO2 levels between 35-45 mmHg
- Endotracheal intubation shall be confirmed by: visualization of the ETT passing through the vocal cords, auscultation, and continuous EtCO2 monitoring.
Patient Assessment/Treatment
Ventilatory Rates
- Adults: 10 breaths/minute (1 breath every 6 seconds) with a pulse.
- Adults: 6 breaths/minute ( 1 breath every 10 seconds) without a pulse
- Children: 20 breaths/minute (1 breath every 3 seconds) with a pulse.
- Children: 10 breaths/minute ( 1 breath every 6 seconds) without a pulse
- Neonates: 40 breaths/minute
Patient Assessment/Treatment
Circulation
- Carotid and radial pulse present, assess capillary refill, assess skin color, condition and temperature.
- Apply AED/LP/ZOLL on all unconscious patients.
- Perform MICCR on all cardiac arrest patients and defibrillate as needed.
- Pediatrics: After BVM- oxygenation and ventilation of 1 minute for infants/children and 30 seconds for neonates (birth to 1 month), begin chest compressions if the heart rate remains below 60 BPM with signs of poor perfusion (AMS).
Patient Assessment/Treatment
EtCO2 Monitoring
- The following patients should be monitored if the EtCO2 nasal cannula sampling device is available:
- In respiratory distress
- With an altered mental status
- Sedated patients or patients receiving pain medication
- Patient administered Ketamine
- Seizure patient
- Requiring ventilatory support (ETT, IGEL, CPAP, etc)
Patient Assessment/Treatment
ECG Monitoring
• All ALS patients shall be continuously monitored in lead II.
• Patients who present with any of the following cardiac or possible cardiac symptoms shall have a 12
lead ECG performed:
- Chest/arm/neck/jaw/upper back/shoulder/epigastric pain or discomfort
- Palpitations
- Syncope, lightheadedness, general weakness, or fatigue
- CHF, SOB, or hypotension
- Unexplained diaphoresis or nausea
• 12 lead ECGs shall be repeated every 5 minutes and upon a ROSC (if transporting leave cables
connected until patient is turned over to the ED staff).
Patient Assessment/Treatment
Glucose
A BGL shall be documented for patients with any of the following:
- history of diabetes,
- suspected drug or alcohol use,
- altered mental status,
- general weakness,
- seizure,
- syncope/lightheadedness,
- dizziness,
- poisoning,
- stroke,
- and cardiac arrest.
Patient Assessment/Treatment
Vital Signs
All patients will be evaluated with a complete set of vital signs which shall be documented as follows (BP, HR, RR, Skin, Temp, O2Sat)
* Priority 3 at least 2 sets of complete vital signs and every 15 minutes
* Priority 2 patients every 5 minutes
• Pulse (rate and quality)
• Respiratory (rate and quality)
• Skin (color, condition, and temperature)
• Blood Pressure/Capillary Refill
• A complete set of vital signs shall be documented as follows (BP, HR, RR, Skin, Temp, O2Sat.)
• A blood pressure shall be checked before and after the administration of a drug known to effect blood pressure.
• For the purposes of these protocols, adult hypotension is defined as a systolic blood pressure less than 100 mmHg.
• A manual blood pressure should be taken to confirm any abnormal or significant change of an automatic blood pressure cuff reading.
Patient Assessment/Treatment
Definitions of Pediatric Patients
- EMS: Puberty is defined as breast development for females and underarm, chest, or facial hair on males. Once a child reaches puberty, use the adult EMS Protocols.
- Pediatric is defined as the absence of puberty for EMS
- For Medical ED- Pediatric is defined as 17 y/o or younger/ 18 = adult medical
- For Trauma Alerts -Pediatric is defined as 15 y/o or younger/ 16= adult trauma
Patient Assessment/Treatment
Pediatric Respiratory Rates
- Neonate: Birth to 1 month (40-60 breaths/min)
- Infants: 1 month to 1 year (30-60 breaths/min)
- Toddlers: 1-3 y/o (24-40 breaths/min)
- Preschooler: 4-5 y/o (22-34 breaths/min)
- School age: 6-12 y/o (18-30 breaths/min)
- Adolescent ages 13-18 y/o (12-16 breaths/min)
Patient Assessment/Treatment
Pediatric heart Rates
- Newborn to 3 months: 85-205, mean 140 beats/ min
- 3 months to 2 years: 100- 190, mean 130 beats/min
- 2 years to 10 years 60- 140, mean 80 beats/min
- Greater than 10 years old: 60-100, mean 75 beats/min
Patient Assessment/Treatment
Pediatric Hypotension:
- Neonates: SBP less than 60
- Infants: SBP less than 70
- Children 1-10 years: SBP less than 70 + (age in years x 2)
- Children greater than 10 years: SBP less than 90
Transport Priorities
- Priority One: Patients in Cardiac or Respiratory Arrest
- Priority Two: Unstable patients with life-threatening conditions
- Priority Three: Stable patients with no life-threatening conditions
Transport Destinations
All Priority One Medical Patients:
- All Primary cardiac arrest patients will be transported to the closest approved STEMI Facility if transport time is less than 20 minutes.
- Pediatric patients who have regained a ROSC shall be transported to a comprehensive pediatric emergency department. Pulseless pediatric patients shall be transported to closest appropriate emergency department (excluding Free Standing ED’s)..
- All others patients shall be transported to the closest appropriate hospital emergency department (excluding FreeStandingED’s).
Transport Destinations
All Priority Two Medical Patients
• Shall be transported to the closest appropriate emergency department.
Transport Destinations
All Priority Three Patients
• Should be transported to the closest appropriate emergency department.
Transport Destinations
Free Standing Emergency Departments
Patients may be transported to a “Free Standing ED” upon the patient’s request and:
• Excludes all ALS patients
• Patient must be informed that if transported to a Free Standing ED and they subsequently require
admission, they may need to be transferred to another facility.
• Patient must sign an Emergency Transport Disclaimer.
Transport Destinations
Trauma Patients
- All adult and pediatric trauma alert patients meeting trauma alert criteria, shall be transported to the closest appropriate (Pediatric or Adult) Trauma Center.
- Trauma patients who arrest in the presence of Fire Rescue personnel, shall be transported to the closest Trauma Center.
- All pregnant (visibly or by history of gestation >20 weeks) patients meeting Trauma Alert criteria shall go to closest Trauma/OB Facility.(Broward Health Medical Center or Memorial Regional)
- All intubated interfacility transfers MUST be both paralyzed and sedated by the sending facility. If the sending facility physician refuses to administer paralytics, The Battalion Chief or EMS 17 will be contacted.
Transport Destination
STEMI Alerts
- Once a STEMI Alert has been determined, the 12 lead must be transmitted and the patient should have transport expedited to the closest approved STEMI Facility.
- The patient shall be transported by air (if available) to the closest approved STEMI facility with surgical backup if the ground transport time to the closest approved STEMI Facility is greater than 20 minutes. Refer to the Hospital Capabilities List for the approved STEMI Facilities and STEMI Facilities with surgical backup.
Transport Destination
Stroke Alerts
Transport to the closest Comprehensive Stroke Center
All Stroke Alerts shall be transported to a Comprehensive Stroke Center
• Refer to the Hospital Capabilities List for the Comprehensive Stroke Centers.
• The patient shall be transported by air (if available) to the closest Comprehensive Stroke Center if the ground transport time to the closest Comprehensive Stroke Center is greater than 20 minutes.
Transport Destination
Definitions of a pediatric Stroke (less than 18 years of age)
• All Pediatric Stroke Alerts shall be transported to a Pediatric Comprehensive ED/Comprehensive Stroke Center ( BHMC or JDCH)
Comprehensive Pediatric Emergency Department:
These hospitals have pediatric admitting capabilities and surgery options. They also have pediatric intensive care units (PICU).
Transport Destinations OBSTETRICAL PATIENTS (DEFINED AS PREGANCY 20 WEEKS OR GREATER)
- Patients less than 20 weeks are GYN cases and can be transported to closest ED.
- Over 20 weeks with any abdominal/pelvic pain transport to the closest OB hospital.
- Over 20 weeks with a NON OB related minor concern can go to the closest ED. (if patient is over 20 weeks with any constitutional symptoms, transport to OB hospital)
- Stable patients over 20 weeks may go to the OB hospital of their choice within 40 minutes.
- Over 20 week and in cardiac arrest transport to closest OB Hospital
- Over 20 weeks and trauma transport to Trauma/OB Hospital
Transport Destinations
Decompression Sickness & Carbon Monoxide Poisoning
- Patients with decompression sickness or carbon monoxide poisoning shall be transported nearest Hyperbaric Chamber Center (encode prior to transport to confirm availability of Hyperbaric chamber). If unavailable transport to closet ED WITH HELIPAD
- Consider Air Rescue transport if transport time is greater than 20 minutes. ( Maximum 500 ft.)
- Diver Alert Network (D.A.N) is a good resource 800-662-3637
Transport Destinations
Psychiatric Patients
• Stable psychiatric patients shall be transported to the closest appropriate facility.
• Unstable psychiatric patients shall be transported to the closest appropriate emergency department
for stabilization.
Transport Destinations
Helicopter Operational Criteria
The guidelines for air ambulance transport include, but are not limited to the following:
• Trauma patients that meet the trauma scorecard methodology and criteria as set forth in the rules and regulations of Broward County Trauma Report
• Pre-hospital ground transport to a Trauma Center is greater than 20 minutes; or,
• Pre-hospital scene extrication time of a trauma patient is greater than 15 minutes; or,
• Pre-hospital ground response time to the scene is greater than 10 minutes; or,
• Mass Casualty Incidents (MCI) involving multiple patients with traumatic injuries; or,
• To augment or expedite pre-hospital ground transport, or
• To transport a patient upon request by the EMS provider.
Transport Destinations
Helicopter Will Not be Used
(Ground Transport Will Be Required)
- Any patient the pilot or crew determines is not safe to transport.
- Bariatric patient weight- as per pilots judgement
- Patient who is combative and cannot be physically and/or chemically restrained.
- Hazmat contaminated patient.
Cardiac Arrest Epinephrine Drip
Adult: Mix 2mg of Epinephrine in 100ml of NS and run over 16 minutes.
Pediatric: Cardiac weight based dose and double the amount, then mix into 100 ml of NS and run over 16 minutes.
Patient Assessment/ Treatment
SOAP - Subjective
S = Subjective
- Chief Complaint - Why did the person call 911
- History of the present illness (O, P, Q, R, S, T, A)
- Onset: gradual or sudden?
- Palliative: What makes the symptom better?
- Provoke: What makes the symptom worse?
- Previous: Previous similar episodes?
- Quality: (What kind or pain) Pressure, squeezing, aching, dull, etc.
- Radiation: Does the pain or discomfort radiate? Where?
- Severity of pain: 1-10 scale, Faces pain scale for pediatrics.
- Time: What time did the symptoms begin?
- Associated: What are the associated signs and symptoms?
- S.A.M.P.L.E. history
- Signs and symptoms
- Allergies
- Medications: Prescribed, over the counter, or not prescribed to patient
- Past Medical History: Heart Attack, asthma, COPD, diabetes, hypertension, stroke, etc,
- Last Oral Intake
- Events Preceding
Patient Assessment/ Treatment
SOAP - Objective
O = Objective
- Physical Exam
- Vital signs
- Physical Exam findings
Patient Assessment/ Treatment
SOAP - Assessment and Plan
- In narrative form summarize diagnosis, treatment, and disposition.
Pediatric Cardiac Arrest
- children with HR below 60 and signs of poor perfusion.
- Pediatrics - After BVM oxygenation and ventilation of 1 minute for infants/ children and 30 seconds for neonates (birth to 1 month), begin chest compressions if the heart rate remains below 60BPM with signs of poor perfusion (AMS)
Neonate Patients: APGAR Scoring
APGAR
Appearance Pulse Grimace Activity Respirations
Neonate Patients: APGAR Scoring
Appearance:
Blue/Pale = 0
Body Pink/ Extremities Blue = 1
Completely Pink = 2
Neonate Patients: APGAR Scoring
Pulse:
Absent = 0
Below 100 = 1
Above 100 = 2
Neonate Patients: APGAR Scoring
Grimace:
No Response = 0
Grimaces = 1
Cries = 2
Neonate Patients: APGAR Scoring
Activity:
Limp = 0
Some Flexion of extremities = 1
Active motion = 2
Neonate Patients: APGAR Scoring
Respirations:
Absent = 0
Slow/ Irregular = 1
Good Strong Cry = 2
Trauma Centers
- Broward General
- North Broward
- Memorial Regional
- Delray Medical
- Aventura
Pediatric Trauma Centers
- Broward General
- Memorial Regional (JDCH)
- Delray Medical
Pediatric Medical Centers
- Coral Springs
- Imperial Point
- Broward General
- North Broward
- Holy Cross
- Memorial Miramar
- Memorial Regional (JDCH)
- Memorial West
- Northwest Medical
- Plantation
- University
- West Boca
Pediatric Admission Centers
- Coral Springs
- Broward General
- Memorial Regional (JDCH)
- Memorial West
- Northwest Medical
- Plantation
- West Boca
OB Facilities
Coral Springs Broward General Holy Cross Memorial Miramar Memorial Regional Memorial West Northwest Plantation Boca Regional West Boca
Psych Facilities
Imperial Point Broward General Florida Medical Memorial Regional Plantation University Delray Medical Aventura
Pediatric Psych Facilities
Memorial Regional
University
Comprehensive Stroke Facilities
Broward General North Broward Cleveland Clinic Florida Medical Center Holy Cross Memorial Regional Memorial West West Side Regional Boca Regional Aventura
Ice Centers
Imperial Point Broward General Broward North Cleveland Clinic Florida Medical Center Holy Cross Memorial Pembroke Memorial Regional Memorial West Northwest Westside Regional Boca Regional Delray Medical Aventura
Cath Centers
Broward General North Broward Cleveland Clinic Florida Medical Center Holy Cross Memorial Regional Memorial West Northwest Medical Westside Regional Boca Regional Delray Medical Aventura
LVAD Centers
Cleveland Clinic
Holy Cross
Memorial Regional
